Abstract
IntroductionPoor leptomeningeal collateral flow is related to worse clinical outcome in acute ischemic stroke, but the factors that determine leptomeningeal collateral patency are largely unknown. We explored the determinants of leptomeningeal collateral flow and assessed their effect on the relation between leptomeningeal collateral flow and clinical outcome.MethodsWe included 484 patients from the Dutch acute stroke study (DUST) with a middle cerebral artery (MCA) occlusion. The determinants of poor leptomeningeal collateral flow (≤50 % collateral filling) were identified with logistic regression. We calculated the relative risk (RR) of poor leptomeningeal collateral flow in relation to poor clinical outcome (90-day modified Rankin Scale 3–6) using Poisson regression and assessed whether the determinants of leptomeningeal collateral flow affected this relation.ResultsLeptomeningeal collateral flow was poor in 142 patients (29 %). In multivariable analyses, higher admission glucose level (odds ratio (OR) 1.1 per mmol/L increase (95 % CI 1.0–1.2)), a proximal MCA occlusion (OR 1.9 (95 % CI 1.3–3.0)), and an incomplete posterior circle of Willis (OR 1.7 (95 % CI 1.1–2.6)) were independently related to poor leptomeningeal collateral flow. Poor leptomeningeal collateral flow was related to poor clinical outcome (unadjusted RR 1.7 (95 % CI 1.4–2.0)), and this relation was not affected by the determinants of leptomeningeal collateral flow.ConclusionOur study shows that admission glucose level, a proximal MCA occlusion, and an incomplete ipsilateral posterior circle of Willis are determinants of leptomeningeal collateral flow that represent a combination of congenital, acquired, and acute factors. After adjustment for these determinants, leptomeningeal collateral flow remains related to clinical outcome.
Highlights
Poor leptomeningeal collateral flow is related to worse clinical outcome in acute ischemic stroke, but the factors that determine leptomeningeal collateral patency are largely unknown
Our study shows that admission glucose level, a proximal middle cerebral artery (MCA) occlusion, and an incomplete ipsilateral posterior circle of Willis are determinants of leptomeningeal collateral flow that represent a combination of congenital, acquired, and acute factors
After adjustment for these determinants, leptomeningeal collateral flow remains related to clinical outcome
Summary
A total of 489 patients had an occlusion of an M1 or M2 segment on admission CTA (Fig. 1). Univariable logistic regression analyses showed that higher admission glucose levels, presence of a proximal intracranial occlusion, and an incomplete ipsilateral posterior circle of Willis were related to poor leptomeningeal collateral flow (Table 2). All variables that were determinants of poor leptomeningeal collateral flow in univariable analyses were related to poor leptomeningeal collateral flow in multivariable logistic regression analyses (Table 3) These analyses show that higher admission glucose levels (OR 1.1 per mmol/L increase (95 % CI 1.0–1.2)), presence of a proximal MCA occlusion (OR 1.9 (95 % CI 1.3–3.0)), and an incomplete posterior circle of Willis (OR 1.7 (95 % CI 1.1–2.6)) were independently related to poor leptomeningeal collateral flow. The corresponding unadjusted RR for the relation between poor leptomeningeal collateral flow and poor clinical outcome was 1.7 (95 % CI 1.4–2.0) In multivariable analyses this relation was not affected by the determinants of poor leptomeningeal collateral flow: admission glucose level, presence of a proximal MCA occlusion, and circle of Willis completeness (Table 4). There was no interaction of admission glucose level, presence of a proximal MCA occlusion, and circle of Willis completeness with the patency of leptomeningeal collaterals for their relation with clinical outcome (all interaction term p values >0.05)
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