Abstract
Objective: To evaluate the association between cerebral small vessel disease (CSVD) burden and degree of disability based on modified Rankin Score at 90 days, in patients presenting with emergent large vessel occlusion (ELVO) within 6 hours of last known well. Methods: We conducted a retrospective analysis of all patients presenting with an ELVO between May 2016 and July 2018. Patients with a TICI score of 2b or 3 were included and evaluated for CSVD burden as quantified by white matter hyperintensities in the non-affected hemisphere, on T2-FLAIR MRI using the Fazekas score (0-3). 90-day modified Rankin Scale scores (mRS, range 0-6) and patient information was collected from the Houston Methodist Hospital Outcomes Based Prospective Endpoints in Stroke (HOPES) registry. Results: 138 patients were evaluated, TICI 2b/3 was achieved in 114, and 84 patients were able to undergo MRI. Factors excluding patients from MRI included: medical instability, implantable devices, and death. All 84 patients were successfully re-evaluated at 90 days and divided into two cohorts, functionally independent (mRS 0-2) and functional dependent/deceased (mRS 3-6). Among the 84 patients, 37 (mean age 69.4y [SD, 14.5]; 54% female) were determined to be functionally independent (14, mRS 0; 19, mRS 1; 4, mRS 2) with the average Fazekas score for each subclass and the cohort; (mRS 0, 1.07; mRS 1, 0.89; mRS 2, 1; 0.97). The remaining 47 patients (mean age 71.1y [SD, 15.8]; 55% female) were determined to have a significant degree of disability, or were deceased (8, mRS 3; 10, mRS 4; 15, mRS 5; 14, mRS 6). Average Fazekas scores were (mRS 3, 1.75; mRS 4, 1.90; mRS 5, 2.13; mRS 6, 1.93; 1.96). Potentially confounding variables, including the use of intravenous alteplase (78% vs. 76%), and door to groin puncture time (204m [SD, 74m] vs. 206m [SD, 54m]) were found to be non-significant contributors. Conclusion: Based on our analytical cohort of ELVO patients undergoing thrombectomy, CSVD burden, classified by Fazekas score on T2-FLAIR MRI, was found to correlate with worse 90-day mRS. These results may be explained by potentially poor cerebrovascular reserve and diminished collateral blood flow in patients with greater CVSD burden.
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