Collaterals and Outcomes After Endovascular Treatment in Acute Large Vessel Occlusion: Disparity by Stroke Etiologies

Background: Collateral circulation provides compensatory flow to ischemic brain regions in acute large vessel occlusion (LVO), which had been associated with better outcomes after endovascular treatment (EVT).

Aims: We aimed to reveal the pre-EVT collateral status and its associations with outcomes after EVT, in patients with acute LVO with different etiologies.

Methods: Based on a prospective, multicenter registry, we analyzed patients with acute, intracranial anterior-circulation LVO due to large artery atherosclerosis (LAA) and cardioembolism (CE), who underwent EVT within 24 h. Pre-EVT leptomeningeal collateral status was classified on digital subtraction angiography by ASITN/SIR grading system. Outcomes included good 3-month functional outcome (modified Rankin Scale [mRS] 0-2), 3-month mRS distribution, successful recanalization, early neurological deterioration, symptomatic intracranial hemorrhage (sICH), and 3-month mortality.

Results: Among 805 patients (median age 66 years), 450 and 355, respectively, had LVO due to LAA and CE, of whom 57.8% and 56.6% ( = 0.742) had good pre-EVT collaterals. In LAA patients, good collaterals were associated with lower risk of sICH (adjusted odds ratio [OR]= 0.40; 95% CI = 0.17-0.94;  = 0.036) but not functional outcomes. In CE patients, good collaterals were associated with a higher chance of good functional outcome (adjusted OR = 1.55; 95% CI = 0.96-2.51;  = 0.072) and lower mRS at 3 months (adjusted common OR = 0.64; 95% CI = 0.43-0.94;  = 0.021). However, there was no significant CE/LAA and collateral status interaction on any outcome.

Conclusions: The study revealed comparable pre-EVT collateral status in patients with LVO due to LAA versus CE who received EVT within 24 h, but the pre-EVT collaterals may have different protective effects for post-EVT outcomes in these two groups of patients.