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FLAIR vascular hyperintensities predict functional outcome after endovascular thrombectomy in patients with large ischemic cores

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Abstract

Objectives

To establish whether collateral circulation was associated with functional outcome in stroke patients with large infarct size (Alberta Stroke Program Early CT Score [ASPECTS] ≤ 5) undergoing endovascular thrombectomy (EVT)

Methods

Consecutive patients with acute ischemic stroke due to large-vessel occlusion in the anterior circulation and an ASPECTS of ≤ 5 were analyzed. Quantification of collateral circulation was performed using a fluid-attenuated inversion recovery vascular hyperintensity (FVH)–ASPECTS rating system (score ranging from 0 [no FVH] to 7 [FVHs abutting all ASPECTS cortical areas]) by two independent neuroradiologists. Good functional outcome was defined by modified Rankin Scale (mRS) score of 0 to 3 at 3 months. We determined the association between FVH score and clinical outcome using multivariable regression analyses.

Results

A total of 139 patients (age, 63.1 ± 20.8 years; men, 51.8%) admitted between March 2012 and December 2017 were included. Good functional outcome (mRS 0–3) was observed in 65 (46.8%) patients, functional independence (mRS 0–2) was achieved in 43 (30.9%) patients, and 33 (23.7%) patients died at 90 days. The median FVH score was 4 (IQR, 3–5). FVH score was independently correlated with good outcome (adjusted OR = 1.41 [95% CI, 1.03–1.92]; p = 0.03 per 1-point increase).

Conclusions

In stroke patients with large-volume infarcts, good collaterals as measured by the FVH–ASPECTS rating system are associated with improved outcomes and may help select patients for reperfusion therapy.

Key Points

• Endovascular thrombectomy can allow almost 1 in 2 patients with large infarct cores to achieve good functional outcome (modified Rankin Scale [mRS] of 0–3) and 1 in 3 patients to regain functional independence (mRS 0–2) at 3 months.

• The extent of FVH score (as reflected by FLAIR vascular hyperintensity [FVH]–Alberta Stroke Program Early CT Score [ASPECTS] values) is associated with functional outcome at 3 months in this patient group.

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Abbreviations

AIS:

Acute ischemic stroke

ASPECTS:

Alberta Stroke Program Early CT Score

DWI:

Diffusion-weighted imaging

EVT:

Endovascular thrombectomy

FVH:

Fluid-attenuated inversion recovery vascular hyperintensity

LVO:

Large-vessel occlusion

mRS:

Modified Rankin Scale

mTICI:

Modified Treatment in Cerebral Infarction

NIHSS:

National Institutes of Health Stroke Scale

sICH:

Symptomatic intracranial hemorrhage

tPA:

Tissue plasminogen activator

References

  1. Goyal M, Menon BK, van Zwam WH et al (2016) Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 387:1723–1731. https://doi.org/10.1016/S0140-6736(16)00163-X

  2. Sarraj A, Hassan AE, Savitz S et al (2019) Outcomes of endovascular thrombectomy vs medical management alone in patients with large ischemic cores: a Secondary Analysis of the Optimizing Patient’s Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT) study. JAMA Neurol 76:1147–1156. https://doi.org/10.1001/jamaneurol.2019.2109

    Article  PubMed  PubMed Central  Google Scholar 

  3. Johannes K, Panagiotis C-I, Leonidas P et al (2019) Mechanical thrombectomy in ischemic stroke patients with Alberta Stroke Program Early Computed Tomography Score 0–5. Stroke 50:880–888. https://doi.org/10.1161/STROKEAHA.118.023465

    Article  Google Scholar 

  4. Cagnazzo F, Derraz I, Dargazanli C et al (2019) Mechanical thrombectomy in patients with acute ischemic stroke and ASPECTS ≤6: a meta-analysis. J Neurointerv Surg 2019-015237. https://doi.org/10.1136/neurintsurg-2019-015237

  5. Rocha M, Jovin TG (2017) Fast versus slow progressors of infarct growth in large vessel occlusion stroke: clinical and research implications. Stroke 48:2621–2627. https://doi.org/10.1161/STROKEAHA.117.017673

    Article  PubMed  Google Scholar 

  6. Campbell BCV, Majoie CBLM, Albers GW et al (2019) Penumbral imaging and functional outcome in patients with anterior circulation ischaemic stroke treated with endovascular thrombectomy versus medical therapy: a meta-analysis of individual patient-level data. Lancet Neurol 18:46–55. https://doi.org/10.1016/S1474-4422(18)30314-4

    Article  PubMed  Google Scholar 

  7. Tan Benjamin YQ, Kong W-Y, Prakash P et al (2016) Good intracranial collaterals trump poor ASPECTS (Alberta Stroke Program Early CT Score) for intravenous thrombolysis in anterior circulation acute ischemic stroke. Stroke 47:2292–2298. https://doi.org/10.1161/STROKEAHA.116.013879

    Article  CAS  PubMed  Google Scholar 

  8. Broocks G, Kniep H, Schramm P et al (2019) Patients with low Alberta Stroke Program Early CT Score (ASPECTS) but good collaterals benefit from endovascular recanalization. J Neurointerv Surg. https://doi.org/10.1136/neurintsurg-2019-015308

  9. Nave AH, Kufner A, Bücke P et al (2018) Hyperintense vessels, collateralization, and functional outcome in patients with stroke receiving endovascular treatment. Stroke 49:675–681. https://doi.org/10.1161/STROKEAHA.117.019588

    Article  PubMed  Google Scholar 

  10. Liu D, Scalzo F, Rao NM et al (2016) Fluid-attenuated inversion recovery vascular hyperintensity topography, novel imaging marker for revascularization in middle cerebral artery occlusion. Stroke 47:2763–2769. https://doi.org/10.1161/STROKEAHA.116.013953

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Legrand L, Tisserand M, Turc G et al (2016) Fluid-attenuated inversion recovery vascular hyperintensities–diffusion-weighted imaging mismatch identifies acute stroke patients most likely to benefit from recanalization. Stroke 47:424–427. https://doi.org/10.1161/STROKEAHA.115.010999

    Article  PubMed  Google Scholar 

  12. Derraz I, Pou M, Labreuche J et al (2021) Clot burden score and collateral status and their impact on functional outcome in acute ischemic stroke. AJNR Am J Neuroradiol 42:42–48. https://doi.org/10.3174/ajnr.A6865

  13. Derraz I, Ahmed R, Benali A et al (2021) FLAIR vascular hyperintensities and functional outcome in nonagenarians with anterior circulation large-vessel ischemic stroke treated with endovascular thrombectomy. Eur Radiol. https://doi.org/10.1007/s00330-021-07866-1

  14. Panni P, Gory B, Xie Y et al (2019) Acute stroke with large ischemic core treated by thrombectomy. Stroke 50:1164–1171. https://doi.org/10.1161/STROKEAHA.118.024295

    Article  PubMed  Google Scholar 

  15. Rangaraju S, Haussen D, Nogueira RG et al (2017) Comparison of 3-month stroke disability and quality of life across modified Rankin Scale categories. Interv Neurol 6:36–41. https://doi.org/10.1159/000452634

    Article  PubMed  Google Scholar 

  16. Brown DL, Johnston KC, Wagner DP, Clarke HE (2004) Predicting major neurological improvement with intravenous recombinant tissue plasminogen activator treatment of stroke. Stroke 35:147–150. https://doi.org/10.1161/01.STR.0000105396.93273.72

    Article  CAS  PubMed  Google Scholar 

  17. Berger C, Fiorelli M, Steiner T et al (2001) Hemorrhagic transformation of ischemic brain tissue: asymptomatic or symptomatic? Stroke 32:1330–1335. https://doi.org/10.1161/01.STR.32.6.1330

    Article  CAS  PubMed  Google Scholar 

  18. Broocks G, Hanning U, Flottmann F et al (2019) Clinical benefit of thrombectomy in stroke patients with low ASPECTS is mediated by oedema reduction. Brain J Neurol 142:1399–1407. https://doi.org/10.1093/brain/awz057

    Article  Google Scholar 

  19. Román LS, Menon BK, Blasco J et al (2018) Imaging features and safety and efficacy of endovascular stroke treatment: a meta-analysis of individual patient-level data. Lancet Neurol 17:895–904. https://doi.org/10.1016/S1474-4422(18)30242-4

    Article  PubMed  Google Scholar 

  20. Albers GW (2018) Endovascular thrombectomy in patients with large infarctions: reasons for restraint. Lancet Neurol 17:836–837. https://doi.org/10.1016/S1474-4422(18)30273-4

    Article  PubMed  Google Scholar 

  21. Farzin B, Fahed R, Guilbert F et al (2016) Early CT changes in patients admitted for thrombectomy: intrarater and interrater agreement. Neurology 87:249–256. https://doi.org/10.1212/WNL.0000000000002860

    Article  PubMed  PubMed Central  Google Scholar 

  22. Fahed R, Maacha MB, Ducroux C et al (2018) Agreement between core laboratory and study investigators for imaging scores in a thrombectomy trial. J Neurointerv Surg 10:e30–e30. https://doi.org/10.1136/neurintsurg-2018-013867

  23. Rebello LC, Bouslama M, Haussen DC et al (2017) Endovascular treatment for patients with acute stroke who have a large ischemic core and large mismatch imaging profile. JAMA Neurol 74:34–40. https://doi.org/10.1001/jamaneurol.2016.3954

    Article  PubMed  Google Scholar 

  24. Qazi EM, Sohn SI, Mishra S et al (2015) Thrombus characteristics are related to collaterals and angioarchitecture in acute stroke. Can J Neurol Sci 42:381–388. https://doi.org/10.1017/cjn.2015.291

    Article  PubMed  Google Scholar 

  25. Dutra BG, Tolhuisen ML, Alves Heitor CBR et al (2019) Thrombus imaging characteristics and outcomes in acute ischemic stroke patients undergoing endovascular treatment. Stroke 50:2057–2064. https://doi.org/10.1161/STROKEAHA.118.024247

    Article  PubMed  Google Scholar 

  26. Souza LCS, Yoo AJ, Chaudhry ZA et al (2012) Malignant CTA collateral profile is highly specific for large admission DWI infarct core and poor outcome in acute stroke. AJNR Am J Neuroradiol 33:1331–1336. https://doi.org/10.3174/ajnr.A2985

  27. Menon BK, Campbell Bruce CV, Christopher L, Mayank G (2015) Role of imaging in current acute ischemic stroke workflow for endovascular therapy. Stroke 46:1453–1461. https://doi.org/10.1161/STROKEAHA.115.009160

    Article  CAS  PubMed  Google Scholar 

  28. McDonough R, Elsayed S, Faizy TD et al (2020) Computed tomography-based triage of extensive baseline infarction: ASPECTS and collaterals versus perfusion imaging for outcome prediction. J Neurointerv Surg. https://doi.org/10.1136/neurintsurg-2020-016848

  29. Mair G, von Kummer R, Adami A et al (2015) Observer reliability of CT angiography in the assessment of acute ischaemic stroke: data from the Third International Stroke Trial. Neuroradiology 57:1–9. https://doi.org/10.1007/s00234-014-1441-0

    Article  PubMed  Google Scholar 

  30. Lu S, Zhang X, Xu X et al (2019) Comparison of CT angiography collaterals for predicting target perfusion profile and clinical outcome in patients with acute ischemic stroke. Eur Radiol 29:4922–4929. https://doi.org/10.1007/s00330-019-06027-9

    Article  PubMed  Google Scholar 

  31. Leslie-Mazwi TM, Hirsch JA, Falcone GJ et al (2016) Endovascular stroke treatment outcomes after patient selection based on magnetic resonance imaging and clinical criteria. JAMA Neurol 73:43–49. https://doi.org/10.1001/jamaneurol.2015.3000

    Article  PubMed  Google Scholar 

  32. Campbell Bruce CV, Søren C, Levi CR et al (2011) Cerebral blood flow is the optimal CT perfusion parameter for assessing infarct core. Stroke 42:3435–3440. https://doi.org/10.1161/STROKEAHA.111.618355

    Article  CAS  PubMed  Google Scholar 

  33. Copen WA, Yoo AJ, Rost NS et al (2017) In patients with suspected acute stroke, CT perfusion-based cerebral blood flow maps cannot substitute for DWI in measuring the ischemic core. PLoS One 12:e0188891. https://doi.org/10.1371/journal.pone.0188891

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Authors and Affiliations

  1. Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France

    Imad Derraz, Raed Ahmed, Cyril Dargazanli, Federico Cagnazzo, Gregory Gascou, Carlos Riquelme, Pierre-Henri Lefevre, Alain Bonafe & Vincent Costalat

  2. Department of Neurology, Hôpital Gui de Chauliac, Montpellier University Medical Center, Montpellier, France

    Isabelle Mourand, Nicolas Gaillard & Caroline Arquizan

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  1. Imad Derraz
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  2. Raed Ahmed
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Correspondence to Imad Derraz.

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The scientific guarantor of this publication is Vincent Costalat, MD, PhD.

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Derraz, I., Ahmed, R., Mourand, I. et al. FLAIR vascular hyperintensities predict functional outcome after endovascular thrombectomy in patients with large ischemic cores. Eur Radiol 32, 6136–6144 (2022). https://doi.org/10.1007/s00330-022-08683-w

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