J Stroke.  2022 Sep;24(3):372-382. 10.5853/jos.2022.01046.

Venous Outflow Profiles Are Linked to Clinical Outcomes in Ischemic Stroke Patients with Extensive Baseline Infarct

  • 1Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  • 2Central Institute of Mental Health, Medical Faculty Mannheim, Mannheim, Germany
  • 3Department of Neuroradiology, Erasme Medical Center, Brussels, Belgium
  • 4Department of Radiology, Jessenius Faculty of Medicine in Martin Clinic of Radiology, Comenius University in Bratislava, Martin, Slovakia
  • 5Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
  • 6Department of Diagnostic and Interventional Neuroradiology, University Medical Hospital Basel, Basel, Switzerland
  • 7Department of Neuroradiology, MD Andersen Cancer Center, Houston, TX, USA
  • 8Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA


Background and Purpose
The benefit of endovascular thrombectomy (EVT) treatment is still unclear in stroke patients presenting with extensive baseline infarct. The use of additional imaging biomarkers could improve clinical outcome prediction and individualized EVT selection in this vulnerable cohort. We hypothesized that cerebral venous outflow (VO) may be associated with functional outcomes in patients with low Alberta Stroke Program Early CT Score (ASPECTS).
We conducted a retrospective multicenter cohort study of patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). Extensive baseline infarct was defined by an ASPECTS of ≤5 on admission computed tomography (CT). VO profiles were assessed on admission CT angiography using the Cortical Vein Opacification Score (COVES). Favorable VO was defined as COVES ≥3. Multivariable logistic regression was used to determine the association between cerebral VO and good clinical outcomes (90-day modified Rankin Scale score of ≤3).
A total of 98 patients met the inclusion criteria. Patients with extensive baseline infarct and favorable VO achieved significantly more often good clinical outcomes compared to patients with unfavorable VO (45.5% vs. 10.5%, P<0.001). Higher COVES were strongly associated with good clinical outcomes (odds ratio, 2.17; 95% confidence interval, 1.15 to 4.57; P=0.024), independent of ASPECTS, National Institutes of Health Stroke Scale, and success of EVT.
Cerebral VO profiles are associated with good clinical outcomes in AIS-LVO patients with extensive baseline infarct. VO profiles could serve as a useful additional imaging biomarker for treatment selection and outcome prediction in low ASPECTS patients.


Ischemic stroke; Cerebral edema; Cerebrovascular circulation; Thrombectomy; Neuroimaging


  • Figure 1. Patient with acute ischemic stroke due to occlusion of the right internal carotid artery presenting with favorable cerebral venous outflow profile. Green arrows indicate moderate/full venous contrast filling of the (A) vein of Labbé, (B) superficial middle cerebral vein, and (C) sinus sphenoparietalis. Red arrow indicates missing venous contrast filling.

  • Figure 2. Venous outflow profiles stratified by clinical outcome. Note that the rate of favorable cortical venous outflow (Cortical Vein Opacification Score [COVES] ≥3) was significantly higher in patients with good clinical outcome (GCO) compared to poor clinical outcome (PCO) (P≤0.001; black dashed line).

  • Figure 3. Alluvial diagram illustrating the clinical outcome (90-day modified Rankin Scale [mRS]) in relation to stroke extent on pretreatment non-contrast computed tomography (Alberta Stroke Program Early CT Score [ASPECTS]) and cortical venous outflow (Cortical Vein Opacification Score [COVES]). Green color spectrum for stream fields between blocks indicates good clinical outcome (GCO) and red color spectrum indicates poor clinical outcome (PCO). Note that no patient with an ASPECTS of 0 to 2 achieved GCO (dark red), while almost one in two with GCO exhibited favorable venous outflow (COVES ≥3; dark green).

  • Figure 4. Predicted probabilities from the multivariable logistic regression model displayed in Table 3. Note that more favorable venous outflow (VO), higher Alberta Stroke Program Early CT Score (ASPECTS) and excellent mechanical recanalization thrombolysis in cerebral infarction (TICI) 2c/3 clearly increased the predicted probability of good clinical outcome (90-day modified Rankin Scale [mRS] of 0–3). Cortical Vein Opacification Score (COVES) was kept constant at 0 and 3 for (A) poor VO and (B) favorable VO, respectively. Admission National Institutes of Health Stroke Scale (NIHSS) was kept constant at 18 (median admission NIHSS). Shaded error bars represent one standard deviation.



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