Analysis Of Factors Influencing Unfavorable Outcomes After Endovascular Treatment Following Successful Recanalization In Acute Anterior Circulation Large Vessel Occlusion

Background and objectiveDespite successful recanalization with endovascular treatment(EVT)in the anterior circulation,approximately 50%of patients fail to achieve functional independence at 3 months.Blood pressure is a modifiable factor that frequently influences functional outcomes after EVT.Several studies suggested a correlation between increased blood pressure variability(BPV)and unfavorable outcomes subsequent to EVT.Nevertheless,there is a dearth of research on early BPV following EVT and its impact on clinical outcomes,particularly in different collateral statuses.The objective of this study was to assess the correlation between early BPV within 6 and 24 hours after successful recanalization of EVT and its association with futile recanalization(FR)and all-cause mortality based on different collateral statuses.MethodsWe conducted a retrospective analysis of prospectively and consecutively registered cases of EVT following successful recanalization in acute large vessel occlusion between November 2015 and December 2022.BPV was assessed during the initial 6 hours and 24 hours following EVT for SBP using 5 methodologies including difference between maximum and minimum(Max-Min),standard deviation(SD),coefficient of variation(CV),successive variations(SV),and variation independent of mean(VIM).The BPV was then stratified into tertiles.The primary outcome was defined as FR,indicating unfavorable outcomes(mRS[modified Rankin Scale]scores of 3-6 at 3 months)in patients with successful recanalization following EVT.The secondary outcome was all-cause mortality within 3 months.Logistic multiple regression analysis was conducted to explore the relationship between BPV within 6 and 24 hours and both primary and secondary outcomes.Additionally,stratified analysis was performed based on different collateral statuses.ResultsOf the 411 patients included in final analysis,203(49.4%)developed FR following EVT,and 68(16.5%)died within 3 months.In the primary outcome,compared to the lowest tertile of SBP variability parameters,the adjusted odds ratios(ORs)for the highest tertile were as follows:SBP Max-Min1-24H 2.454(95%confidence interval[CI]1.315-4.629;Ptrend=0.005),SBP VIM1-24H 2.413(95%CI 1.301-4.518;Ptrend=0.006),SBP CV1-24H 2.035(95%CI 1.109-3.759;Ptrend=0.023),SBP SD1-24H 2.777(95%CI 1.483-5.260;Ptrend=0.002),SBP SV1-24H 2.362(95%CI 1.315-4.286;Ptrend=0.004).In the subgroup with unfavorable collateral status,the adjusted ORs for the highest quartile in each model were as follows:VIM1-24H 3.184(95%CI 1.106-9.610;Ptrend=0.036),SD1-24H 3.939(95%CI 1.373-11.965;Ptrend=0.013),SV1-24H 4.282(95%CI 1.449-13.619;Ptrend=0.011),suggesting an increased risk of FR.No similar trend was observed in the subgroup with favorable collateral status.Regarding secondary outcomes,when compared to the lowest tertile of SBP variability parameters,the adjusted ORs for the highest tertile in each model were as follows:SBP VIM1-6H 2.317(95%CI 1.118-4.980;Ptrend=0.023),SBP SD1-6H 2.521(95%CI 1.220-5.412;Ptrend=0.010),SBP SV1-6H 3.147(95%CI 1.512-6.873;Ptrend=0.002),SBP Max-Min1-24H 3.969(95%CI 1.823-9.228,Ptrend=0.001),SBP VIM1-24H 4.194(95%CI 1.897-10.006;Ptrend<0.001),SBP CV1-24H 3.107(95%CI 1.454-6.985;Ptrend=0.003),SBP SD1-24H 4.178(95%CI 1.886-9.979;Ptrend<0.001),SBP SV1-24H 4.381(95%CI 1.983-10.437;Ptrend=0.001).In the subgroup with unfavorable collateral status,compared to the lowest tertile of SBP SV1-6H,the model revealed an adjusted OR of 4.890(95%CI 1.581-17.491;Ptrend=O.005),suggesting an association with the risk of all-cause mortality within 3 months.ConclusionThis study reveals that increased SBP variability during the initial 6 hours following successful recanalization is associated with a higher risk of all-cause mortality.Similarly,heightened SBP variability within the initial 24 hours following successful recanalization is linked to an increased risk of both FR and all-cause mortality.Among patients with unfavorable collateral status,elevated SBP variability during the initial 6 hours after successful recanalization is linked to an increased risk of all-cause mortality.Furthermore,an increase in SBP variability during the initial 24 hours following successful recanalization elevates the risk of FR.Background and ObjectiveMalignant cerebral edema(MCE)is a critical factor that affects the functional outcomes following EVT.Previous investigations have established an association between BPV and functional outcomes following EVT.However,the relationship between BPV following EVT and MCE remains unclear.Our preliminary research has revealed that there are significant differences in SBP variability after EVT based on different collateral statuses,impacting functional outcome.Therefore,this study aims to investigate the association between SBP parameters within 6 hours and 24 hours after successful recanalization and the presence of MCE based on collateral status.MethodsWe performed a retrospective analysis of cases prospectively and consecutively registered for endovascular treatment(EVT)following successful recanalization in acute large vessel occlusion from November 2015 to December 2022.BPV was assessed within the initial 6 hours and 24 hours following EVT for SBP variability using 5 methodologies including Max-Min,SD,CV,SV,and VIM.And then BPV was stratified into tertiles.Multiple logistic regression analyses were performed to investigate the association between SBP parameters within both 6 hours and 24 hours following EVT and the presence of MCE.Subgroup analyses were then performed,stratified by collateral status.ResultsA total of 420 cases were included in this study.Of these,76 cases(18.1%)developed MCE.Multivariate logistic regression analysis,adjusting for potential confounding factors,revealed a negative correlation between a favorable collateral status before EVT and the presence of MCE.The subgroup analysis focused on patients with unfavorable collateral status,revealing higher OR for the highest tertiles in each model compared to those in the lowest tertile of SBP variability parameters.The results were as follows:Max-Min1-6H 3.703(95%CI 1.176-12.893;Ptrend=0.024;PH-L=0.667),VIM1-6H 3.347(95%CI 1.146-10.712;Ptrend=0.024;PH-L=0.465),and CV1-6H 2.877(95%CI 1.033-8.541;Ptrend=0.032;PH-L=0.828).These findings suggest an elevated risk of MCE following EVT in patients with unfavorable collateral status,with no similar trend observed in those with favorable collateral status.ConclusionsThis study has revealed an inverse association between a favorable collateral status prior to EVT and the presence of MCE following successful recanalization.Additionally,among patients with unfavorable collateral status,an elevation in SBP variabilities within 6 hours following EVT is associated with an increased risk of MCE.Background and ObjectiveThe management of blood pressure plays a crucial role in reducing MCE and improving functional outcomes subsequent to EVT following successful recanalization.Nonetheless,even after successful recanalization,up to 50%of patients fail to achieve neurological independence.While preliminary research has indicated an association between cortical venous outflow profiles and functional outcomes,investigations into the influence of cortical venous outflow on functional outcomes following EVT remain relatively limited.Consequently,this study aims to explore the association between venous outflow profiles and functional outcomes after EVT,as well as the association between venous outflow profiles and futile recanalization following EVT.MethodsThis study utilized a continuous cohort dataset from our institution,including cases of acute large-vessel occlusion from October 2018 to December 2022,all of whom underwent computed tomography perfusion(CTP)evaluation before undergoing EVT.The primary outcome was defined as the functional independence(mRS≤2)at 3 months following EVT.Secondary outcomes included FR,excellent outcome(mRS≤1),favorable outcome(mRS≤3)at 3-month,and all-cause mortality within 3 months.Futile recanalization is defined as an unfavorable outcome with mRS score of 3-6 at 3 months following successful recanalization.The Cortical Vein Opacification Score(COVES)was performed to assess venous outflow profiles,with a COVES score of≥3 indicating favorable venous outflow(VO+).Multivariable regression analysis was performed to evaluate the association between venous outflow profiles and clinical outcomes.ResultsOut of the 244 patients who underwent CTP assessments,170 met the inclusion criteria.50.6%(86)achieved functional independence at 3-month,while 45.9%(68)experienced FR after successful reperfusion.Multivariable logistic regression,adjusting confounding factors,demonstrated a positive association between COVES and functional independence(OR 2.480,95%CI 1.633-3.989;P<0.001),excellent outcomes(OR 2.058,95%CI 1.414-3.154;P<0.001),and favorable outcomes(OR 2.473,95%CI 1.604-4.034;P<0.001)at 3-month.Conversely,COVES demonstrated a negative association with all-cause mortality within 3 months(OR 0.425,95%CI 0.234-0.709;P=0.002).Among patients with successful recanalization,COVES was negatively associated with FR(OR 0.387,95%CI 0.228-0.611;P<0.001).ConclusionFavorable venous outflow profiles emerge as reliable predictors of functional outcomes at 3-month and all-cause mortality within 3 months.Furthermore,in patients with successful recanalization,favorable venous outflow profiles serve as significant imaging predictor for FR.Therefore,the pre-EVT assessment of venous outflow profiles is of paramount significance in patient selection and outcome prediction,providing essential evidence for personalized EVT.Background and ObjectiveCerebral edema subsequent to EVT serves as a mediator in FR,potentially diminishing the benefits of EVT.Our previous research has demonstrated that unfavorable cortical venous outflow heightens the risk of FR after EVT.Therefore,we hypothesize an association between cortical venous outflow and the presence of cerebral edema following successful EVT.Consequently,this study aims to assess the relationship between venous outflow and the presence of cerebral edema subsequent to successful EVT,utilizing multimodal imaging from our institution.MethodThis study consecutively included cases of acute large-vessel occlusion from October 2018 to December 2022,all of which underwent CTP evaluation before EVT.The primary outcome was defined as the presence of MCE within 24-72 hours following EVT,and the secondary outcome was defined as the presence of moderate to severe cerebral edema(MSCE)within 24-72 hours following EVT.The COVES was performed to evaluate venous outflow profiles,with a COVES score of>3 indicating VO+.Multivariable logistic regression analysis was performed to investigate the relationship between factors with outcomes.In the process of model construction,we analyzed COVES scores and VO+separately.The predictive abilities of COVES,VO+,early infarct growth rate(EIGR),baseline Alberta Stroke Program Early CT Score(ASPECTS)score,and different models for MCE or MSCE were evaluated by area under the curve(AUC).ResultsOut of the 244 cases who underwent CTP assessments,150 cases met the inclusion criteria.Among them,18%developed MCE,and 31.3%experienced MSCE following successful recanalization.COVES scores exhibited a significant negative correlation with the presence of MCE(OR=0.186,95%CI 0.075-0.384;P<0.001)and MSCE(OR=0.501,95%CI 0.293-0.808;P=0.007)after adjusting for confounding factors.In the primary outcome,COVES demonstrated superior predictive value for MCE(AUC 0.857,95%CI 0.788-0.926)compared to the baseline ASPECTS score(AUC 0.711,95%CI 0.596-0.827)and EIGR(AUC 0.714,95%CI 0.599-0.829).Both model one(AUC 0.895,95%CI 0.832-0.958)and model two(AUC 0.893,95%CI 0.835-0.950)outperformed model three(AUC 0.813,95%CI 0.715-0.912)in predicting MCE.Similarly,in secondary outcomes,COVES(AUC 0.763,95%CI 0.678-0.847),the baseline ASPECTS score(AUC 0.766,95%CI 0.677-0.855),and EIGR(AUC 0.714,95%CI 0.623-0.806)demonstrated comparable predictive value for MSCE.All three models(model one AUC 0.892,95%CI 0.831-0.954;model two AUC 0.866,95%CI 0.824-0.947;model three AUC 0.860,95%CI 0.794-0.925)exhibited high predictive value for MSCE.ConclusionThis study revealed that in patients with successful recanalization following acute anterior circulation large-vessel occlusion,unfavorable venous outflow profiles prior to EVT,lower baseline ASPECTS scores,and higher EIGR were all significantly associated with an increased risk of both MCE and MSCE.Notably,pre-EVT venous outflow profiles exhibited a notably higher predictive value for the risk of MCE.Background and ObjectiveFollowing successful EVT recanalization,the prevalence of MCE remains relatively high.Timely prediction of MCE is crucial for case selection and perioperative management.However,risk factors and predictors of MCE in patients with acute anterior circulation large vessel occlusion after successful recanalization of EVT have not been fully explored.This study aims to assess the risk factors and construct a predictive model for MCE after EVT following successful recanalization in cases of acute anterior large vessel occlusion.MethodsWe analyzed consecutive ischemic stroke patients who underwent EVT at our institution from November 2015 to April 2022.Based on the results of the univariate analysis,only variables that showed a P-value<0.1 and have clinical significance based on previous studies were included in the multivariate logistic regression analysis.Subsequently,a nomogram was constructed based on the outcomes of the multivariate logistic regression analysis.AUC were used to predict the probability of MCE following successful perfusion.Calibration plots and the Hosmer-Lemeshow test were used to assess the agreement between the actual and predicted probabilities of the risk of MCE after successful reperfusion.ResultsA total of 307 patients were included and 48(15.6%)were diagnosed with MCE after successful reperfusion.Those with MCE had lower rates of favorable outcome(15.2%vs.59.6%,P<0.001)and good outcome(17.4%vs.68.4%,P<0.001)at 3 months,and a higher rate of mortality within 3 months(54.3%vs.8.8%,P<0.001)compared to those without MCE.Predictors of MCE after successful reperfusion included baseline glucose level,baseline National Institutes of Health Stroke Scale(NIHSS)score,stroke etiology,occlusion site and puncture to recanalization time(PTR)>120 min.The AUC of the nomogram was 0.805(95%CI,0.756-0.847).ConclusionsMCE after successful reperfusion is associated with adverse outcome and mortality.A nomogram containing baseline glucose level,baseline NIHSS score,stroke etiology,occlusion site and PTR>120 min may predict the risk of MCE after successful reperfusion in patients with acute ischemic stroke and treated successfully with EVT.