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Collateral Circulation in Endovascular Therapy

for Acute Ischemic Stroke:

Smaller Strokes, Improved Reperfusion, Less

Hemorrhagic Transformation and Better Outcomes

David S Liebeskind, MD

Professor of Neurology & Director of Stroke Imaging

Associate Neurology Director, UCLA Stroke Center

Consultant to Concentric Medical and CoAxia

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Collateral Circulation in Endovascular Therapy

for Acute Ischemic Stroke:

Smaller Strokes, Improved Reperfusion, Less Hemorrhagic

Transformation and Better Outcomes

David S Liebeskind

Qing Hao

Nerses Sanossian

Jessica S Choe

Albert K Fong

Radoslav Raychev

Latisha K Ali

Doojin Kim

Sidney Starkman

Paul M Vespa

Hermelinda G Abcede

Peter Adamczyk

Nestor R Gonzalez

Satoshi Tateshima

Reza Jahan

Gary R Duckwiler

Fernando Vinuela

Jeffrey L Saver

for the UCLA Collateral Investigators

University of California, Los Angeles

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Collaterals

Collateral circulation moderates the impact of acute

cerebral occlusion and may influence outcome from

recanalization treatment

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Collaterals

Noninvasive angiography provides some information on

collateral status, but catheter angiography prior to

endovascular therapy remains a unique opportunity to

verify collateral grade

Spatial and temporal features may extend our knowledge

on pathophysiology and treatment of other strokes

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Objective

We conducted a comprehensive study of collaterals in

acute anterior circulation occlusion to substantiate

previous associations with collaterals and their impact on

endovascular stroke therapy

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Methods

Consecutive patients undergoing endovascular therapy

for acute ischemic stroke due to anterior circulation

occlusion were analyzed with respect to collaterals

Collateral grade was assessed with the ASITN/SIR scale on

baseline angiography

Univariate and multivariate regression analyses detailed

the relationship of collateral grade with clinical, laboratory

and imaging parameters

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ASITN/SIR collateral grade

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Results

113 patients, mean age was 66.9±17 years, 61.9% were

female and pretreatment NIHSS median 17 (range 2-38)

Proportion of cases in each collateral grade:

0 - 3.5%

1 - 13.3 %

2 - 38.9%

3 - 31%

4 - 13.3%

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Correlates of collaterals

Age and gender not associated with the degree of

collateral circulation

Among medical history and laboratory variables, on

multivariate ordinal regression

only predictor of more robust collaterals was current statin

use (b 1.413, p=0.020)

predictors of worse collaterals were history of hyperlipidemia

(b -1.872, p=0.001), White population (b -1.361, p=0.007) and

higher WBC (b -0.306, p=0.044)

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Smaller strokes

More extensive collaterals correlated with smaller baseline

DWI lesion volume (b 0.025, p=0.001)

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Improved reperfusion

Angiographic collateral grade did not correlate with PWI

lesion volumes for Tmax thresholds at 2, 4, 6, or 8 seconds

More robust collaterals were associated with higher TICI

reperfusion rates (ρ0.191, p=0.043)

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Less hemorrhagic transformation

Better collaterals had lower hemorrhagic transformation

rates (ρ -0.229, p=0.015)

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Better outcomes

mRS at discharge inversely correlated with collateral

grade (ρ -0.317, p=0.001)

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Limitations

Limitations include retrospective nature, confounding

factors, prior associations noted, yet first simultaneous

description of all implications

Correlation versus causality?

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Future of collaterals?

Incorporate critical information on collaterals or

alternative?

Next stage – systematic evaluation of collaterals

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Conclusion

Extent of collateral circulation before endovascular

therapy exhibits a striking impact on achievement of

reperfusion, tissue fate and functional outcome

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