Angiographic collateral status predicts functional outcome and early neurological deterioration in large-vessel occlusion stroke treated with endovascular therapy

 Why are you incompetently? predicting failure to recover than delivering recovery?

Laziness? Incompetence? Or just don't care? NO leadership? NO strategy? Not my job? Not my Problem!

Angiographic collateral status predicts functional outcome and early neurological deterioration in large-vessel occlusion stroke treated with endovascular therapy

Junying Li 1,2†

L

Lei Chen 1†

Z

Zhongjiao Lu 3

Y

Yanhui Li 2

Y

Yaling Wang 2



Lanying He 1

D

Dan Yang 1*

• 1. Department of Neurology, West China School of Medicine, Sichuan University, Sichuan University affiliated Chengdu Second People’s Hospital, Chengdu Second People’s Hospital, Chengdu, Sichuan, China

• 2. Bai Lian chi Community Health Center, Chengdu, Sichuan, China

Abstract

Background: 

Despite successful recanalization with endovascular treatment (EVT) for acute ischemic stroke (AIS), many patients experience poor outcomes. While collateral circulation is a known prognostic factor, its dynamic assessment via digital subtraction angiography (DSA) and its relationship to outcomes post-EVT require further investigation.

Methods: 

This single-center retrospective study analyzed 185 consecutive AIS patients with large vessel occlusion treated with EVT. Collateral status was graded on pre-treatment DSA using the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) scale and categorized as poor, fair, or good. The primary outcome was functional independence (modified Rankin Scale [mRS] score 0–2) at 90 days. Secondary outcomes included early neurological deterioration (END) within 7 days and 90-day mortality.

Results: 

Patients with good collaterals had significantly higher rates of functional independence (66.1%) compared to those with fair (45.9%) and poor collaterals (13.2%). Conversely, the incidences of END (1.8% vs. 8.2% vs. 23.5%) and 90-day mortality (1.8% vs. 11.5% vs. 27.9%) were progressively higher in the good, fair, and poor collateral groups, respectively. Multivariable logistic regression confirmed that a higher collateral score was an independent predictor of good functional outcome and was independently associated with a lower risk of END and mortality.

Conclusion: 

DSA-assessed collateral status is a strong independent predictor of 90-day functional outcome, END, and mortality in AIS patients following EVT. Robust pretreatment collaterals are associated with markedly improved recovery and survival, highlighting the critical prognostic value of collateral assessment in guiding treatment and patient management.

Introduction

Endovascular treatment (EVT) is now established as the standard therapy for acute ischemic stroke (AIS) caused by large-vessel occlusion (LVO) within 24 h (1, 2), with multiple randomized trials demonstrating substantial reductions in disability and mortality (3). However, even after technically successful recanalization, nearly half of patients fail to achieve functional independence at 3 months (4). Notably, considerable outcome variability persists among patients with similar occlusion sites, baseline characteristics, and reperfusion success. This highlights the need for reliable, imaging-based biomarkers to refine treatment selection and improve prognostic precision in EVT population.

Collateral circulation is recognized as one of the most critical determinants of ischemic tissue fate (5, 6). Robust collaterals maintain residual perfusion to the penumbra, slow infarct progression, preserve metabolic viability, and enhance the likelihood of favorable neurological recovery (7, 8). Despite this recognized importance, the extent to which collateral integrity continues to influence outcomes after successful EVT remains incompletely understood. Existing studies have yielded conflicting results, with some demonstrating a strong association between good collaterals and improved outcomes (9, 10), while others reported no significant relationship (11, 12).

Emerging evidence further suggests that collateral status may modulate the time dependence of EVT efficacy. Patients with poor collaterals experience substantial declines in outcome with prolonged onset-to-reperfusion times, whereas those with robust collaterals show relative resistance to ischemic delay (13). Although collateral enhancement has been proposed as a therapeutic target, the clinical impact remains uncertain, partly due to heterogeneous collateral assessment methods and variable patient responses (14). Most prior studies have relied on computed tomography angiography (CTA) for collateral evaluation, where CTA-based grading has shown predictive value for post-EVT outcomes (15–17). However, CTA provides only a static snapshot of vascular filling, whereas digital subtraction angiography (DSA) offers dynamic, higher-resolution assessment of collateral flow. Despite these advantages, the prognostic implications of DSA-based collateral grading remain insufficiently explored. Existing evidence is limited, often restricted to either anterior or posterior circulation strokes, and prior studies have reported mixed findings regarding the strength and consistency of these associations (18, 19).

To address these knowledge gaps, the present study systematically evaluated the relationship between DSA-determined collateral status and short-term functional outcomes in AIS patients with LVO undergoing EVT. In addition, we examined the interaction between collateral status and reperfusion success, along with other clinical and imaging predictors of outcome. This work aims to clarify the prognostic value of angiographic collaterals and provide more precise insights into their role in EVT-treated AIS.

Prediction of collateral circulation grading and functional outcomes in acute ischemic stroke using FLAIR vascular hyperintensity combined with multimodal CT parameters

Predictions DO NOTHING FOR STROKE RECOVERY, and with NO protocols written, COMPLETELY FUCKING USELESS! You're fired! All the mentors and senior researchers need to be fired for not having an objective of writing EXACT rehab protocols from research!

 Prediction of collateral circulation grading and functional outcomes in acute ischemic stroke using FLAIR vascular hyperintensity combined with multimodal CT parameters

Qiushi Yang^1,2Yanxin Ma^2*Xin Qu^1,2Yu Chen^1,2Hui Sun^1,2Gang Yao²

• ¹Mudanjiang Medical University, Mudanjiang, Heilongjiang, China
• ²Department of Radiology, Daqing Oilfield General Hospital, Daqing, Heilongjiang, China

Background/objectives: The variability in acute ischemic stroke (AIS) outcomes is closely associated with collateral circulation status. While fluid-attenuated inversion recovery vascular hyperintensity (FVH) and multimodal CT parameters (e.g., rLMC score, rCBV) were associated with 90-day functional outcomes in AIS patients, their combined predictive value and clinical utility warrant further investigation. This study investigates the combined predictive value of FVH and multimodal CT parameters for collateral assessment and prognosis in AIS.

Methods: We retrospectively and consecutively enrolled AIS patients with internal carotid artery or middle cerebral artery stenosis/occlusion who did not receive intravenous thrombolysis or mechanical thrombectomy. All patients underwent one-stop CT angiography–CT perfusion and multimodal MRI within 72 h of symptom onset. Evaluations included FVH scores (based on modified ASPECTS regions), rLMC scores, Maas scores, and ASITN/SIR collateral grading. Spearman analysis assessed correlations between FVH and CTA collateral scores. Univariate and multivariate logistic regression indicated the independent predictors of a 90-day functional outcome [favorable (mRS 0–2) vs. poor (mRS 3–6)], with receiver operating characteristic (ROC) curves evaluating predictive performance.

Results: The cohort comprised 112 patients (70 favorable outcomes, 42 poor outcomes). FVH scores showed a negative correlation with ASITN/SIR collateral grades (r = −0.432, p < 0.001). Compared to the favorable outcome group, the poor outcome group exhibited higher baseline National Institute of Health Stroke Scale (NIHSS) scores, elevated FVH scores, reduced rLMC scores, and lower rCBV values (all p < 0.05). Multivariate analysis indicated that NIHSS score, FVH score, rLMC score, and rCBV were independent predictors of poor outcomes. ROC analysis demonstrated strong predictive performance for rLMC score (AUC = 0.848, 95%CI 0.778–0.919), FVH score (AUC = 0.662, 95%CI 0.550–0.774), and rCBV (AUC = 0.727, 95%CI 0.631–0.822).

Conclusion: Multimodal CT combined with MRI facilitates early AIS diagnosis and collateral assessment. The integration of FVH with CT parameters (rLMC score and rCBV) was associated with the prediction of functional outcomes in AIS patients.

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Quantitative insights into stroke recovery utilizing delayed vessel ratio from color-coded multiphase computed tomography angiography

Predicting recovery is totally fucking useless. DELIVER EXACT RECOVERY PROTOCOLS! I'd fire anyone doing prediction research, it's useless!

 Quantitative insights into stroke recovery utilizing delayed vessel ratio from color-coded multiphase computed tomography angiography

Yu Lin^1,2,3†, Xiaoxiao Zhang^2†, Zhen Xing¹, Xiefeng Yang¹, Qingwen Tong⁴, Shaomao Lv², Jinan Wang^2,3 and Dairong Cao^1,5,6,7*

¹Department of Radiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China

²Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Clinical Medicine of Fujian Medical University, Xiamen, China

³Xiamen Radiology Quality Control Center, Zhongshan Hospital Affiliated to Xiamen University, School of Clinical Medicine of Fujian Medical University, Xiamen, China

⁴Department of Health Examination, Xiamen Humanity Hospital Fujian Medical University, Xiamen, China

⁵Department of Radiology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital of Fujian Medical University, Fuzhou, China

⁶Fujian Provincial Key Laboratory of Precision Medicine for Cancer, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China

⁷Key Laboratory of Radiation Biology of Fujian Higher Education Institutions, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China

Edited by
Alan Wang, The University of Auckland, New Zealand

Reviewed by
Rodrigo Assar, University of Chile, Chile
Jihoon Kang, Seoul National University Bundang Hospital, Republic of Korea

*Correspondence
Dairong Cao, dairongcao@163.com

^†These authors have contributed equally to this work and share first authorship

Received 30 January 2025
Accepted 03 June 2025
Published 18 June 2025

Citation
Lin Y, Zhang X, Xing Z, Yang X, Tong Q, Lv S, Wang J and Cao D (2025) Quantitative insights into stroke recovery utilizing delayed vessel ratio from color-coded multiphase computed tomography angiography. Front. Neurol. 16:1568717. doi: 10.3389/fneur.2025.1568717

Background and objective: 

The color-coded multiphase computed tomography angiography (cmCTA) is an accredited technique that employs color-coding to visually depict the temporal dynamics of collateral blood flow in patients with acute ischemic stroke (AIS). This research aimed to assess the quantification of cmCTA in AIS patients for characterizing arterial and venous collateral flow, and predicting functional outcomes.

Methods: 

A retrospective study was performed on a consecutive cohort of AIS patients with large vessel occlusion who underwent cmCTA scan and reconstruction. Collateral ratio and delayed vessel ratio (DVR) were determined through semi-automatic delineation and calculation on the anterior cerebral artery regions and Alberta Stroke Program Early CT (ASPECT) Score regions of cmCTA maps. Deep venous outflow (DVO) and superficial venous outflow (SVO) scores were assessed using a 6-point scale. Logistic regression and propensity score were applied to confounding factors adjustment and model construction. Receiver operating characteristic curve, calibration curve, and decision curve analysis were utilized to evaluate the prediction model of functional independence and excellent recovery.

Results: 

Well-developed arterial collaterals as depicted by low DVR and adequate venous collaterals as indicated by high DVO or SVO were correlated with better outcomes (All p < 0.001). Adjusted DVR showed areas under the curve of 0.81–0.90 for predicting functional independence and excellent recovery. Adjusted DVO showed areas under the curve of 0.88 for predicting functional independence and excellent recovery. Each prediction model demonstrated good precision and net benefit.

Conclusion: 

The application of DVR and other parameters in cmCTA offers a quantitative perspective on the conventional ASPECT scoring scheme utilizing grayscale CT images. DVR from cmCTA may enhance pre-treatment collateral assessment and post-treatment outcome prediction in AIS, facilitating informed treatment decisions.

Predicting vessel recanalization in extracranial internal carotid artery dissection: a nomogram based on ultrasonography and clinical features

 Collaterals grew around my blocked right carotid artery 13 years post stroke. Now 6 years later I still haven't had another stroke. This research told me nothing, what is the objective identification of a high risk patient? I'd have everyone fired!

Predicting vessel recanalization in extracranial internal carotid artery dissection: a nomogram based on ultrasonography and clinical features

Xinchun Xu^1,2,3Yanhong Yan^1,2Yafeng Qu³Lianlian Zhang^1,2Pinjing Hui^1,2*

• ¹Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
• ²Department of Stroke Center, The First Affiliated Hospital of Soochow University, Suzhou, China
• ³Department of Ultrasound, The Affiliated Zhangjiagang Hospital of Soochow University, Suzhou, China

Background: Extracranial internal carotid artery dissection (EICAD) is a prominent factor in ischemic stroke in young patients, and vessel recanalization is correlated with stroke recurrence. We propose to determine the possible association between carotid duplex ultrasound (CDU) features, clinical factors, and vessel recanalization in EICAD patients.

Methods: In the current retrospective study, data from 202 patients diagnosed with EICAD by CDU and confirmed by computed tomography angiography (CTA) or high-resolution magnetic resonance imaging (HRMRI) were encompassed. Patients were randomized 7:3 into training cohort (n = 142) and validation cohort (n = 60). The least absolute shrinkage and selection operator (LASSO) regression analysis and multivariate logistic regression analysis were used to build a nomogram to predict recanalization. At last, we assessed the performance of the nomogram with an area under the receiver operating characteristic curve (AUC), calibration curve, decision curve analysis (DCA), and clinical impact curve (CIC).

Results: The nomogram included CDU features (intramural hematoma, Intraluminal thrombus, and stenosis degree) and age, with AUC values of 0.906 (95% CI: 0.857–0.946) and 0.903 (95% CI: 0.820–0.963) in the training cohort and the validation cohort, respectively. Using a probability cutoff of 0.5 derived from the Youden index, patients were stratified into high-risk (recanalization probability <50%) and low-risk groups (≥50%). DCA showed that the nomogram performed significantly better across various threshold probabilities, and CIC demonstrated that the nomogram offers superior net benefit across a broad range of threshold probabilities, indicating its significant predictive value.

Conclusion: A nomogram depended on CDU and clinical features could accurately predict(Then what is the prediction protocol? Didn't create one? You're fucking useless!) recanalization in EICAD patients. The nomogram may facilitate early identification of high-risk patients and personalized therapeutic strategies.

Introduction

Extracranial internal carotid artery dissection (EICAD) is a disorder characterized by the passage of blood via a rip in the arterial wall layers, resulting in the blood entering the space between these layers, causing the carotid wall to separate into two layers and interfering with blood flow, which can lead to secondary stenosis or aneurysmal dilatation (1). Carotid artery dissection (CAD) accounts for around 25% of strokes in young individuals, making it a significant factor in stroke occurrence among individuals in their youth and middle age (2). Therefore, the accurate diagnosis and effective treatment of carotid artery dissection, as well as the enhancement of patients’ prognosis, are of crucial in clinical practice. Digital subtraction angiography (DSA) has traditionally been considered the most reliable method for diagnosing EICAD. However, this technique is an invasive examination and cannot clearly show the morphology of arterial wall, so it has certain limitations in the clinical diagnosis and treatment process (3). In recent times, high-resolution magnetic resonance imaging (HRMRI) has been increasingly employed in clinical practice. It has a high detection rate for intramural hematoma and can clearly show the structure of the vessel wall. However, it is time-consuming (4). Carotid Doppler ultrasound (CDU) has emerged as a valuable diagnostic modality for the evaluation of EICAD. It offers several advantages over other imaging techniques, such as being non-invasive and cost-effective, and it can observe the lumen and artery wall of the extracranial internal carotid artery in real-time. Therefore, CDU is of great value in evaluating the variations in vascular wall structure of EICAD patients.

Previous studies have been conducted on the recanalization rate of CAD (5–7), while limited attention has been given to the influence factors of recanalization. Furthermore, the nomogram is progressively employed as a visual aid for the purpose of illness prevention. However, few studies have combined CDU characteristics and clinical factors to establish a nomogram to evaluate the recanalization of EICAD. We aim to combine CDU features and clinical factors to identify those factors that are significantly correlated to vessel recanalization and to establish a nomogram to forecast the recanalization probability.

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