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Collaterals are a major determinant of the core but not the penumbra volume in acute ischemic stroke

  • Diagnostic Neuroradiology
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Abstract

Purpose

Determinants of early loss of ischemic tissue (core) or its prolonged survival (penumbra) in acute ischemic stroke (AIS) are poorly understood. We aimed to identify radiological associations of core and penumbra volumes on CT perfusion (CTP) in a large cohort of AIS.

Methods

In the ASTRAL registry (2003–2016), we identified consecutive AIS patients with proximal middle cerebral artery (MCA) occlusion. We calculated core and penumbra volumes using established thresholds and the mismatch ratio (MR). We graded collaterals into three categories on CT-angiography. We used clot burden score (CBS) to quantify the clot length. We related CTP volumes to radiological variables in multivariate regression analyses, adjusted for time from stroke onset to first imaging.

Results

The median age of the 415 included patients was 69 years (IQR = 21) and 49% were female. Median admission NIHSS was 16 (11) and median delay to imaging 2.2 h (1.9). Lower core volumes were associated with higher ASPECTS (hazard ratio = 1.08), absence of hyperdense MCA sign (HR = 0.70), higher CBS (i.e., smaller clot, HR = 1.10), and better collaterals (HR = 1.95). Higher penumbra volumes were related to lower CBS (i.e., longer clot, HR = 1.08) and proximal intracranial occlusion (HR = 1.47), but not to collaterals. Higher MR was found in absence of hyperdense MCA sign (HR = 1.28), absence of distal intracranial occlusion (HR = 1.39), and with better collaterals (HR = 0.52).

Conclusions

In AIS, better collaterals were associated with lower core volumes, but not with higher penumbra volumes. This suggests a major role of collaterals in early tissue loss and their limited significance as marker of salvageable tissue.

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Abbreviations

AIS:

Acute ischemic stroke

ASPECTS:

Alberta Stroke Program Early CT Score

CBS:

Clot burden score

CTA:

CT-angiography

CTP:

CT perfusion

MCA:

Middle cerebral artery

MR:

Mismatch ratio

mRS:

Modified Rankin score

NIHSS:

National Institutes of Health Stroke Scale

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Acknowledgements

We thank Melanie Price Hirt for English language correction and editing.

Funding

This study was funded by the European Academy of Neurology and the Swiss Heart Foundation.

Author information

Authors and Affiliations

  1. Stroke Center, Neurology Service, Lausanne University Hospital, Rue du Bugnon, 46, 1011, Lausanne, Switzerland

    Stefania Nannoni, Carlo W. Cereda, Gaia Sirimarco, Dimitris Lambrou, Davide Strambo, Ashraf Eskandari & Patrik Michel

  2. Stroke Center, Neurology Service, Neurocenter of Southern Switzerland, Ospedale Civico di Lugano, Lugano, Switzerland

    Carlo W. Cereda

  3. Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland

    Vincent Dunet

  4. Department of Radiology, Neuroradiology Division, Stanford University and Medical Center, Stanford, USA

    Max Wintermark

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  1. Stefania Nannoni
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Contributions

SN studied the concept and design and helped in the analysis and interpretation and preparation of the article. CWC, GS and DS helped in the interpretation of data and critical revision of the article for important intellectual content. DL carried out data analysis and interpretation and helped in the preparation of the article. AE helped in data acquisition and analysis. VD helped in data acquisition and critical revision of the article for important intellectual content. MW contributed to the conception and design and helped in the interpretation of data. PM studied the concept and design and helped in the data acquisition, analysis, and interpretation and critical revision of the article for important intellectual content, study supervision.

Corresponding author

Correspondence to Stefania Nannoni.

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Conflict of interest

In the last 3 years, PM received research grants from the Swiss Heart Foundation, Boehringer-Ingelheim and BMS through his institution; speaker fees from Boehringer-Ingelheim, Bayer, Daiichi-Sankyo, Medtronic and Amgen; honoraria from scientific advisory boards from Boehringer-Ingelheim, Bayer, Pfizer and BMS; and consulting fees from Medtronic, Astra-Zeneca and Amgen. PM's institution (CHUV) receives all of the support for stroke education and research. GS served on scientific advisory boards for Amgen and Daiichi-Sankyo. CWC received research grants from the Swiss Heart Foundation, Advisory Board of Research (EOC) and Boehringer-Ingelheim in the last 3 years through his institution, and honoraria from scientific advisory boards from Boehringer-Ingelheim, Bayer and Pfizer.

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Nannoni, S., Cereda, C.W., Sirimarco, G. et al. Collaterals are a major determinant of the core but not the penumbra volume in acute ischemic stroke. Neuroradiology 61, 971–978 (2019). https://doi.org/10.1007/s00234-019-02224-x

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