Computed Tomography Angiography Collateral Profile Is Directly Linked to Early Edema Progression Rate in Acute Ischemic Stroke

Abstract

Background and Purpose— Poor collateral flow is associated with poor clinical outcome in acute ischemic stroke and may indicate futile recanalization after successful thrombectomy. Pronounced early formation of cerebral ischemic edema may be the link between poor collateral status and declined functional outcome, but this relationship has not been investigated yet. We hypothesized that collateral status is associated with early lesion water uptake as quantitative marker for edema progression. Methods— One hundred seventy-six patients with middle cerebral artery stroke who underwent mechanical thrombectomy were analyzed. Status of cerebral collateral circulation (collaterals status [CS]) was derived using an established 5-point scoring system in admission computed tomography angiography, and good collaterals were defined as CS 3 to 4. Ischemic brain edema dynamics were quantified using early edema progression rate (EPR). EPR was derived from quantitative lesion water uptake in admission computed tomography divided by time from symptom onset to imaging. Good clinical outcome was defined as modified Rankin Scale score 0 to 2 after 90 days. Results— The median EPR was 1.4% per hour (interquartile range, 0.5–3.5%) in patients with good collaterals, which was lower than the median EPR in patients with poor collaterals of 5.8% per hour (interquartile range, 2.1–5.9%; P <0.0001). In multivariable regression analysis, lower CS was significantly and independently associated with higher EPR (1.6% EPR per 1-point CS; P =0.002). A higher EPR was associated with reduced likelihood of good clinical outcome: odds ratio 0.87; (95% CI, 0.76–0.99; P =0.03). Conclusions— Patients with poor CS had significantly higher EPR, which was associated with worse clinical outcome. These patients might benefit from adjuvant antiedematous treatment.

Absent Cortical Venous Filling Is Associated with Aggravated Brain Edema in Acute Ischemic Stroke

“…Previous studies showed that collateral filling is significantly associated with an early edema progression rate and plays a role in the development of MCE. 7,19 Our univariate analysis showed that patients with MCE had a significantly lower rate of good collateral filling than those without MCE. However, in the multivariate analysis, this factor could not predict NWU or the occurrence of MCE.…”

“…6 Recently, the arterial collateral status has been observed as it relates to the early edema progression rate. 7 However, the absence of cortical venous filling could potentially be a better indicator of aggravating brain edema than the arterial collateral status because the venous system is responsible for approximately 70% of the cerebral blood volume. 8 In a case series including 14 patients, cranial venous outflow abnormalities increased the rate of early fatal edema after MCA infarction.…”

Incomplete or failed thrombectomy in acute stroke patients with Alberta Stroke Program Early Computed Tomography Score 0–5 – how harmful is trying?

“…This finding suggests that patients with large early infarcts should be treated endovascularly rather than limit the treatment to medical options for avoiding possible thrombectomy-related complications. Furthermore, the risk of secondary intracerebral hemorrhage has always been a major concern in treating patients with large ischaemic cores, possibly resulting in a vicious cycle of increased intracranial pressure and swelling with consecutive fatal outcome [11,12]. No significant differences were observed on comparing the rates of hemorrhage treated medically only compared to failed or incomplete recanalization; however, there was a tendency towards higher overall rates of hemorrhage in patients receiving MT (3/71 vs. 12/98; P = 0.08) but the prespecified level of statistical significance was not reached, most probably due to the underpowered sample size of the study.…”

Net Water Uptake Calculated in Standardized and Blindly Outlined Regions of the Middle Cerebral Artery Territory Predicts the Development of Malignant Edema in Patients With Acute Large Hemispheric Infarction

“…There have been several studies exploring valid predictors of ME in LHI patients, such as the National Institutes of Health Stroke Scale (NIHSS), presence of hyperdense artery sign, a higher level of blood glucose, decreased level of consciousness, early infarct signs, intracranial cerebrospinal fluid volume, fluid balance variations, collateral circulation (10)(11)(12)(13)(14)(15)(16)(17).…”