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Venous outflow profiles are associated with early edema progression in ischemic stroke
Noel van Hornhttps://orcid.org/0000-0001-5764-19821, Jeremy J Heit2, Reza Kabiri1, Gabriel Broockshttps://orcid.org/0000-0002-7575-98501, Soren Christensen3, Michael Mlynash3, Lukas Meyer1, Michael H Schoenfeld4, Maarten G Lansberghttps://orcid.org/0000-0002-3545-69273, Gregory W Albers3, Jens Fiehler1, Max Wintermark2, and Tobias D Faizyhttps://orcid.org/0000-0002-1631-20201,2
Background:
In patients with acute ischemic stroke due to large vessel occlusion (AIS–LVO), development of extensive early ischemic brain edema is associated with poor functional outcomes, despite timely treatment. Robust cortical venous outflow (VO) profiles correlate with favorable tissue perfusion. We hypothesized that favorable VO profiles (VO+) correlate with a reduced early edema progression rate (EPR) and good functional outcomes.
Methods:
Multicenter, retrospective analysis to investigate AIS–LVO patients treated by mechanical thrombectomy between May 2013 and December 2020. Baseline computed tomography angiography (CTA) was used to determine VO using the cortical vein opacification score (COVES); VO+ was defined as COVES ⩾ 3 and unfavorable as COVES ⩽ 2. EPR was determined as the ratio of net water uptake (NWU) on baseline non-contrast CT and time from symptom onset to admission imaging. Multivariable regression analysis was performed to assess primary (EPR) and secondary outcome (good functional outcomes defined as 0–2 points on the modified Rankin scale).
Results:
A total of 728 patients were included. Primary outcome analysis showed VO+ (β: –0.03, SE: 0.009, p = 0.002), lower presentation National Institutes of Health Stroke Scale (NIHSS; β: 0.002, SE: 0.001, p = 0.002), and decreased time from onset to admission imaging (β: –0.00002, SE: 0.00004, p < 0.001) were independently associated with reduced EPR. VO+ also predicted good functional outcomes (odds ratio (OR): 5.07, 95% CI: 2.839–9.039, p < 0.001), while controlling for presentation NIHSS, time from onset to imaging, general vessel reperfusion, baseline Alberta Stroke Program Early CT Score, infarct core volume, EPR, and favorable arterial collaterals.
Conclusions:
Favorable VO profiles were associated with slower infarct edema progression and good long-term functional outcomes as well as better neurological status and ischemic brain alterations at admission.
Keywords
Brain, collaterals, edema, ischemic stroke, mechanical thrombolysis, neuroimaging
1Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
2Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
3Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
4Department of Radiology, University Hospital of Cologne, Cologne, Germany
Corresponding author(s):
Noel van Horn, Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany. Email: no.vanhorn@uke.de
Introduction
In patients with acute ischemic stroke due to large vessel occlusion (AIS–LVO), rapid development of extensive early ischemic brain edema is associated with poor functional outcomes.1 However, in these patients, robust arterial collateral blood flow was found to be associated with less ischemic damage to the brain, likely due to the perseverance of blood flow to and through the ischemic tissue.2–4
Arterial collaterals are usually assessed on computed tomography angiography (CTA) images, but only reflect the arterial component of the microvascular circuit and do not reliably measure cerebral perfusion.5 It has been presumed that the critical patterns of tissue hypoperfusion are determined by the most distal arterial branches and the associated venous outflow (VO) profiles.6,7
Recent studies reported that favorable VO profiles are associated with less ischemic lesion net water uptake (NWU) on follow-up imaging and favorable functional outcomes of AIS–LVO patients treated by mechanical thrombectomy (MT).8 However, the association between VO profiles and early edema progression in AIS–LVO patients remains unclear. More comprehensive data on the effect of robust venous drainage on cerebral edema development are needed to better understand the pathophysiological factors that influence early edema progression between the time from symptom onset to baseline imaging.
We hypothesized that favorable VO profiles are associated with less early edema progression in AIS–LVO patients. We tested this hypothesis by determining VO using the cortical vein opacification score (COVES)9 on baseline CTA images and early ischemic NWU10 on admission head non-contrast CT (NCCT) images. Early edema progression rate (EPR) was calculated as the ratio of NWU on admission NCCT imaging divided by the time from symptom onset to baseline imaging.
Keywords
Brain, collaterals, edema, ischemic stroke, mechanical thrombolysis, neuroimaging
1Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
2Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
3Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
4Department of Radiology, University Hospital of Cologne, Cologne, Germany
Corresponding author(s):
Noel van Horn, Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany. Email: no.vanhorn@uke.de
Introduction
In patients with acute ischemic stroke due to large vessel occlusion (AIS–LVO), rapid development of extensive early ischemic brain edema is associated with poor functional outcomes.1 However, in these patients, robust arterial collateral blood flow was found to be associated with less ischemic damage to the brain, likely due to the perseverance of blood flow to and through the ischemic tissue.2–4
Arterial collaterals are usually assessed on computed tomography angiography (CTA) images, but only reflect the arterial component of the microvascular circuit and do not reliably measure cerebral perfusion.5 It has been presumed that the critical patterns of tissue hypoperfusion are determined by the most distal arterial branches and the associated venous outflow (VO) profiles.6,7
Recent studies reported that favorable VO profiles are associated with less ischemic lesion net water uptake (NWU) on follow-up imaging and favorable functional outcomes of AIS–LVO patients treated by mechanical thrombectomy (MT).8 However, the association between VO profiles and early edema progression in AIS–LVO patients remains unclear. More comprehensive data on the effect of robust venous drainage on cerebral edema development are needed to better understand the pathophysiological factors that influence early edema progression between the time from symptom onset to baseline imaging.
We hypothesized that favorable VO profiles are associated with less early edema progression in AIS–LVO patients. We tested this hypothesis by determining VO using the cortical vein opacification score (COVES)9 on baseline CTA images and early ischemic NWU10 on admission head non-contrast CT (NCCT) images. Early edema progression rate (EPR) was calculated as the ratio of NWU on admission NCCT imaging divided by the time from symptom onset to baseline imaging.
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