The Effect And Underlying Mechanisms Of Intracranial Venous Drainage On Outcomes In Acute Ischemic Stroke Patients Receiving Reperfusion Therapy

Part One The prognostic value of intracranial venous drainage for outcomes in acute ischemic stroke patients receiving reperfusion therapyAims: To verify the hypothesis that venous drainage patterns were associated with outcomes after reperfusion therapy in acute ischemic stroke(AIS)patients.Methods: We retrospectively reviewed our database of anterior circulation AIS patients who performed baseline brain multi-mode computed tomography(CT)and received reperfusion therapy from May 2009 to March 2019.Based on four-dimensional CT angiography(4D-CTA),we evaluated the contrast enhancement degree of sphenoparietal sinus,superficial middle cerebral vein,vein of Labbé,vein of Trolard,thalamostriate vein,internal cerebral vein,and basal vein of Rosenthal and constructed a Cerebral Venous Scale(CVS).Hemorrhagic transformation(HT)was ascertained using European Cooperative Acute Stroke Study(ECASS)II criteria.Poor outcome was defined as modified Rankin Scale(m RS)of 3-6 at 3 months.Receiver operator characteristic curve and logistic regression was used to identify the relationship between CVS and HT,poor outcome or death.Results: A total of 696 patients were included.CVS score was 2(0-5).263(37.8%)had HT,319(45.8%)had poor outcome and 96(10.9%)patients dead.The c-statistic was 0.685,0.683,0.723 for HT,poor outcome and mortality rate,respectively(all p<0.001).CVS ?1,?3,?6 was independently associated with higher rate of HT(82.9% vs 52.2%,OR=1.867,95%CI=1.179-2.955,p=0.008),poor outcome(60.8% vs 31.3%,OR=1.602,95%CI=1.057-2.427,p=0.026),and death(26.8% vs 6.6%,OR=2.323,95%CI=1.223-4.214,p=0.010),respectively.Conclusion: Poor venous drainage was associated with high risk of HT and poor outcome in AIS patients receiving reperfusion therapy.The CVS may be a useful tool to predict clinical outcome after reperfusion therapy.Part Two The underlying mechanisms of poor intracranial venous drainage on outcomes in AIS patients receiving reperfusion therapyAims: To detect investigate the interaction of poor intracranial venous drainage with tissue perfusion status and blood-brain barrier permeability(BBBP)in AIS patients receiving reperfusion therapy.Methods: We retrospectively reviewed our database of anterior circulation AIS patients who performed baseline brain multi-mode CT and received reperfusion therapy from May 2009 to March 2019.Hypoperfusion was defined as Tmax>6s and reperfusion defined as?70% of reperfusion rate.Malignant brain edema was defined as more than 5 scale according to Wardlaw's method.Penumbral tissue loss ratio was defined as(24h infarct volume – baseline core volume)/(baseline hypoperfusion volume – baseline core volume).Relative permeability-surface area product(r PS)was used to represent BBBP.The r PS in hypoperfusion region(r PShypo-i),non-hypoperfusion region(r PSnonhypo-i)and their morrir regions(r PShypo-c and r PSnonhypo-c)were meassured before and at 24-hour after reperfusion therapy.Results: The analysis was conducted in 490 patients.332(67.8%)patients achieved reperfusion.CVS was not associated with reperfusion status [3(1-5)vs 3(1-6),p=0.10].In reperfusion group,CVS was significantly associated with malignant brain edema(OR=1.305,95%CI=1.087-1.567,p=0.004),while in non-reperfusion group,CVS was associated with penumbral tissue loss ratio(?=0.256,p=0.001).CVS was significantly associated with baseline ln(r PShypo-i)(B=0.083,95%CI=0.034-0.131,p=0.001),and r PShypo-i(?=0.700,p<0.001),r PShypo-c(?=0.411,p=0.021),r PSnonhypo-i(?=0.465,p=0.029)at 24-hour after reperfusion therapy,respectively.Conclusion: Poor intracranial venous drainage influenced the tissue outcome including malignant edema and penumbral tissue loss under different reperfusion status,and was involved in the BBB disruption in AIS patients receiving reperfusion therapy.Part Three The influencing factors of poor intracranial venous drainage in acute ischemic stroke patients receiving reperfusion therapyAims: To explore the potential influencing factors of poor intracranial venous drainage in AIS patients receiving reperfusion therapy.Methods: We retrospectively reviewed our database of anterior circulation AIS patients who performed baseline brain multi-mode CT and received reperfusion therapy from May 2009 to March 2019.Based on 4D-CTA,we evaluated CVS in all patients and regional leptomeningeal collateral(r LMC-M)score in middle cerebral artery-M1 segment occlusion patients.To indicate the intracranial cerebral pressure(ICP),we measured optic nerve sheath diameter(ONSD).Logistic regression analysis was used to examine factors associated with CVS.Results: A total of 638 patients were included.Baseline ASPECTS(OR=0.504,95%CI= 0.427-0.596,p<0.001),atrial fibrillation(OR=1.877,95%CI=1.256-2.805,p=0.002),baseline ln(D-dimer)(OR=1.366,95%CI=1.077-1.732,p=0.010)were independently associated with CVS.However,mean ONSD was not significantly associated with CVS(p=0.163).Lower baseline r LMC-M were independently associated with higher CVS(OR=0.816,95%CI=0.754-0.882,p<0.001).Conclusion: Hypoperfusion,hypercoagulation status and poor collaterals may be associated with the development of poor intracranial venous drainage in AIS patients receiving reperfusion therapy.