Prolonged venous transit is associated with worse neurological recovery in successfully reperfused large vessel strokes

Janet Mei; Hamza Adel Salim; Dhairya A Lakhani; Licia Luna; Aneri Balar; Mona Shahriari; Nathan Z Hyson; Francis Deng; Adam A Dmytriw; Adrien Guenego; Vaibhav Vagal; Victor C Urrutia; Elisabeth B Marsh; Hanzhang Lu; Risheng Xu; Rich Leigh; Dylan Wolman; Gaurang Shah; Benjamin Pulli; Kambiz Nael; Gregory W Albers; Max Wintermark; Jeremy J Heit; Tobias D Faizy; Argye E Hillis; Raf Llinas; Vivek Yedavalli

doi:10.1002/acn3.52243

Prolonged venous transit is associated with worse neurological recovery in successfully reperfused large vessel strokes

Ann Clin Transl Neurol. 2024 Nov 11. doi: 10.1002/acn3.52243. Online ahead of print.

Authors

Janet Mei¹, Hamza Adel Salim^{1

2}, Dhairya A Lakhani¹, Licia Luna¹, Aneri Balar¹, Mona Shahriari¹, Nathan Z Hyson¹, Francis Deng¹, Adam A Dmytriw^{3

4

5}, Adrien Guenego⁶, Vaibhav Vagal⁷, Victor C Urrutia¹, Elisabeth B Marsh¹, Hanzhang Lu¹, Risheng Xu¹, Rich Leigh¹, Dylan Wolman⁸, Gaurang Shah⁹, Benjamin Pulli¹⁰, Kambiz Nael¹¹, Gregory W Albers¹⁰, Max Wintermark², Jeremy J Heit¹⁰, Tobias D Faizy¹², Argye E Hillis¹, Raf Llinas¹, Vivek Yedavalli¹

Affiliations

¹ Division of Neuroradiology, Department of Radiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA.
² Department of Neuroradiology, MD Anderson Medical Center, Houston, Texas, 77030, USA.
³ Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA.
⁴ Department of Medical Imaging, Neurovascular Centre, St. Michael's Hospital, Toronto, Ontario, Canada.
⁵ Department of Neurosurgery, Neurovascular Centre, St. Michael's Hospital, Toronto, Ontario, Canada.
⁶ Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium.
⁷ Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA.
⁸ Department of Radiology, Brown University, Providence, Rhode Island, USA.
⁹ Department of Radiology, Division of Neuroradiology, University of Michigan, Ann Arbor, Michigan, USA.
¹⁰ Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, California, USA.
¹¹ Department of Radiology & Biomedical Imaging, University of California, San Francisco, California, USA.
¹² Department of Radiology, Neuroendovascular Program, University Medical Center, Münster, Germany.

PMID: 39529443
DOI: 10.1002/acn3.52243

Abstract

Objective: Venous outflow (VO) impairment predicts unfavorable outcomes in patients with acute ischemic stroke caused by large vessel occlusion (AIS-LVO). Prolonged venous transit (PVT), a visual qualitative VO marker on CT perfusion (CTP) time to maximum (Tmax) maps, has been associated with unfavorable 90-day functional outcomes despite successful reperfusion. This study investigates the association between PVT and percent change on the National Institutes of Health Stroke Scale (NIHSS) among AIS-LVO patients who have undergone successful reperfusion.

Methods: We performed a retrospective analysis of prospectively collected data from consecutive adult AIS-LVO patients with successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b/2c/3). PVT+ was defined as Tmax ≥10 s in the superior sagittal sinus, torcula, or both. The primary outcome was continuous NIHSS percent change and dichotomous NIHSS percent change ≥70%. Regression analyses were performed to assess the effect of PVT on NIHSS percent change.

Results: In 119 patients of median (IQR) age 71 (63-81) years, the admission and discharge NIHSS scores were significantly higher in PVT+ patients compared to PVT- patients (17 [14-23.5] vs. 13 [9.5-19], p = 0.011, and 7.5 [4-12] vs. 3 [1-7], p < 0.001, respectively). After adjusting for age, sex, hypertension, diabetes, atrial fibrillation, administration of intravenous thrombolysis (IVT), Alberta Stroke Program Early CT Scores (ASPECTS), mTICI 2c and/or 3, Tmax >6 s volume, and hemorrhagic transformation, PVT+ was significantly associated with lower NIHSS percent change (B = -0.163, 95%CI -0.326 to -0.001, p = 0.049) and was less likely to achieve higher than 70% NIHSS improvement (OR = 0.331, 95% CI 0.127-0.863, p = 0.024).

Interpretation: PVT+ was significantly associated with reduced neurological improvement despite successful reperfusion in AIS-LVO patients, highlighting the critical role of VO impairment in short-term functional outcomes. These findings further validate PVT as a valuable adjunct imaging biomarker derived from CTP for assessing VO profiles in AIS-LVO.