Poor Internal Jugular Venous Outflow Is Associated with Poor Cortical Venous Outflow and Outcomes after Successful Endovascular Reperfusion Therapy

Abstract

Many patients show poor outcomes following endovascular reperfusion therapy (ERT), and poor cortical venous outflow is a risk factor for these poor outcomes. We investigated the association between the outflow of the internal jugular vein (IJV) and baseline cortical venous outflow and the outcomes after ERT. We retrospectively enrolled 78 patients diagnosed with an acute anterior circulation stroke and successful ERT. Poor IJV outflow on the affected side was defined as stenosis ≥50% or occlusion of ipsilateral IJV, and poor outflow of bilateral IJVs was defined as stenosis ≥50% or occlusion of both IJVs. Poor cortical venous outflow was defined as a cortical vein opacification score (COVES) of 0 on admission. Multivariate analysis showed that poor outflow of IJV on the affected side was an independent predictor for hemorrhagic transformation. The poor outflow of bilateral IJVs was an independent risk factor for poor clinical outcomes. These patients also had numerical trends of a higher incidence of symptomatic intracranial hemorrhage, midline shift >10 mm, and in-hospital mortality; however, statistical significance was not observed. Additionally, poor IJV outflow was an independent determinant of poor cortical venous outflow. For acute large vessel occlusion patients, poor IJV outflow is associated with poor baseline cortical venous outflow and outcomes after successful ERT.

Keywords: angiography; endovascular reperfusion therapy; prognosis; stroke; venous flow.

Figure 1

Flow chart. ERT: endovascular reperfusion therapy, mTICI: modified thrombolysis in cerebral ischemia, mRS: modified Rankin Scale, ICA: internal carotid artery, MCA: middle cerebral artery.

Figure 2

Association between imaging and clinical outcomes and the outflow of bilateral internal jugular veins (IJVs). Patients with a favorable outflow of bilateral IJVs were less likely to undergo hemorrhagic transformation (HT) (A), symptomatic intracranial hemorrhage (sICH) (B), severe midline shift (C), and poor functional outcome (D).

Figure 3

Representative images of the outflow profile of internal jugular veins and outcomes. An adult patient with an acute right middle cerebral artery occlusion (A) was admitted with a National Institutes of Health Stroke Scale score of 19. The patient received a thrombectomy for 6 h following stroke onset and achieved successful reperfusion (modified thrombolysis in cerebral infarction score = 3) (B). Three-dimensional reconstructed computed tomography (CT) venography shows that the right transverse sinus is larger than the left (C), and bilateral internal jugular veins are severely narrowed on the axial CT angiography (D,E, black arrows). On the non-contrast CT scan within 24 h after thrombectomy, a parenchymal hematoma, midline shift, and subfalcine hernia are present (F). Sixteen days after thrombectomy (15 days after decompressive craniectomy), there is an apparent cerebral edema (G). The patient’s modified Rankin Scale score at discharge is 5.