Appearance of medullary and cortical veins on multiphase CT-angiography in patients with acute ischemic stroke

ElsevierVolume 224, January 2023, 107523Clinical Neurology and NeurosurgeryAuthor links open overlay panelAbstractObjective

We sought to determine if interhemispheric asymmetry of cortical and medullary veins evaluated on CT angiography can provide a more accurate prediction of outcome in patients with acute ischemic stroke when compared to hemispheric asymmetry of cortical or medullary vein drainage alone.

Methods

We retrospectively reviewed a database of patients with anterior circulation distribution acute ischemic stroke, who were evaluated by multiphase CTA. Cortical veins were evaluated using the adopted Prognostic Evaluation based on Cortical vein score difference In Stroke (PRECISE) system. Medullary veins were evaluated by the presence of asymmetry determined by 5 or more medullary veins visualized in one hemisphere as compared to the contralateral. Good clinical outcome was defined as a Modified Rankin Scale of 0–2 at 90 days.

Results

64 patients were included. The adopted PRECISE score was associated with a good clinical outcome in patients with AIS (OR=3.29; 95 % CI: 1.16 – 9.30; p = 0.023) and had a stronger association with clinical outcome (AUC=0.644) as compared to the asymmetry of MV (AUC=0.609). In a multivariable logistic regression model, combined medullary and cortical vein asymmetry were independently associated with clinical outcomes (AUC=0.721).

Conclusion

Combined cortical and medullary vein interhemispheric asymmetry is a stronger predictor of clinical outcome in acute ischemic stroke compared to cortical or medullary vein asymmetry alone.

Introduction

The role of neuroimaging in acute ischemic stroke (AIS) has become increasingly important with the advancements in treatment options, in particular, endovascular therapy. The discovery of neuroimaging biomarkers to help with treatment selection as well as prognostication are needed. One particular neuroimaging biomarker that may be useful for prognosis and treatment selection is cerebral venous drainage [1], [2], [3], [4], [5].

Anatomically, cerebral veins can be divided into cortical (CV) and medullary (MV) veins. Cortical and medullary veins have extensive anastomotic overlap, potentially allowing for outflow redistribution in the setting of disrupted blood outflow [6], [7]. Prior studies have demonstrated an association between delayed cortical venous drainage on CT-angiography images (CTA) in patients with AIS and s clinical outcomes [1], [2], [3], [8]. More recently, one study has demonstrated that medullary veins can also be assessed on multiphase CTA and a reduction in visualized MV ipsilateral to the AIS being associated with a poor clinical outcome [4].

In this study, we sought to determine if the combination of reduced CV and MV drainage observed on multiphase CTA has greater prognostic value in patients with AIS in MCA distribution, compared to either reduced CV or MV drainage alone.

Section snippetsPatients

We retrospectively reviewed patients presenting with an anterior circulation distribution acute ischemic stroke between 09/01/18–11/16/19 at a single academic comprehensive stroke center in the United States. Local IRB approval was obtained prior to initiation of the study.

Patients were included if they met the following clinical and imaging criteria: ≥ 18 years old, clinical symptoms consistent with acute stroke, presentation to the emergency room within 12 h of last known well, imaging

Patient characteristics

A total of 84 patients with anterior circulation distribution AIS were identified in our institutional stroke database, of which 64 met all clinical inclusion and exclusion criteria. Mean age was 66.2 years ± 15.7, 40.6 % were female, median baseline NIHSS score was 13 (IQR 12), median Alberta Stroke Program Early CT Score (ASPECTS) at first available CT was 9 (IQR 3), median time from stroke symptom onset to baseline CT was 3 h (IQR 5.5 h). There were 38/64 (59.4 %) who had right cerebral

Discussion

In this study we observed 1) CV status, measured by adopted PRECISE score, is associated with clinical outcome in patients with AIS independently from MV status, and 2) combined CV and MV status is a stronger predictor of clinical outcome compared to CV or MV individually.

The prior studies have shown that cortical venous status assessed on CTA can act as a surrogate of cerebral perfusion in patients with MCA distribution AIS [1], [2], [3]. Similar to what has been published, our study

Conclusion

Although both MV and CV status are independently associated with clinical outcome in patients with AIS, CV status, appears to have a greater association with clinical outcome compared to MV status. Additionally, combined MV and CV status appear to be a stronger predictor of a clinical outcome.

CRediT authorship contribution statement

M. Reza Taheri: Conceptualization, Methodology, Investigation, Resources, Data curation, Writing – review & editing, Visualization, Project administration, Supervision. Aleksandr A. Drozdov: Conceptualization, Methodology, Investigation, Writing – original draft, Visualization. Andrew D. Sparks: Software, Formal analysis. Christopher R. Leon Guerrero: Investigation, Resources, Data curation, Writing – review & editing, Supervision. Mudit Arora: Data curation.

Conflict of interest

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors declare no conflict of interest.

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