The role of asymmetrical prominent veins sign in early neurological deterioration of acute ischemic stroke patients

 So you're predicting early neurological deterioration but giving us NOTHING on how to prevent it. Useless. Do we have no one in the world that wants to solve stroke?

The role of asymmetrical prominent veins sign in early neurological deterioration of acute ischemic stroke patients

Kuankuan Huang^1†, Jianfang Liu^2†, Wenwei Yun^2†, Yin Cao^2* and Min Zhang^2*

• ¹First People's Hospital in Guangyuan, Guangyuan, China
• ²Department of Neurology, Changzhou No. 2 People's Hospital Affiliated to Nanjing Medical University, Changzhou, China

Background and purpose: Asymmetrical prominent veins sign (APVS) often appears on susceptibility-weighted angiography (SWAN) images in patients with acute stroke. Early neurological deterioration (END) is highly correlated with survival prognosis in patients with ischemic stroke. This study sought to explore the relationship between APVS and END in patients with acute stroke.

Methods: The subjects retrospectively enrolled in this study were patients with acute ischemic stroke in the middle cerebral artery supply area. All patients underwent head MRI, including the SWAN sequence, within 7 days of stroke symptom onset. END was defined as clinical deterioration or recurrence within 72 h after ischemic stroke. The volume of infarction on diffusion-weighted imaging was measured. Univariate and multivariate analyses were used to analyze the relationship between APVS and END. Spearman correlation between APVS grades and infarct volume, white matter hyperintensity (WMH) volume, and offending vessel were also analyzed.

Results: A total of 157 patients with middle cerebral artery infarct between September 2018 and April 2020 were included in the study. APVS appeared on MRI in 84 of 157 patients, and 34 of 157 patients were diagnosed with END. In patients with END, the proportion of severe APVS was higher than in patients without END (P = 0.001, x² = 14.659). Patients with END were older and had a larger volume of infarct and WMH than patients without END (all P < 0.05). After adjustments were made for related risk factors of END, the severity of APVS was still related to END (OR = 2.56, 95% CI, 1.38–4.75; P for trend = 0.003). Spearman correlation showed that APVS grades were positively related to infarct volume (r = 0.289, P < 0.001) and 3-month modified Rankin Scale score (r = 0.203, P = 0.011) and negatively related to offending vessels (r = −0.170, P = 0.034).

Conclusion: APVS may be an important predictor of END in patients with acute ischemic stroke.

Introduction

Susceptibility-weighted angiography (SWAN), which is analogous to susceptibility-weighted imaging (SWI), is an imaging technique that identifies differences in magnetic sensitivity caused by unevenness of the local magnetic field (such as with blood or iron) in tissues. This technique can effectively display veins, blood metabolites, and iron deposits in patients with cerebrovascular disease. Compared with conventional MRI sequences, SWAN can more sensitively display cerebral venules, microbleeds, and iron deposition (1, 2).

The imaging of small veins with SWAN is based on the principle of blood oxygen level. On SWAN, patients with cerebrovascular disease may demonstrate the asymmetrical prominent veins sign (APVS), which refers to veins that are wider and longer in one hemisphere of the brain than in the other. APVS can be categorized based on location, with patients demonstrating the asymmetrical cortical veins sign (ACVS) or the asymmetrical medullary veins sign (AMVS) (3).

Deoxyhemoglobin is used as an endogenous contrast agent to display the structure of intracranial veins. Therefore, the degree of vein development in SWAN is mainly dependent on the amount of deoxyhemoglobin in venous blood (4). APVS is usually not present in healthy patients but is often present in patients who have experienced an ischemic stroke (5, 6).

The appearance of APVS is pathophysiologically complex. In the ischemic penumbra of patients with acute ischemic stroke, the brain tissue is in a state of poor perfusion. This results in increased tissue oxygen uptake increased concentration of venous deoxyhemoglobin and increased magnetic sensitivity of veins.

The clinical significance of APVS remains controversial. Some researchers hold the view that APVS in the infarct zone may represent the ischemic penumbra, as the oxygen uptake index in the penumbra zone is elevated, which is considered collateral branches of the ischemic penumbra. One study found that the presence of APVS is related to the early improvement of cerebral infarction (7). In a study of patients undergoing thrombolysis, those with AMVS identified on MRI before thrombolysis had better early reperfusion (8), which led researchers to conclude that the presence of APVS is associated with collateral circulation and is a good predictor of prognosis in patients with stroke (9, 10). However, other studies in patients with stroke who did not undergo thrombolysis demonstrated conflicting results, showing that the presence of APVS indicated poor arterial supply and was associated with adverse outcomes (6, 11). These conflicting findings obscure the clinical significance of APVS in patients with stroke. In particular, research has not yet clearly demonstrated the potential association between APVS and the presence of early neurological deterioration (END), which is a predictor of short-term and long-term prognosis and occurs in 10–40% of patients with ischemic stroke (12, 13).

The purpose of this study, therefore, was to explore the clinical role of APVS in cerebral infarction. In particular, we sought to determine whether a relationship exists between APVS and END in patients with acute stroke.

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