Faizy Tobias Djamsched, Mlynash Michael, Kabiri Reza, Christensen Soren, Kuraitis Gabriella Marie, Mader Marius M, Flottmann Fabian, Broocks Gabriel, Lansberg Maarten G, Albers Gregory W, Marks Michael P, Fiehler Jens, Wintermark Max, Heit Jeremy J
From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany.
Neurology. 2022 Jun 6;98(23):e2296-e2306. doi: 10.1212/WNL.0000000000200340.
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 radiologic outcomes.
This was a multicenter retrospective cohort study of patients with acute stroke undergoing thrombectomy triage. CCC was determined by quantifying pial arterial collaterals, tissue-level collaterals, and venous outflow (VO). Pial arterial collaterals were determined by CT angiography; tissue-level collaterals were assessed on CT perfusion. VO was assessed on CT angiography using the cortical vein opacification score. Three groups were defined: CCC+ (good pial collaterals, tissue-level collaterals, and VO), CCC- (poor pial collaterals, tissue-level collaterals, and VO), and CCC (the remainder of the patients). Primary outcome was functional independence (modified Rankin Scale score 0-2) at 90 days. Secondary outcome was final infarct volume.
A total of 647 patients met inclusion criteria: 176 CCC+, 345 CCC, and 126 CCC-. Multivariable ordinal logistic regression showed that CCC+ predicted good functional outcomes (odds ratio [OR] 18.9 [95% CI 8-44.5]; < 0.001) compared with CCC- and CCC. CCC patients likely had better functional outcomes compared with CCC- patients (OR 2.5 [95% CI 1.2-5.4]; = 0.014). Quantile regression analysis (50th percentile) showed that CCC+ (β -78.5, 95% CI -96.0 to -61.1; < 0.001) and CCC (β -64.0, 95% CI -82.4 to -45.6; < 0.001) profiles were associated with considerably lower final infarct volumes compared with CCC- profiles.
Comprehensive assessment of the collateral blood flow cascade in patients with acute stroke is a strong predictor of clinical and radiologic outcomes in patients treated by thrombectomy.
在接受血栓切除术治疗的因大血管闭塞导致急性缺血性卒中的患者中，强大的脑侧支循环与良好预后相关。然而，侧支循环状态评估大多依赖单一影像学生物标志物，一种更全面的整体方法可能会在医学影像上对侧支循环灌注生物学提供更深入的见解。全面侧支循环定义为脑动脉血流通过脑组织并进入引流静脉。我们假设在动脉、组织和静脉水平对脑侧支循环级联（CCC）进行综合分析可预测临床和影像学结果。
这是一项对接受血栓切除术分流的急性卒中患者的多中心回顾性队列研究。通过量化软脑膜动脉侧支循环、组织水平侧支循环和静脉流出（VO）来确定CCC。软脑膜动脉侧支循环通过CT血管造影确定；组织水平侧支循环在CT灌注上进行评估。VO通过使用皮质静脉显影评分在CT血管造影上进行评估。定义了三组：CCC +（良好的软脑膜侧支循环、组织水平侧支循环和VO）、CCC -（不良的软脑膜侧支循环、组织水平侧支循环和VO）和CCC（其余患者）。主要结局是90天时的功能独立性（改良Rankin量表评分0 - 2）。次要结局是最终梗死体积。
共有647例患者符合纳入标准：176例CCC +、345例CCC和126例CCC -。多变量有序逻辑回归显示，与CCC -和CCC相比，CCC +预测良好的功能结局（优势比[OR] 18.9 [95% CI 8 - 44.5]；P < 0.001）。与CCC -患者相比，CCC患者可能有更好的功能结局（OR 2.5 [95% CI 1.2 - 5.4]；P = 0.014）。分位数回归分析（第50百分位数）显示，与CCC -曲线相比，CCC +（β -78.5，95% CI -96.0至 -61.1；P < 0.001）和CCC（β -64.0，95% CI -82.4至 -45.6；P < 0.001）曲线与最终梗死体积显著更低相关。
对急性卒中患者侧支循环血流级联进行综合评估是血栓切除术治疗患者临床和影像学结果的有力预测指标。
