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Increased volumes of mildly elevated capillary transit time heterogeneity positively predict favorable outcome and negatively predict intracranial hemorrhage in acute ischemic stroke with large vessel occlusion

  • Magnetic Resonance
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Abstract

Objectives

In patients with acute ischemic stroke, we aimed to investigate whether microvascular changes, as indexed by capillary transit time heterogeneity (CTH), contribute to the decline of the chance for favorable outcome over time and whether they are a predictor of an intracranial hemorrhage (ICH).

Methods

We retrospectively calculated CTH maps for 131 consecutive patients with acute ischemic stroke due to large vessel occlusion of the anterior circulation who had a relevant MRI PWI-DWI mismatch and were treated with endovascular thrombectomy (ET). Multivariable logistic regressions were conducted with favorable outcome (mRS ≤ 2 after 3 months) and occurrence of an ICH as dependent variables and the volume of mildly elevated CTH as independent variable adjusted for age, successful recanalization, hypertension, diabetes, atrial fibrillation, NIHSS score on admission, DWI lesion volume, and symptom-onset-to-treatment time (OTT).

Results

A larger volume of mildly elevated CTH was a positive predictor of favorable outcome (OR 1.17; 1.03–1.33; p = 0.019) and a negative predictor of ICH (OR 0.83; 0.73–0.96; p = 0.009). As expected, successful recanalization (OR 5.54; 1.8–17; p = 0.003), low NIHSS on admission (OR 0.9; 0.82–1.00; p = 0.045), short OTT (OR 0.96; 0.94–0.99; p = 0.006), and low DWI volume (OR 0.68; 0.49–0.94; p = 0.021) were also predictors of favorable outcome, whereas other negative predictors of ICH were atrial fibrillation (OR 2.69; 1.10–6.57; p = 0.030), high NIHSS score on admission (OR 1.10 (1.01–1.19); p = 0.030), and large DWI volume (OR 1.51; 1.17–1.19; p = 0.002).

Conclusion

An increased volume of mildly elevated CTH is a positive predictor of favorable outcome and a negative predictor for ICH in patients with acute ischemic stroke and mismatch undergoing ET.

Key Points

• The classification of potentially salvageable tissue and infarct core based on traditional net perfusion parameters (as Tmax or CBF) does not account for the microvascular distribution of blood.

• However, the microvascular distribution of blood, as indexed by the capillary transit time heterogeneity (CTH), directly affects the availability of oxygen within the hypoperfused tissue and should therefore be respected in acute ischemic stroke imaging.

• In our study, mildly elevated CTH is found to be a positive predictor for a favorable clinical outcome and a negative predictor for the occurrence of an intracranial hemorrhage in patients with acute ischemic stroke and homogenous mismatch who underwent ET.

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Abbreviations

CBF:

Cerebral blood flow

CBV:

Cerebral blood volume

CTH:

Capillary transit time heterogeneity

ET:

Endovascular thrombectomy

ICA:

Internal carotid artery

LVO:

Large vessel occlusion

MCA:

Middle cerebral artery

mRS:

Modified Rankin scale

MTT:

Mean transit time

NECT:

Non-enhanced CT imaging

NIHSS:

National Institute of Health Stroke Scale

OEF:

Oxygen extraction fraction

OTT:

Symptom-onset-to-treatment time

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Funding

The authors state that this work has not received any funding.

Author information

Authors and Affiliations

  1. Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany

    A. Potreck, J. Pfaff, M. Bendszus & S. Mundiyanapurath

  2. Department of Neurology, University Hospital Heidelberg, INF 400, 69120, Heidelberg, Germany

    S. Loebel & S. Mundiyanapurath

  3. Center of Functionally Integrative Neuroscience and MINDLab, Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark

    L. Østergaard & K. Mouridsen

  4. Department of Neuroradiology, Aarhus University Hospital, Aarhus, Denmark

    L. Østergaard

  5. Department of Radiology and Neuroradiology, University Hospital Essen, Essen, Germany

    A. Radbruch

Authors
  1. A. Potreck
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  2. S. Loebel
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  3. J. Pfaff
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  4. L. Østergaard
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  5. K. Mouridsen
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  6. A. Radbruch
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  7. M. Bendszus
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  8. S. Mundiyanapurath
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Corresponding author

Correspondence to S. Mundiyanapurath.

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Guarantor

The scientific guarantor of this publication is S. Mundiyanapurath.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors has significant statistical expertise.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.

Study subjects or cohorts overlap

The study population differs by only eight patients (in whom PWI quality was not sufficient for CTH analysis) from the cohort in a preceding work by Mundiyanapurath et al [7]. While this preceding work concentrated on the effect of perfusion-diffusion mismatch early or late after symptom onset, we now investigated the role of the perfusion index CTH in regard to the prediction of a favorable outcome and the occurrence of an intracranial hemorrhage after endovascular thrombectomy.

Methodology

• retrospective

• diagnostic study

• performed at one institution

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Potreck, A., Loebel, S., Pfaff, J. et al. Increased volumes of mildly elevated capillary transit time heterogeneity positively predict favorable outcome and negatively predict intracranial hemorrhage in acute ischemic stroke with large vessel occlusion. Eur Radiol 29, 3523–3532 (2019). https://doi.org/10.1007/s00330-019-06064-4

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  • DOI: https://doi.org/10.1007/s00330-019-06064-4

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