| Objective:The aim was to study the respective associations of DSA-based collateral flow and drainage of cortical veins with 90-day stroke outcome,and determine if a physiologically relevant combined clinical criteria,arterial and venous grading model is accurate in determining neurological outcomes in patients with acute middle cerebral artery(MCA)occlusion after mechanical thrombectomy(MT).Methods:The clinical and imaging data from consecutive ischemic stroke patients with acute MCA occlusion who underwent intra-arterial treatment(IAT)from May 1,2013 to March 1,2018 were reviewed.Collateral flow was graded 0 to 4 according to the American Society of Interventional and Therapeutic Neuroradiology collateral grading system(ACG),and 0-1,2 and 3-4 were graded ‘poor’,‘intermediate’ and ‘good’ respectively.Absent filling,early or delay filling,normal filling of ipsilateral cortical vein on DSA is assigned 0,1,2 points respectively.The affected hemisphere composite score of four superficial drainage veins[superficial middle cerebral vein(SMCV)+vein of Trolard(VOT)+vein of Labbé(VOL)+basal vein of Rosenthal(BVR)] was graded 0 to 8,and 0-4,5 and 6-8 were graded ‘poor’,‘intermediate’ and ‘good’ respectively.Successful reperfusion was defined as a modified Thrombolysis in Cerebral Infarction(mTICI)2b or 3 at the end of the procedure.The unfavorable outcome was defined as a 90-day modified Rankin Scale score of 3 to 6.The relationship of both arterial collaterals and venous drainage status with mRS at 90 was assessed,and the logistic regression analysis model combined clinical criteria,arterial and venous grade was established to predict neurological outcomes.RESULTS:A total of 188 patients with acute MCA occlusion who underwent MT were included.There were 116 males(61.7%)and 72 females(38.3%)with an age of 68.0(61.0,77.0)years.Among them,ACG grade 0-1,28 cases(14.9%);grade 2,99 cases(52.7%);grade 3-4,61 cases(32.4%).The superficial drainage veins of 161 patients were scored,0-4 points in 37 cases(23.0%),5 points in 15 cases(9.3%),and 6-8 points in 109 cases(67.7%).176 patients(93.6%)achieved mTICI 2b/3,51(27.1%)developed hemorrhagic transformation,and 11(5.9%)symptomatic intracranial hemorrhage(sICH).The unfavorable outcome was 38.3%,mortality 9.0% at follow-up of 90 days.(1)Baseline National Institutes of Health Stroke Scale(NIHSS)[OR(95% CI): 1.113(1.031,1.202),P = 0.0062],ACG grade [OR(95% CI): 0.385(0.193,0.769),P = 0.0068],composite score of superficial drainage veins[OR(95% CI): 0.642(0.499,0.825),P = 0.0005] was independent predictor of poor outcome.The number of passes of stent retriever[OR(95% CI): 1.493(1.054,2.115),P = 0.024] was an independent predictor of hemorrhagic transformation after MT.(2)There was no significant difference in successful recanalization between the three groups of poor,moderate and good collaterals,however the incidence of hemorrhagic transformation,sICH,mortality and poor outcome were significant different.The incidence of hemorrhagic transformation was lower in the good collaterals group than in the moderate and poor collaterals(P<0.05),but there was no difference between the moderate and poor collaterals(P>0.05).sICH: the good collaterals group was lower than the poor collaterals(P<0.05),but there was no difference between the moderate and good collaterals,and between the moderate and poor collaterals(P>0.05).Mortality: the good collaterals group was lower than the poor and moderate collaterals(P<0.05),while there was no difference between the moderate and poor collaterals(P>0.05);Poor outcome: The good collaterals group was lower than the moderate and poor collaterals(P<0.05),and the moderate collaterals was lower than the poor collaterals(P<0.05).In both cardioembolic stroke(CE)and large artery atherosclerotic stroke(LAA),if the collateral grade is high,the rate of poor outcome tends to be low;however there was no difference in stroke of undetermined etiology.When onset-to-groin puncture time≤6h,there was a significant difference of the rate of poor outcome in different collateral grades,but not in the time>6h group.(3)There was no significant difference in successful recanalization and hemorrhagic transformation between the three groups of poor,moderate and good venous drainage,but the rate of sICH,mortality and poor outcome were significantly different.The rate of sICH was lower in the good venous drainage group than the poor group(P<0.05),but there was no difference between the moderate and good venous drainage group,and between the moderate and poor venous drainage group(P>0.05).Mortality: the good venous drainage group was lower than the poor and moderate groups(P<0.05),while there was no difference between the moderate and poor groups(P>0.05).Poor outcome: Both the good and moderate venous drainage groups were lower than the poor group(P<0.05),while there was no difference between the moderate and good groups(P>0.05).(4)After multivariate regression analysis,a logistic regression analysis model was established to predict clinical outcomes.The area under curve(AUC)of receiver operating characteristic curve(ROC)was 0.822,the sensitivity and specificity was 83.0%,66.3% respectively.Compared to individual clinical or imaging scales including baseline NIHSS,ACG grade,and composite score of four cortical veins,the logistic regression analysis model was more accurate in predicting stroke outcomes in patients with acute MCA occlusion after MT(P <0.01).Conclusions:This study demonstrates that collateral status and superficial venous drainage status on cerebral angiography can be used to assess the clinical outcomes in patients with acute MCA occlusion who underwent MT.The logistic regression analysis model based on NIHSS score,ACG scale,and four cortical veins composite score have a better predictive effect for poor outcome after mechanical thrombectomy.It may help to guide strategy adjustment in intraoperative treatment and postoperative individualized management. |
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