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Original research
Poor venous outflow is associated with hyperintense acute reperfusion marker on follow-up MRI in patients with acute ischemic stroke with a large vessel occlusion
  1. Aroosa Zamarud1,
  2. Nicole Yuen2,
  3. Anke Wouters2,
  4. Michael Mlynash2,
  5. Stephen M Hugdal1,
  6. Pierre Seners2,
  7. Jamie Kesten1,
  8. Vivek Yedavalli3,
  9. Tobias D Faizy4,
  10. Gregory W Albers2,
  11. Maarten G Lansberg2,
  12. Jeremy J Heit1
    1. 1Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
    2. 2Department of Neurology, Stanford University School of Medicine, Stanford, California, USA
    3. 3Department of Radiology, Johns Hopkins Medicine, Baltimore, Maryland, USA
    4. 4Universität Münster, Munster, Nordrhein-Westfalen, Germany
    1. Correspondence to Dr Jeremy J Heit; jheit{at}stanford.edu

    Abstract

    Background Hyperintense acute reperfusion marker (HARM) refers to delayed enhancement in the subarachnoid or subpial space on post-contrast fluid attenuated inversion recovery (FLAIR) images. HARM is a measure of blood–brain barrier breakdown, which has been correlated with poor outcomes in patients with acute ischemic stroke with large vessel occlusion (AIS-LVO). We hypothesized that unfavorable venous outflow (VO) would be correlated with HARM after thrombectomy treatment of AIS-LVO.

    Objective To determine whether poor VO is associated with HARM on follow-up MRI after stroke in patients with AIS-LVO.

    Methods Patients with AIS-LVO from the prospective CRISP2 and DEFUSE2 studies with a baseline CT angiography (CTA) scan and a follow-up MRI with FLAIR sequence were screened for enrollment. VO was measured on the baseline CTA scan using the cortical venous opacification score (COVES). HARM was determined on FLAIR sequences at the follow-up MRI. The primary outcome was the occurrence of HARM between those with good VO (VO+; COVES 3–6) and bad VO (VO−; COVES 0–2).

    Results 121 patients were included; 60.3% (n=73) had VO+ and 39.7% (n=48) had VO−. Patients with VO− had higher presentation National Institutes of Health Stroke Scale scores (18 (IQR 12–20) vs 12 (IQR 8–16) in VO+; P<0.001). Middle cerebral artery M1 segment occlusions were more common in VO− patients (65% vs 43% VO+; P=0.028). VO− patients also had a larger pre-treatment ischemic core (23 (4–44) mL vs 12 (3–22) mL in VO+; P=0.049) and Tmax >6 s volumes (105 (72–142) mL vs 66 (35–95) mL in VO+; P<0.001). VO− patients were more likely to develop HARM after thrombectomy (31% vs 10% in VO+; P=0.003). On multivariable regression analysis, VO− (OR=3.6 (95% CI 1.2 to 10.6); P=0.02) and the presence of any ICH (OR=3.6 (95% CI 1.2 to 10.5); P=0.02) were independently associated with the occurrence of HARM.

    Conclusions In patients with AIS-LVO, VO− correlated with HARM on post-thrombectomy MRI.

    • Stroke
    • Thrombectomy
    • CT Angiography
    • MRI

    Data availability statement

    Data are available upon reasonable request.

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    Data availability statement

    Data are available upon reasonable request.

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    Footnotes

    • X @aroosazamarud10, @vsyedavalli, @JeremyHeitMDPHD

    • Contributors All authors listed have contributed sufficiently to the project to be included as authors, and all those who are qualified to be authors are listed in the author byline. Dr. Jeremy Heit is the guarantor for this article.

    • Funding We express our sincere gratitude to the patients who participated in the CT Perfusion to Predict Response to Recanalization in Ischemic Stroke Project (CRISP2) study, and to the National Institute of Neurological Disorders and Stroke (NINDS) for their funding support (NIH grant awarded to MGL, reference R01 NS075209).

    • Competing interests None declared.

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