HomeStroke: Vascular and Interventional NeurologyVol. 2, No. 6Venous Outflow and Parenchymal Hemorrhage: A Clogged Drain Problem? Open AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessEditorialPDF/EPUBVenous Outflow and Parenchymal Hemorrhage: A Clogged Drain Problem? Tobias D. Faizy, MD and Jeremy J. Heit, MD, PhD Tobias D. FaizyTobias D. Faizy , Department of Diagnostic and Interventional Neuroradiology, , University Medical Center Hamburg‐Eppendorf, , Hamburg, , Germany, Search for more papers by this author and Jeremy J. HeitJeremy J. Heit *Correspondence to: Jeremy J. Heit, MD, PhD, Department of Radiology, Stanford University, Stanford, CA 94305. E‐mail: E-mail Address: [email protected] , Department of Radiology, , Stanford University, , Stanford, , CA, Search for more papers by this author Originally published23 Nov 2022https://doi.org/10.1161/SVIN.122.000672Stroke: Vascular and Interventional Neurology. 2022;2:e000672Endovascular thrombectomy has become the standard treatment of acute ischemic stroke due to large vessel occlusion (AIS‐LVO), and successful thrombectomy leads to improved patient outcomes.1, 2 A number of well‐described imaging factors may be used to evaluate suitable approaches to thrombectomy treatment and can help to predict procedural outcomes in stroke patients, and efforts are increasingly focused on identifying predictors of poor outcome despite successful thrombectomy.3Reperfusion hemorrhage is common after thrombectomy, and it has been linked to poor outcomes in patients. Parenchymal hematomas (PHs) are the most severe form of reperfusion hemorrhage and are associated with worse clinical outcomes and increased mortality.3, 4, 5 Given the clinical importance of PH, several prior studies have sought to identify imaging biomarkers that predict PH development. Very low cerebral blood volume, lower Alberta Stroke Program Early Computed Tomography (CT) Score, and the presence of an early cerebral vein assessed on postreperfusion digital subtraction angiography have been associated with an increased risk of PH.6, 7, 8 In composite, these studies suggest that impaired microvascular blood flow, poor tissue microperfusion, and blood–brain barrier disruption may play a pivotal role in PH development. The identification of new imaging biomarkers that predict PH development is of high interest and will guide future studies designed to test therapies that might reduce the frequency and impact of PH.Venous outflow (VO) in AIS‐LVO patients has emerged as an important measure of brain perfusion, collateral status, and the robustness of microvascular perfusion.9, 10, 11, 12, 13, 14 As opposed to conventional CT angiography‐based or even CT perfusion‐based imaging biomarkers of collateralization, information about cortical venous contrast opacification may be a more sensitive measure of tissue perfusion, as it reflects blood flow exiting the ischemic tissue.15 However, whether VO governs the development of PH after thrombectomy remains poorly described.16In this issue of Stroke: Vascular and Interventional Neurology (SVIN), the ESCAPE‐NA1 (Safety and Efficacy of Nerinetide (NA‐1) in Subjects Undergoing Endovascular Thrombectomy for Stroke) investigators asked whether VO predicts PH development in AIS‐LVO patients.17 The authors looked at 545 patients in the ESCAPE‐NA1 study and scored VO on prethrombectomy CT angiography.13 They found that PH was more commonly observed in patients with poor VO compared with those with good VO (15.2% versus 4.7%). In addition, poor VO was strongly associated with unfavorable clinical outcomes.The results of this study add knowledge to our understanding of cerebral perfusion in AIS‐LVO patients and the consequences of poor venous egress. It has been presumed that the most critical patterns of hypoperfusion are reflected by the most distally located cerebral vessels; that is, small cerebral arteries and arterioles, capillaries, and the venous drainage of these microvascular structures.18 Thus, CT‐derived information of VO profiles may fill the gap of a need for a reliable and comparatively easily assessable imaging biomarker that reflects these critical patterns of hypoperfusion and the extent of ischemic damage. As the authors point out, poor venous contrast opacification may reflect the presence of impaired cerebral perfusion and indicate a higher likelihood of irreversible ischemic damage, which highlights the importance of venous assessment in hemorrhagic risk stratification. In addition, and similar to the manner in which patients with venous sinus thrombosis develop intra‐PH, the author's findings suggest that adequate egress for blood to exit ischemic brain tissue is needed to avoid PH development in AIS‐LVO patients after thrombectomy.The finding that poor VO is strongly associated with both postthrombectomy PH13, 16 and poor clinical outcomes10, 13 raises the possibility of using VO as a selection criterion to determine thrombectomy treatment eligibility. In addition, VO may be a useful imaging marker to identify patients for future neuroprotective trials designed to prevent reperfusion hemorrhage and to improve clinical outcomes. Prospective studies are warranted to test this hypothesis.This study has some limitations. The study is a post hoc analysis of a randomized trial with strict selection criteria, and VO assessment was not a prespecified aim or variable m in the ESCAPE‐NA1 trial. Symptomatic hemorrhage was not assessed, due to the low incidence of patients with this entity. Finally, VO scores were not compared to measures of perfusion imaging, which could provide additional insights into understanding stroke pathophysiology and the impact of venous drainage on cerebral hemodynamics.VO profiles have not yet been investigated in prospective randomized clinical trials. More studies of that nature are warranted, and further validation is needed to cement this important concept and imaging biomarker in AIS‐LVO patients. In addition, methods to automate VO detection may facilitate wider adoption and standardization.In conclusion, this interesting study adds further value of VO in the evaluation of AIS‐LVO patients. We look forward to additional studies into VO that will continue to improve our understanding of stroke pathophysiology, patient stratification for future studies, and prognostication.Sources of FundingNone.DisclosureJeremy J. Heit is a consultant for Medtronic and MicroVention and a member of the medical and scientific advisory board for iSchemaView.AcknowledgmentsNone.Footnotes*Correspondence to: Jeremy J. Heit, MD, PhD, Department of Radiology, Stanford University, Stanford, CA 94305. E‐mail: [email protected]eduThe opinions expressed in this article are not necessarily those of the editors, the American Heart Association, or the Society of Vascular and Interventional Neurology.References1 Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega‐Gutierrez S, McTaggart RA, Torbey MT, Kim‐Tenser M, Leslie‐Mazwi T, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med. 2018; 378:708‐718. https://doi.org/10.1056/NEJMoa1713973CrossrefMedlineGoogle Scholar2 Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, Roy D, Jovin TG, Willinsky RA, Sapkota BL, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. 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Published on behalf of the American Heart Association, Inc., and the Society of Vascular and Interventional Neurology by Wiley Periodicals LLC.This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.https://doi.org/10.1161/SVIN.122.000672 Manuscript receivedSeptember 20, 2022Manuscript acceptedOctober 4, 2022Originally publishedNovember 23, 2022 PDF download