Skip to main content

Advertisement

SpringerLink
Log in

Association Between Hypoperfusion Intensity Ratio and Postthrombectomy Malignant Brain Edema for Acute Ischemic Stroke

  • Original work
  • Published:
Neurocritical Care Aims and scope Submit manuscript

The Original Article was published on 26 December 2023

Abstract

Background

Malignant brain edema (MBE) is a life-threatening complication that can occur after mechanical thrombectomy (MT) for acute ischemic stroke. The hypoperfusion intensity ratio (HIR) reflects the tissue-level perfusion status within the ischemic territory. This study investigated the association between HIR and MBE occurrence after MT in patients with anterior circulation large artery occlusion.

Methods

We conducted a retrospective cohort study of patients who received MT at a comprehensive stroke center from February 2020 to June 2022. Using computed tomography perfusion, the HIR was derived from the ratio of tissue volume with a time to maximum (Tmax) > 10 s to that with a Tmax > 6 s. We dichotomized patients based on the occurrence of MBE following MT. The primary outcome, assessed using a multivariable logistic regression model, was the MBE occurrence post MT. The secondary outcome focused on favorable outcomes, defined as achieving a modified Rankin Scale score of 0–2 at 90 days.

Results

Of the 603 included patients, 90 (14.9%) developed MBE after MT. The median HIR exhibited a significantly higher value in the MBE group compared with the non-MBE group (0.5 vs. 0.3; P < 0.001). Multivariable logistic regression analysis indicated that a higher HIR (adjusted odds ratio [aOR] 8.98; 95% confidence interval [CI] 2.85–28.25; P < 0.001), baseline large infarction (Alberta Stroke Program Early Computed Tomography Score < 6; aOR 1.77; 95% CI 1.04–3.01; P = 0.035), internal carotid artery occlusion (aOR 1.80; 95% CI 1.07–3.01; P = 0.028), and unsuccessful recanalization (aOR 8.45; 95% CI 4.75–15.03; P < 0.001) were independently associated with MBE post MT. Among those with successful recanalization, a higher HIR (P = 0.017) and baseline large infarction (P = 0.032) remained as predictors of MBE occurrence. Furthermore, a higher HIR (P = 0.001) and the occurrence of MBE (P < 0.001) both correlated with reduced odds of achieving favorable outcomes.

Conclusions

The presence of a higher HIR on pretreatment perfusion imaging serves as a robust predictor for MBE occurrence after MT, irrespective of successful recanalization.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387(10029):1723–31.

    Article  PubMed  Google Scholar 

  2. Jovin TG, Nogueira RG, Lansberg MG, et al. Thrombectomy for anterior circulation stroke beyond 6 h from time last known well (AURORA): a systematic review and individual patient data meta-analysis. Lancet. 2022;399(10321):249–58.

    Article  PubMed  Google Scholar 

  3. Huo X, Ma G, Tong X, et al. Trial of endovascular therapy for acute ischemic stroke with large infarct. N Engl J Med. 2023;388(14):1272–83.

    Article  CAS  PubMed  Google Scholar 

  4. Yoshimura S, Sakai N, Yamagami H, et al. Endovascular therapy for acute stroke with a large ischemic region. N Engl J Med. 2022;386(14):1303–13.

    Article  PubMed  Google Scholar 

  5. Sarraj A, Hassan AE, Abraham MG, et al. Trial of endovascular thrombectomy for large ischemic strokes. N Engl J Med. 2023;388(14):1259–71.

    Article  PubMed  Google Scholar 

  6. Vahedi K, Hofmeijer J, Juettler E, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol. 2007;6(3):215–22.

    Article  PubMed  Google Scholar 

  7. Huang X, Chen C, Wang H, Cai Q, Li Z, Xu J, Yuan L, Xu X, Yang Q, Zhou Z, Liu X. The ACORNS grading scale: a novel tool for the prediction of malignant brain edema after endovascular thrombectomy. J Neurointerventional Surg. 2023;15(e2):e190–7.

    Article  Google Scholar 

  8. Guo W, Xu J, Zhao W, et al. A nomogram for predicting malignant cerebral artery infarction in the modern thrombectomy era. Front Neurol. 2022;13:934051.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Bernsen MLE, Kauw F, Martens JM, et al. Malignant infarction after endovascular treatment: Incidence and prediction. Int J Stroke. 2022;17(2):198–206.

    Article  PubMed  Google Scholar 

  10. Kimberly WT, Dutra BG, Boers AMM, et al. Association of reperfusion with brain edema in patients with acute ischemic stroke: a secondary analysis of the MR CLEAN trial. JAMA Neurol. 2018;75(4):453–61.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Maier IL, Behme D, Schnieder M, et al. Early computed tomography-based scores to predict decompressive hemicraniectomy after endovascular therapy in acute ischemic stroke. PLoS ONE. 2017;12(3):e0173737.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Huang X, Yang Q, Shi X, et al. Predictors of malignant brain edema after mechanical thrombectomy for acute ischemic stroke. J Neurointerv Surg. 2019;11(10):994–8.

    Article  PubMed  Google Scholar 

  13. Olivot JM, Mlynash M, Inoue M, et al. Hypoperfusion intensity ratio predicts infarct progression and functional outcome in the DEFUSE 2 Cohort. Stroke. 2014;45(4):1018–23.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Guenego A, Fahed R, Albers GW, et al. Hypoperfusion intensity ratio correlates with angiographic collaterals in acute ischaemic stroke with M1 occlusion. Eur J Neurol. 2020;27(5):864–70.

    Article  CAS  PubMed  Google Scholar 

  15. de Havenon A, Mlynash M, Kim-Tenser MA, et al. Results from DEFUSE 3: good collaterals are associated with reduced ischemic core growth but not neurologic outcome. Stroke. 2019;50(3):632–8.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Faizy TD, Kabiri R, Christensen S, et al. Perfusion imaging-based tissue-level collaterals predict ischemic lesion net water uptake in patients with acute ischemic stroke and large vessel occlusion. J Cereb Blood Flow Metab. 2021;41(8):2067–75.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Murray NM, Culbertson CJ, Wolman DN, Mlynash M, Lansberg MG. Hypoperfusion intensity ratio predicts malignant edema and functional outcome in large-vessel occlusive stroke with poor revascularization. Neurocrit Care. 2021;35(1):79–86.

    Article  CAS  PubMed  Google Scholar 

  18. Sarraj A, Kleinig TJ, Hassan AE, et al. Association of endovascular thrombectomy vs medical management with functional and safety outcomes in patients treated beyond 24 hours of last known well: The select late study. JAMA Neurol. 2023;80(2):172–82.

    Article  PubMed  Google Scholar 

  19. von Elm E, Altman DG, Egger M, et al. Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007;335(7624):806–8.

    Article  Google Scholar 

  20. von Kummer R, Broderick JP, Campbell BC, et al. The heidelberg bleeding classification: classification of bleeding events after ischemic stroke and reperfusion therapy. Stroke. 2015;46(10):2981–6.

    Article  Google Scholar 

  21. Higashida RT, Furlan AJ, Roberts H, et al. Trial design and reporting standards for intra-arterial cerebral thrombolysis for acute ischemic stroke. Stroke. 2003;34(8):e109–37.

    Article  PubMed  Google Scholar 

  22. Yang P, Zhang Y, Zhang L, et al. Endovascular thrombectomy with or without intravenous Alteplase in acute stroke. N Engl J Med. 2020;382(21):1981–93.

    Article  CAS  PubMed  Google Scholar 

  23. Wardlaw JM, Sellar R. A simple practical classification of cerebral infarcts on CT and its interobserver reliability. AJNR Am J Neuroradiol. 1994;15(10):1933–9.

    CAS  PubMed  PubMed Central  Google Scholar 

  24. Ong CJ, Gluckstein J, Laurido-Soto O, Yan Y, Dhar R, Lee JM. Enhanced detection of Edema in malignant anterior circulation stroke (EDEMA) score: a risk prediction tool. Stroke. 2017;48(7):1969–72.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Investigators RBT, Qiu Z, Li F, et al. Effect of Intravenous Tirofiban vs Placebo before endovascular Thrombectomy on functional outcomes in large vessel occlusion stroke: The RESCUE BT randomized clinical trial. JAMA. 2022;328(6):543–53.

    Article  Google Scholar 

  26. Haggenmüller B, Kreiser K, Sollmann N, Huber M, Vogele D, Schmidt SA, Beer M, Schmitz B, Ozpeynirci Y, Rosskopf J, Kloth C. Pictorial review on imaging findings in cerebral CTP in patients with acute stroke and its mimics: a primer for general radiologists. Diagnostics. 2023;13(3):447.

    Article  PubMed  PubMed Central  Google Scholar 

  27. van Horn N, Broocks G, Kabiri R, Kraemer MC, Christensen S, Mlynash M, Meyer L, Lansberg MG, Albers GW, Sporns P, Guenego A. Cerebral hypoperfusion intensity ratio is linked to progressive early edema formation. J Clin Med. 2022;11(9):2373.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Winkelmeier L, Heit JJ, Adusumilli G, et al. Hypoperfusion intensity ratio is correlated with the risk of parenchymal hematoma after endovascular stroke treatment. Stroke. 2023;54(1):135–43.

    Article  CAS  PubMed  Google Scholar 

  29. Guenego A, Mlynash M, Christensen S, et al. Hypoperfusion ratio predicts infarct growth during transfer for thrombectomy. Ann Neurol. 2018;84(4):616–20.

    Article  PubMed  Google Scholar 

  30. Faizy TD, Mlynash M, Kabiri R, Christensen S, Kuraitis G, Meyer L, Bechstein M, Van Horn N, Lansberg MG, Albers G, Fiehler J. Favourable arterial, tissue-level and venous collaterals correlate with early neurological improvement after successful thrombectomy treatment of acute ischaemic stroke. J Neurol Neurosurg Psychiatr. 2022;93(7):701–6.

    Article  Google Scholar 

  31. Maslias E, Nannoni S, Bartolini B, et al. Early-versus-Late endovascular stroke treatment: similar frequencies of Nonrevascularization and Postprocedural cerebrovascular complications in a large single-center cohort study. AJNR Am J Neuroradiol. 2023;44(6):687–92.

    Article  CAS  PubMed  Google Scholar 

  32. Albers GW, Marks MP, Kemp S, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med. 2018;378(8):708–18.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang, Beijing, 100020, China

    Wang Chen, Shuna Yang, Lei Yang & Wenli Hu

  2. Department of Neurology, Linyi People’s Hospital, Linyi, Shandong, China

    Xianjun Wang, Ji Liu, Mengen Wang & Zixiang Gong

Authors
  1. Wang Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Xianjun Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ji Liu
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Mengen Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Shuna Yang
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Lei Yang
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Zixiang Gong
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Wenli Hu
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Conceptualization: WH; data collection: WC, JL, MW, ZG; data analysis: WC, XW, SY, LY; drafting of the manuscript: WC; study supervision and organization: WH; revising of the manuscript: XW.

Corresponding author

Correspondence to Wenli Hu.

Ethics declarations

Conflicts of interest

There are no conflicts of interest to declare.

Ethical Approval

The local institutional ethics committees (Beijing Chaoyang Hospital and Linyi People’s Hospital) approved the study in accordance with the Declaration of Helsinki.

Informed Consent

The institutional review boards waived the need for informed consent for the retrospective study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is related to the commentary article available at https://doi.org/10.1007/s12028-023-01901-3.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 23 kb)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Chen, W., Wang, X., Liu, J. et al. Association Between Hypoperfusion Intensity Ratio and Postthrombectomy Malignant Brain Edema for Acute Ischemic Stroke. Neurocrit Care 40, 196–204 (2024). https://doi.org/10.1007/s12028-023-01900-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12028-023-01900-4

Keywords

Search

Navigation