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Original research
Internal cerebral vein asymmetry is an independent predictor of poor functional outcome in endovascular thrombectomy
  1. May Zin Myint1,
  2. Leonard LL Yeo1,2,3,
  3. Benjamin Y Q Tan1,2,
  4. Ei Zune The1,
  5. Mei Chin Lim2,4,
  6. Ching-Hui Sia2,5,
  7. Hock-Luen Teoh1,2,
  8. Vijay Kumar Sharma1,2,
  9. Bernard Chan1,2,
  10. Aftab Ahmad6,
  11. Prakash Paliwal1,2,
  12. Anil Gopinathan2,4,
  13. Cunli Yang2,4,
  14. Andrew Makmur2,4,
  15. Tommy Andersson3,7,
  16. Fabian Arnberg3,
  17. Staffan Holmin3
  1. 1Division of Neurology, Department of Medicine, National University Health System, Singapore
  2. 2Yong Loo Lin School of Medicine, National University of Singapore, Singapore
  3. 3Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
  4. 4Department of Diagnostic Imaging, National University Health System, Singapore
  5. 5Department of Cardiology, National University Heart Center, Singapore
  6. 6Division of Neurology, Ng Teng Fong General Hospital, Singapore
  7. 7Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
  1. Correspondence to Dr Leonard LL Yeo, National University of Singapore, Singapore, Singapore; leonardyeoll{at}gmail.com

Abstract

Background Endovascular thrombectomy (EVT) in large vessel occlusion (LVO) in anterior circulation acute ischaemic stroke (AIS) results in good functional outcomes in only approximately 60% of the patients. Internal cerebral veins (ICVs) are easily visible, with a consistent midline location, and are linked to stroke outcomes. We hypothesize that ICV asymmetry on multiphasic CT angiogram (mCTA) can be an adjunctive predictor for poor functional outcomes.

Methods We studied consecutive AIS patients from 2017 to 2019 with anterior circulation LVO treated with EVT regardless of intravenous thrombolysis. Asymmetrical ICV was defined as the presence of hypodensity (less opacification) on the ipsilateral occlusion side as compared with the contralateral side. The primary outcome was modified Rankin Score (mRS) score at 3 months. Secondary outcomes were good recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) 2b-3), symptomatic hemorrhage, and mortality.

Results A total of 185 patients were included with a median age of 70 years (IQR 59–77); 87 patients (47%) were female. 82 patients (44.3%) achieved good functional outcomes (mRS 0–2) at 3 months. On multivariate analysis, National Institutes of Health Stroke Scale (NIHSS) (OR 1.076, 95% CI 1.015 to 1.140; p<0.013), poor collateral score (OR 0.285, 95% CI 0.162 to 0.501; p<0.001), asymmetrical ICV on the peak venous phase (OR 2.47, 95% CI 1.115 to 5.471; p<0.026), and late venous phase of the mCTA (OR 2.642, 95% CI 1.161 to 6.016; p<0.021) were independent risks factors of poor outcomes.

Conclusion ICV asymmetry is a novel radiological sign which is independently associated with poor functional outcomes in EVT, even after correction for collateral circulation. Further studies are needed to validate this finding.

  • CT angiography
  • stroke
  • intervention
  • stent
  • thrombectomy

Data availability statement

No data are available. All the data of participants are de-identified and collected from the hospital central registry.

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Data availability statement

No data are available. All the data of participants are de-identified and collected from the hospital central registry.

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Footnotes

  • MZM and LLY are joint first authors.

  • MZM and LLY contributed equally.

  • Contributors MZM was involved in the conception of the article, data acquisition, data analysis, data interpretation, drafting of the article, the final approval, revising critically for important intellectual content and is agreeable to be accountable for all aspects of the work. LLLY was involved in the conception of the article, data acquisition, data analysis, data interpretation, drafting of the article and the final approval. BYQT was involved in data acquisition, data analysis and drafting of the article. MCL was involved in data acquisition, drafting of the article and the final approval. EZT, C-HS, H-LT, VKS, BC, AA, PP, AG, CY, AM, TA, FA and SH were involved in the drafting of the article and the final approval.

  • Funding This research was supported by the National Medical Research Council (NMRC), Singapore (Grant number: NMRC/FLWSHP/043/2017).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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