Comprehensive venous outflow is the optimal venous score in predicting functional outcome in acute ischemic stroke patients

Background: Venous outflow (VO) is a promising prognostic imaging biomarker in acute ischemic stroke (AIS) patients selected for endovascular treatment (EVT). However, the best score for properly assessing VO profiles on multi-phase CT-Angiography (mCTA) remains to be identified. Methods: A series of consecutive AIS patients undergoing EVT for large vessel occlusion within 24 h from symptom onset were investigated. The following scores were rated: cortical vein score difference in stroke (PRECISE, range 0–8), cortical vein opacification score (COVES, range 0–6), comprehensive venous outflow (CVO, range 0–8) and internal cerebral vein (ICV) asymmetry. Receiver operating characteristic curves and multivariable logistic regression analyses were performed to explore the performance of the different VO scores for prediction of a good outcome (modified Rankin Scale 0–2 at 3 months). Results: Three hundred and thirty-six subjects (56.2% females, mean age 74.8) were included, of whom 145 (43.1%) had good outcomes. In multivariable logistic analysis, the CVO score (odds ratio = 2.51, 95% CI = 1.49–4.18, p =.001) was the only independent predictor of good functional outcomes. The AUC of the CVO score was.75 (95% CI =.70–.80), with an optimal cut-off of ≥4 (sensitivity 56%, specificity 69%). Patients with favourable CVO profiles had better pial arterial (70.7%, p <.001) and hypoperfusion intensity ratio (HIR) tissue-related collaterals (HIR =.35, p =.005), higher rates of successful recanalization (95.7%, p <.001) and lower symptomatic intracranial haemorrhage occurrence (6%, p =.020) than those with unfavourable CVO profiles. Conclusion: The CVO score measured on mCTA had the best discriminative performance and was independently associated with functional outcome in AIS patients undergoing EVT within 24 h from onset.