Assessment of Arterial Collateralization and Its Relevance to Intra-arterial Therapy for Acute Ischemic Stroke

Ramaiah, Siva Seeta; Mitchell, Peter; Dowling, Richard; Yan, Bernard

doi:10.1016/j.jstrokecerebrovasdis.2013.03.012

Cited by 11 publications

(7 citation statements)

References 60 publications

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“…We used the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the with abundant collateral flow have better clinical outcomes and smaller infarct volumes after stroke (9)(10)(11)(12)(13). Because of this, collateral flow has been implemented as a patient selection method in the Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times, or ESCAPE, trial, with the assumption that patients with poor collateral vessels would show minimal benefit from treatment (3).…”

Section: Study Design and Participantsmentioning

confidence: 99%

Absence of Cortical Vein Opacification Is Associated with Lack of Intra-arterial Therapy Benefit in Stroke

Jansen

Vuuren

Zwam³

et al. 2018

Radiology

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Purpose To assess the degree of cortical vein opacification in patients with internal carotid artery or middle cerebral artery (MCA) stroke and to evaluate the relationship with treatment benefit from intra-arterial therapy (IAT). Materials and Methods Written informed consent was obtained from all patients in the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands. From the trial's database, all patients (recruited from December 2010 until March 2014) with baseline computed tomographic (CT) angiograms were retrospectively included. Enhancement of the vein of Labbé, sphenoparietal sinus, and superficial middle cerebral vein was graded by one neuroradiologist, as follows: 0, not visible; 1, moderate opacification; and 2, full opacification. The sum for the ipsilateral hemisphere was calculated, resulting in the cortical vein opacification score (COVES) (range, 0-6). Primary outcome was the modified Rankin Scale score at 90 days. Association with treatment according to full cortical vein score and different dichotomized cutoff points was estimated with ordinal logistic regression. Interobserver agreement was assessed by two separate observers who reviewed 100 studies each. Results In total, 397 patients were analyzed. Interaction of the cortical vein score with treatment was significant (P = .044) when dichotomized COVES was 0 versus more than 0. The adjusted odds ratio for shift toward better functional outcome was 1.0 (95% confidence interval [CI]: 0.5, 2.0) for a COVES of 0 (n = 123) and 2.2 (95% CI: 1.6, 4.1) for a COVES greater than 0 (n = 274). The multirater κ value was 0.73. Conclusion In this study, patients with acute middle cerebral artery stroke with absence of cortical vein opacification in the affected hemisphere (COVES = 0) appeared to have no benefit from IAT, whereas patients with venous opacification (COVES >0) were shown to benefit from IAT. RSNA, 2017 Clinical trial registration nos. NTR(1804) and ISRCTN10888758 Online supplemental material is available for this article.

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Section: Study Design and Participantsmentioning

confidence: 99%

Absence of Cortical Vein Opacification Is Associated with Lack of Intra-arterial Therapy Benefit in Stroke

Jansen

Vuuren

Zwam³

et al. 2018

Radiology

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“…Good collaterals are associated with smaller infarct volumes on follow-up imaging and improved clinical outcomes after both intravenous thrombolysis and IAT. 12,[14][15][16][17][18] Other IAT studies used advanced neuroimaging criteria to select patients for inclusion. [6][7][8][9] These selection regimens were used because minimal treatment effect was assumed by the investigators in patients not fulfilling these neuroimaging inclusion criteria.…”

Section: Berkhemer Et Al Collaterals and Intra-arterial Treatment Effmentioning

confidence: 99%

Collateral Status on Baseline Computed Tomographic Angiography and Intra-Arterial Treatment Effect in Patients With Proximal Anterior Circulation Stroke

Berkhemer

Jansen

Beumer

et al. 2016

Stroke

243

180

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Background and Purpose— Recent randomized trials have proven the benefit of intra-arterial treatment (IAT) with retrievable stents in acute ischemic stroke. Patients with poor or absent collaterals (preexistent anastomoses to maintain blood flow in case of a primary vessel occlusion) may gain less clinical benefit from IAT. In this post hoc analysis, we aimed to assess whether the effect of IAT was modified by collateral status on baseline computed tomographic angiography in the Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands (MR CLEAN). Methods— MR CLEAN was a multicenter, randomized trial of IAT versus no IAT. Primary outcome was the modified Rankin Scale at 90 days. The primary effect parameter was the adjusted common odds ratio for a shift in direction of a better outcome on the modified Rankin Scale. Collaterals were graded from 0 (absent) to 3 (good). We used multivariable ordinal logistic regression analysis with interaction terms to estimate treatment effect modification by collateral status. Results— We found a significant modification of treatment effect by collaterals ( P =0.038). The strongest benefit (adjusted common odds ratio 3.2 [95% confidence intervals 1.7–6.2]) was found in patients with good collaterals (grade 3). The adjusted common odds ratio was 1.6 [95% confidence intervals 1.0–2.7] for moderate collaterals (grade 2), 1.2 [95% confidence intervals 0.7–2.3] for poor collaterals (grade 1), and 1.0 [95% confidence intervals 0.1–8.7] for patients with absent collaterals (grade 0). Conclusions— In MR CLEAN, baseline computed tomographic angiography collateral status modified the treatment effect. The benefit of IAT was greatest in patients with good collaterals on baseline computed tomographic angiography. Treatment benefit appeared less and may be absent in patients with absent or poor collaterals. Clinical Trial Registration— URL: http://www.trialregister.nl and http://www.controlled-trials.com . Unique identifier: (NTR)1804 and ISRCTN10888758, respectively.

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“…The connection between leptomeningeal collateral flow (LMF) and survival of brain parenchyma during acute ischemia has been confirmed in a large number of clinical studies [1][2][3][4][5][6][7][8][9] . Better collateral flow is associated with smaller infarct volumes, less hemorrhagic transformation, higher recanalization rates and better clinical outcome.…”

Section: Introductionmentioning

confidence: 99%

Real-Time Estimation of Core Infarct in Angiography Using Collateral Flow

Pop

Manisor²,

Wolff³

et al. 2016

Cerebrovasc Dis

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Background and Purpose: In order to attribute a diagnostic value to angiographic runs performed before revascularization, we aimed at developing a regional evaluation of leptomeningeal collateral flow that can be used to detect and predict infarction when performing stroke endovascular procedures. Materials and Methods: We evaluated all consecutive patients treated for occlusions in the anterior circulation in our center between 2009 and 2013, with MRI imaging performed before the endovascular procedure. Two readers performed an evaluation of collateral circulation in 5 cortical regions based on the vascular anatomy. Regional scores were correlated with the presence of infarction in the same cortical sector on pretreatment and follow-up imaging. Global collateral scores for each patient were correlated with infarct volumes. Results: In 89 patients with 408 cortical regions, we found a significant correlation between the degree of zonal collateral flow and the absence of infarction in the same zone on pretreatment imaging. In a subgroup of 37 recanalized patients (Thrombolysis in Cerebral Infarction scale 3) with 173 cortical zones, retrograde collateral flow to the proximal M4 segment predicted the absence of infarction within the same zone on follow-up imaging (positive predictive value 88.7%). We found good inter-rater agreement for the presence of collateral flow to the M4 proximal segment or further - k = 0.77 (p = 0.05, 95% CI 0.66-0.88). Global collateral scores correlated with infarct volume on initial imaging; all patients with scores ≥4 had infarct volumes ≤70 ml, whereas all patients with global collateral scores ≤1 had infarct volumes ≥70 ml. Conclusion: Anatomic collateral flow evaluation using the angiographic runs performed during stroke endovascular procedures can provide a real-time estimation of the volume and location of core infarct. For each cortical region, good collateral flow is associated with the absence of infarct on pre-treatment imaging, and is predictive of the absence of infarct on follow-up imaging in recanalized patients.

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Assessment of Arterial Collateralization and Its Relevance to Intra-arterial Therapy for Acute Ischemic Stroke

Cited by 11 publications

References 60 publications

Absence of Cortical Vein Opacification Is Associated with Lack of Intra-arterial Therapy Benefit in Stroke

Absence of Cortical Vein Opacification Is Associated with Lack of Intra-arterial Therapy Benefit in Stroke

Collateral Status on Baseline Computed Tomographic Angiography and Intra-Arterial Treatment Effect in Patients With Proximal Anterior Circulation Stroke

Real-Time Estimation of Core Infarct in Angiography Using Collateral Flow

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