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Multicenter Study
. 2024 Nov 22;16(12):1334-1340.
doi: 10.1136/jnis-2023-020921.

Brain edema growth after thrombectomy is associated with comprehensive collateral blood flow

Tobias D Faizy  1 , Laurens Winkelmeier  2 , Michael Mlynash  3 , Gabriel Broocks  2 , Christian Heitkamp  2 , Christian Thaler  2 , Noel van Horn  2 , Pierre Seners  4 , Helge Kniep  2 , Paul Stracke  5 , Kamil Zelenak  6   7 , Maarten G Lansberg  3 , Gregory W Albers  8 , Max Wintermark  9 , Jens Fiehler  2 , Jeremy J Heit  10
Affiliations
Multicenter Study

Brain edema growth after thrombectomy is associated with comprehensive collateral blood flow

Tobias D Faizy et al. J Neurointerv Surg. .

Abstract

Background: We determined whether a comprehensive assessment of cerebral collateral blood flow is associated with ischemic lesion edema growth in patients successfully treated by thrombectomy.

Methods: This was a multicenter retrospective study of ischemic stroke patients who underwent thrombectomy treatment of large vessel occlusions. Collateral status was determined using the cerebral collateral cascade (CCC) model, which comprises three components: arterial collaterals (Tan Scale) and venous outflow profiles (Cortical Vein Opacification Score) on CT angiography, and tissue-level collaterals (hypoperfusion intensity ratio) on CT perfusion. Quantitative ischemic lesion net water uptake (NWU) was used to determine edema growth between admission and follow-up non-contrast head CT (ΔNWU). Three groups were defined: CCC+ (good pial collaterals, tissue-level collaterals, and venous outflow), CCC- (poor pial collaterals, tissue-level collaterals, and venous outflow), and CCCmixed (remainder of patients). Primary outcome was ischemic lesion edema growth (ΔNWU). Multivariable regression models were used to assess the primary and secondary outcomes.

Results: 538 patients were included. 157 patients had CCC+, 274 patients CCCmixed, and 107 patients CCC- profiles. Multivariable regression analysis showed that compared with patients with CCC+ profiles, CCC- (β 1.99, 95% CI 0.68 to 3.30, P=0.003) and CCC mixed (β 1.65, 95% CI 0.75 to 2.56, P<0.001) profiles were associated with greater ischemic lesion edema growth (ΔNWU) after successful thrombectomy treatment. ΔNWU (OR 0.74, 95% CI 0.68 to 0.8, P<0.001) and CCC+ (OR 13.39, 95% CI 4.88 to 36.76, P<0.001) were independently associated with functional independence.

Conclusion: A comprehensive assessment of cerebral collaterals using the CCC model is strongly associated with edema growth and functional independence in acute stroke patients successfully treated by endovascular thrombectomy.

Keywords: Stroke; Thrombectomy; Vein.

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Conflict of interest statement

Competing interests: TDF reports research grants from the German Research Foundation (DFG, Project Number: 411621970) for his work as a postdoctoral scholar at Stanford University. GB reports research grants from the German Research Foundation (DFG) outside of the submitted work. GWA reports equity and consulting for iSchemaView and consulting from Medtronic. MW reports grants and funding from the NIH under the grant numbers (1U01 NS086872-01, 1U01 NS087748-01 and 1R01 NS104094). He reports compensation from Subtle Medical, Magnetic Insight, Icometrix and EMTensor for consultant services and employment by the University of Texas MD Anderson Cancer Center. JF reports stock holdings in Tegus Medical and grants and personal fees from Acandis, Cerenovus, MicroVention, Medtronic, Stryker, Phenox and grants from Route 92 outside the submitted work. JJH reports consulting for Medtronic and MicroVention and Medical and Scientific Advisory Board membership for iSchemaView.

Figures

Figure 1
Figure 1. Extent of cerebral edema growth after thrombectomy stratified by the distinct cerebral collateral cascade (CCC). Boxplots display the extent of ischemic edema formation growth assessed in patients with distinct CCC profiles. Ischemic lesion net water uptake (NWU, %) was used to quantify edema growth on non-contrast head CT images between patient admission and follow-up (ΔNWU). A favorable CCC (CCC+) profile was defined as: Tan ≥50%, hypoperfusion intensity ratio (HIR) ≤0.4, Cortical Vein Opacification Score (COVES) 3–6. An unfavorable CCC (CCC−) profile was regarded as: Tan <50%, HIR >0.4, COVES 0–2. CCCmixed profiles were assigned to patients who did not fulfill the criteria of the CCC+ or CCC− groups. Patients who exhibited CCC+ profiles had significantly lower ΔNWU percentages compared with patients with CCCmixed and CCC− profiles after successful thrombectomy treatment.
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References

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