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. 2025 Feb 27:16:1478240.
doi: 10.3389/fneur.2025.1478240. eCollection 2025.

Relevance of persistent perfusion deficits on clinical outcomes after successful endovascular treatment: a prospective serial magnetic resonance study

Adrián Valls Carbó  1 , Alicia Palomar  2 , Carlos Laredo  3 , Mariano Werner  4 , Laura Dorado  1 , Sebastià Remollo  1 , Josep Munuera  5 , Josep Puig  6 , Yolanda Silva  7 , Natalia Pérez de la Ossa  1 , Meritxell Gomis  1 , Alejandro Bustamante  1 , Carlos Castaño  1 , Lucía Muñoz  1 , Sira Domenech  1 , Mikel Terceño  7 , Mònica Millán  1 , María Hernández-Pérez  1
Affiliations

Relevance of persistent perfusion deficits on clinical outcomes after successful endovascular treatment: a prospective serial magnetic resonance study

Adrián Valls Carbó et al. Front Neurol. .

Abstract

Background: Half of the patients who undergo successful recanalization after endovascular treatment (EVT) experience poor clinical outcomes. Impaired microvascular reperfusion (IMR) may explain this lack of improvement, but its frequency and clinical significance remain unclear. The study aims to describe the frequency and associated factors of IMR.

Materials and methods: We conducted a study on a cohort of patients with anterior large artery occlusion, treated with EVT at a single center, who achieved mTICI ≥2C. Perfusion MRI was obtained at arrival, up to 2 h after EVT (post-EVT MRI), and on day 5. IMR was observed only on the post-EVT relative cerebral blood volume (rCBV) maps as voxels within the follow-up ischemic lesion, exhibiting a > 15% asymmetry compared to a mirror homolog, in the absence of internal carotid occlusion, hemorrhagic transformation, or arterial reocclusion. Patients with an IMR volume greater than 5 mL were defined as having significant IMR. IMR was analyzed as a binary variable (presence/absence using the 5 mL cut-off) and by total and relative volume.

Results: IMR was present in 8 out of 33 patients (24.2%), with 4 out of 11 (36.4%) having mTICI 2C, and 4 out of 22 (18.2%) having mTICI 3. After adjustment for relevant variables, absolute and relative IMR volumes were associated with higher National Institutes of Health Stroke Scale (NIHSS) scores at 5 days (adjusted beta =0.50 [0.05, 0.96], p = 0.03) and at 24 h (adjusted beta = 0.11 [0.02, 0.19], p = 0.01). No independent associations were found between IMR and the 90-day modified Rankin Scale (mRS).

Conclusion: IMR is present in one-quarter of patients and is associated with worse early neurological outcomes.

Keywords: MRI; ischemic stroke; no-reflow; perfusion imaging; reperfusion.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Pipeline of the post-processing. (1) Rigid registration of the DWI post-EVT and its infarct segmentation to the rCBV post-EVT. (2) Post-EVT Infarct flip. (3 and 4) Obtention of the voxel values of the rCBV post-EVT in the contralateral flipped infarct and determination of the 15% threshold. (5) Threshold application within the infarct segmentation. (6) Obtention of the infarct microvascular impairment segmentation. DWI, diffusion-weighted image; EVT, endovascular treatment, rCBV, relative cerebral blood volume.
Figure 2
Figure 2
Consort diagram. EVT, Endovascular treatment; ICA, intracranial carotid artery; mTICI, modified Thrombolysis in Cerebral Infarction.
Figure 3
Figure 3
Representative cases of infarct microvascular impairment (IMR). (A) Post-EVT diffusion-weighted imaging (DWI); (B) Post-EVT relative cerebral blood volume (rCBV); (C) Post-EVT rCBV with overlaid infarct area (light green); (D) Post-EVT rCBV showing the infarct area (green) and regions of IMR (white).
See this image and copyright information in PMC

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