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Increased Ipsilateral Cortical and Deep Cerebral Venous Susceptibility in Adult Hyperacute Stroke

This study examines the relationship between quantitative susceptibility measurement (QSM) in superficial and deep cerebral veins and baseline NIHSS score in hyperacute stroke patients. The results show significantly elevated QSM in both superficial and deep venous systems on the side of ischemia. Elevated thalamostriate vein QSM, especially ipsilaterally, is strongly inversely correlated with presenting NIHSS score, suggesting a potential biomarker of poor prognosis.

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Increased Ipsilateral Cortical and Deep Cerebral Venous Susceptibility in Adult Hyperacute Stroke

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  1. EP: 76 Increased Ipsilateral Cortical and Deep Cerebral Venous Susceptibility in Adult Hyperacute Stroke Paggie Kim MD, Phillip Grigsby BS, UdoOyoyo MS, Paul Jacobson MD

  2. Disclosure None

  3. Purpose To assess the relationship between quantitative susceptibility measurement (QSM) in superficial versus deep cerebral veins and baseline NIHSS score in hyperacute stroke patients selected for endovascular intervention by advanced imaging.

  4. Background Stroke is one of the leading causes of mortality and morbidity in United States. It is the fourth leading cause of death and the leading cause of serious long-term disability.1

  5. Background Multimodality brain imaging plays an important role in the initial evaluation of hyperacute stroke patients in deciding whether they should receive intravenous tissue plasminogen activator (t-PA) or more invasive and expensive intraarterial treatment (IAT), such as mechanical thrombectomy.2

  6. Background MR susceptibility weighted imaging (SWI) is extremely sensitive to paramagnetic substances such as deoxyhemoglobin and iron.3,4 Current clinical application of SWI in stroke is to detect: Intracranial hemorrhage4-6 Cerebral amyloid angiopathy7 Hemorrhagic transformation of acute stroke4 Intraarterial thrombus4

  7. Background Deoxyhemoglobin can be quantified (QSM) utilizing a susceptibility weighted imaging mapping (SWIM) program.8-11 QSM values in parts per billion (ppb) can be actually used to estimate oxygen extraction in combination with several other parameters.9-11

  8. Background SWI uses magnetic susceptibility difference to display a phase difference between regions containing deoxygenated blood and surrounding tissue, which clearly depicts the cerebral veins.6 Increased prominence of cerebral veins in the region of infarction is often present on SWI in stroke patients.11

  9. Material and Methods IRB approved retrospective analysis of 25 consecutive hyperacute stroke patients from 2011-14 meeting criteria: Inclusion: Age > 18 years Acute anterior circulation stroke with large vessel occlusion 3T SWI Endovascular intervention. Exclusion: Poor quality SWI.

  10. Material and Methods • Quantitative susceptibility venous measurements (ppb) were obtained from each cerebral hemispheres: • Largest anterior circulation cortical vein • Thalamostriate • vein (TS)

  11. Material and Methods Statistical analyses: Pairwise comparisons of QSM were made between each group using the Wilcoxon Signed Rank test. Correlations of QSM with presenting NIHSS score were made for each group using Spearman's rho.

  12. Results Study cohort, n=25: Male:Female = 10:15 Mean age: 66 years Location of Large vessel occlusion: Middle cerebral artery: 21 Internal carotid artery: 4

  13. Case example a. c. b. 58-year-old female with acute right MCA infarct from right M1 occlusion. a: Axial SWI image demonstrates asymmetric prominence of the right superficial and deep venous systems. b: Axial diffusion weighted image demonstrates hyperintensity involving the right basal ganglia. c. Corresponding hypointensity is present on the ADC map, representing acute right basal ganglia core infarct.

  14. Results

  15. Results In pairwise comparisons, the cortical veins ipsilateral to the stroke showed major elevation in QSM versus all other vein groups : 163% of contralateral cortical vein (p = 0.001) 135% of ipsilateral TS vein (p = 0.04) 163% of contralateral TS vein (p = 0.001)

  16. p = 0.001 p = 0.16

  17. Results Both ipsilateral and contralateral TS veins showed strong inverse correlation with the presenting NIHSS score.

  18. p= 0.001

  19. p= 0.021

  20. Conclusion Both superficial and deep venous systems show substantially elevated QSM on the side of ischemia in adult hyperacute stroke patients selected for endovascular intervention by advanced imaging.

  21. Conclusion Additionally, elevated thalamostriate vein QSM, especially ipsilaterally, is strongly inversely correlated with presenting NIHSS score. The lack of deep system misery perfusion (i.e. elevated TS QSM) may be a biomarker of poor prognosis.

  22. References • Adams HP, Jr., del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke; a journal of cerebral circulation 2007;38:1655-711. • Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. The New England journal of medicine 2015;372:11-20. • Haacke EM, Xu Y, Cheng YC, Reichenbach JR. Susceptibility weighted imaging (SWI). Magnetic resonance in medicine : official journal of the Society of Magnetic Resonance in Medicine / Society of Magnetic Resonance in Medicine 2004;52:612-8. • Santhosh K, Kesavadas C, Thomas B, Gupta AK, Thamburaj K, Kapilamoorthy TR. Susceptibility weighted imaging: a new tool in magnetic resonance imaging of stroke. Clinical radiology 2009;64:74-83. • Wycliffe ND, Choe J, Holshouser B, Oyoyo UE, Haacke EM, Kido DK. Reliability in detection of hemorrhage in acute stroke by a new three-dimensional gradient recalled echo susceptibility-weighted imaging technique compared to computed tomography: a retrospective study. Journal of magnetic resonance imaging : JMRI 2004;20:372-7. • Yan L, Li YD, Li YH, Li MH, Zhao JG, Chen SW. Outcomes of antiplatelet therapy for haemorrhage patients after thrombolysis: a prospective study based on susceptibility-weighted imaging. La Radiologia medica 2014;119:175-82. • Barnes SR, Haacke EM, Ayaz M, Boikov AS, Kirsch W, Kido D. Semiautomated detection of cerebral microbleeds in magnetic resonance images. Magnetic resonance imaging 2011;29:844-52. • Xia S, Utriainen D, Tang J, et al. Decreased oxygen saturation in asymmetrically prominent cortical veins in patients with cerebral ischemic stroke. Magnetic resonance imaging 2014;32:1272-6. • Hermier M, Nighoghossian N. Contribution of susceptibility-weighted imaging to acute stroke assessment. Stroke; a journal of cerebral circulation 2004;35:1989-94. • Haacke EM, Tang J, Neelavalli J, Cheng YC. Susceptibility mapping as a means to visualize veins and quantify oxygen saturation. Journal of magnetic resonance imaging : JMRI 2010;32:663-76. • Li M, Hu J, Miao Y, et al. In vivo measurement of oxygenation changes after stroke using susceptibility weighted imaging filtered phase data. PloS one 2013;8:e63013.

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