Cortical Vein Opacification for Risk Stratification in Anterior Circulation Endovascular Thrombectomy

Hoffman, Haydn; Ziechmann, Robert; Swarnkar, Amar; Masoud, Hesham; Gould, Grahame

doi:10.1016/j.jstrokecerebrovasdis.2019.02.016

Cited by 36 publications

(53 citation statements)

References 20 publications

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“…12 Favorable VO reflects unhampered antegrade blood transit through the brain tissue and is presumed to be a strong predictor of robust cerebral tissue microperfusion. 14,[24][25][26][27] Our findings suggest that a comprehensive multiparametric assessment of collateral blood flow pathways may more accurately predict tissue survivability, infarct progression, and clinical outcomes in patients with AIS and LVO compared with single measure approaches, which adds to the results of previous studies. 7 Our findings further underscore the importance of a more holistic approach to determine collateral blood flow patterns in patients with acute stroke.…”

Section: Discussionsupporting

confidence: 52%

“…12,13 VO profiles were determined by the degree of contrast opacification within 3 major cortical veins as follows: 0, not visible; 1, moderate opacification; and 2, full opacification using the cortical vein opacification score determined in the vein of Labbé, sphenoparietal sinus, and superficial middle cerebral vein on single-phase CT angiography. 14 VO profiles were determined independently by 2 neuroradiologists (T.D.F., 8 years of experience; and J.J.H., 10 years of experience). Favorable VO was defined as a score of 3-6 and unfavorable VO was regarded a score of 0-2.…”

Section: Imaging Analysismentioning

confidence: 99%

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The Cerebral Collateral Cascade

et al. 2022

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Background and Purpose:Robust cerebral collaterals are associated with favorable outcomes in patients with acute ischemic stroke due to large vessel occlusion treated by thrombectomy. However, collateral status assessment mostly relies on single imaging biomarkers and a more comprehensive holistic approach may provide deeper insights into the biology of collateral perfusion on medical imaging. Comprehensive collateralization is defined as blood flow of cerebral arteries through the brain tissue and into draining veins. We hypothesized that a comprehensive analysis of the cerebral collateral cascade (CCC) on an arterial, tissue and venous level would predict clinical and radiological outcomes.Materials and Methods:Multicenter retrospective cohort study of acute stroke patients undergoing thrombectomy triage. CCC was determined by quantifying pial arterial collaterals, tissue-level collaterals, and venous outflow. Pial arterial collaterals were determined by CT angiography, tissue-level collaterals were assessed on CT perfusion. Venous outflow was assessed on CT angiography using the cortical vein opacification score. 3 groups were defined: CCC+ (good pial collaterals, tissue-level collaterals, and venous outflow), CCC- (poor pial collaterals, tissue-level collaterals, and venous outflow) and CCCmixed (remainder of patients). Primary outcome was functional independence (modified Rankin Scale: 0-2) at 90-days. Secondary outcome was final infarct volume.Results:647 patients met inclusion criteria: 176 CCC+, 345 CCC mixed and 126 CCC-. Multivariable ordinal logistic regression showed that CCC+ predicted good functional outcomes (OR=18.9 [95% CI 8-44.5]; p<0.001) compared to CCC- and CCCmixed patients. CCCmixed patients likely had better functional outcomes compared to CCC- patients (OR=2.5 [95% CI 1.2-5.4]; p=0.014). Quantile regression analysis (50th percentile) showed that CCC+ (β: -78.5, 95% CI -96.0- -61.1; p<0.001) and CCCmixed (β: -64.0, 95% CI -82.4- -45.6; p<0.001) profiles were associated with considerably lower final infarct volumes compared to CCC- profiles.Conclusion:Comprehensive assessment of the collateral blood flow cascade in acute stroke patients is a strong predictor of clinical and radiological outcomes in patients treated by thrombectomy.

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Section: Discussionsupporting

confidence: 52%

Section: Imaging Analysismentioning

confidence: 99%

The Cerebral Collateral Cascade

et al. 2022

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“…The inclusion of patients from two comprehensive stroke centers that routinely perform perfusion imaging may limit the generalizability of our results. Although only patients with complete opacification of the sigmoid sinuses were included in our study, venous opacification has been reported to be affected by the selected imaging protocol, including acquisition timing and rate of contrast injection [11]. Late bolus timing of CTA will likely show venous “contamination,” and too early bolus timing will emphasize arterial contrast with potential underestimation of venous opacification [28].…”

Section: Discussionmentioning

confidence: 99%

“…The COVES was used to quantify VO profiles. COVES determines the opacification of the vein of Labbé, sphenoparietal sinus, and superficial middle cerebral vein on CTA as 0, not visible; 1, moderate opacification; and 2, full opacification [11]. Favorable VO (VO+) was defined as a COVES of 3-6, and unfavorable VO (VO-) was defined as a COVES of 0-2.…”

Section: Imaging Analysismentioning

confidence: 99%

Distinct intra‐arterial clot localization affects tissue‐level collaterals and venous outflow profiles

Faizy

Kabiri

Christensen

et al. 2021

Euro J of Neurology

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Background and purpose Arterial clot localization affects collateral flow to ischemic brain in patients with acute ischemic stroke due to large vessel occlusion (AIS‐LVO). We determined the association between vessel occlusion locations, tissue‐level collaterals (TLC), and venous outflow (VO) profiles and their impact on good functional outcomes. Methods We conducted a multicenter retrospective cohort study of consecutive AIS‐LVO patients who underwent thrombectomy triage. Baseline computed tomographic angiography (CTA) was used to localize vessel occlusion, which was dichotomized into proximal vessel occlusion (PVO; internal carotid artery and proximal first segment of the middle cerebral artery [M1]) and distal vessel occlusion (DVO; distal M1 and M2), and to assess collateral scores. TLC were assessed on computed tomographic perfusion data using the hypoperfusion intensity ratio. VO was determined on baseline CTA by the cortical vein opacification score. Primary outcomes were favorable VO and TLC; secondary outcome was the modified Rankin Scale after 90 days. Results A total of 649 patients met inclusion criteria. Of these, 376 patients (58%) had a PVO and 273 patients (42%) had a DVO. Multivariate ordinal logistic regression showed that DVO predicted favorable TLC (odds ratio [OR] = 1.77, 95% confidence interval [CI] = 1.24–2.52, p = 0.002) and favorable VO (OR = 7.2, 95% CI = 5.2–11.9, p < 0.001). DVO (OR = 3.4, 95% CI = 2.1–5.6, p < 0.001), favorable VO (OR = 6.4, 95% CI = 3.8–10.6, p < 0.001), and favorable TLC (OR = 3.2, 95% CI = 2–5.3, p < 0.001), but not CTA collaterals (OR = 1.07, 95% CI = 0.60–1.91, p = 0.813), were predictors of good functional outcome. Conclusions DVO in AIS‐LVO patients correlates with favorable TLC and VO profiles, which are associated with good functional outcome.

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“…Tissue-level collateral (TLC) blood flow may be measured by CT or MR perfusion imaging, and TLC have been correlated with favourable long-term functional outcomes 12–15. Finally, collateral blood flow may also be measured by the robustness of venous outflow (VO) from ischaemic brain tissue, and favourable VO has been associated with favourable long-term functional outcomes 16–19…”

Section: Introductionmentioning

confidence: 99%

Favourable arterial, tissue-level and venous collaterals correlate with early neurological improvement after successful thrombectomy treatment of acute ischaemic stroke

Faizy

Mlynash

Kabiri

et al. 2022

J Neurol Neurosurg Psychiatry

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Background and purposeEarly neurological improvement (ENI) after thrombectomy is associated with better long-term outcomes in patients with acute ischaemic stroke due to large vessel occlusion (AIS-LVO). Whether cerebral collaterals influence the likelihood of ENI is poorly described. We hypothesised that favourable collateral perfusion at the arterial, tissue-level and venous outflow (VO) levels is associated with ENI after thrombectomy.Materials and methodsMulticentre retrospective study of patients with AIS-LVO treated by thrombectomy. Tissue-level collaterals (TLC) were measured on cerebral perfusion studies by the hypoperfusion intensity ratio. VO and pial arterial collaterals (PAC) were determined by the Cortical Vein Opacification Score and the modified Tan scale on CT angiography, respectively. ENI was defined as improvement of ≥8 points or a National Institutes of Health Stroke Scale score of 0 hour or 1 24 hours after treatment. Multivariable regression analyses were used to determine the association of collateral biomarkers with ENI and good functional outcomes (modified Rankin Scale 0–2).Results646 patients met inclusion criteria. Favourable PAC (OR: 1.9, CI 1.2 to 3.1; p=0.01), favourable VO (OR: 3.3, CI 2.1 to 5.1; p<0.001) and successful reperfusion (OR: 3.1, CI 1.7 to 5.8; p<0.001) were associated with ENI, but favourable TLC were not (p=0.431). Good functional outcomes at 90-days were associated with favourable TLC (OR: 2.2, CI 1.4 to 3.6; p=0.001), VO (OR: 5.7, CI 3.5 to 9.3; p<0.001) and ENI (OR: 5.7, CI 3.3 to 9.8; p<0.001), but not PAC status (p=0.647).ConclusionFavourable PAC and VO were associated with ENI after thrombectomy. Favourable TLC predicted longer term functional recovery after thrombectomy, but the impact of TLC on ENI is strongly dependent on vessel reperfusion.

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Cortical Vein Opacification for Risk Stratification in Anterior Circulation Endovascular Thrombectomy

Cited by 36 publications

References 20 publications

The Cerebral Collateral Cascade

The Cerebral Collateral Cascade

Distinct intra‐arterial clot localization affects tissue‐level collaterals and venous outflow profiles

Favourable arterial, tissue-level and venous collaterals correlate with early neurological improvement after successful thrombectomy treatment of acute ischaemic stroke

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