Prolonged Venous Transit Is Associated with Unfavorable Functional Outcomes in Large-Core Stroke

BACKGROUND AND PURPOSE: Large-core acute ischemic stroke caused by large-vessel occlusion (LVO) is associated with high rates of disability despite mechanical thrombectomy. Prolonged venous transit (PVT), a marker of impaired venous drainage on CTP, has emerged as a potential prognostic indicator, but its role in large-core acute ischemic stroke (AIS)-LVO remains unclear. We aimed to test the hypothesis that PVT is independently associated with unfavorable functional outcomes in patients with large-core AIS-LVO. MATERIALS AND METHODS: We conducted a retrospective cohort study using data from consecutive patients with AIS-LVO and large ischemic core volumes (ASPECTS,6 or relative CBF (rCBF),30% volume $50 mL; per the SELECT-2 trial definition) between September 1, 2016, and September 2, 2024. PVT was assessed on pretreatment CTP based on qualitative time-to-maximum maps and was defined as time-to-maximum $10 seconds in the superior sagittal sinus or torcula. The primary outcome was unfavorable functional recovery at 90 days, defined as an mRS score of 4–6. RESULTS: One hundred patients met the inclusion criteria, and 41 (41%) had PVT. Unfavorable functional outcomes were more frequent in the PVT1 group (59% versus 37%; P ¼ .036). Multivariable analysis confirmed that PVT was independently associated with unfavorable outcomes (adjusted OR, 4.07; 95% CI, 1.15–14.4; P ¼ .03), even after accounting for penumbra size (time-to-maximum ¼ .6s) and large-core volumes (rCBF,30%). Other predictors included older age (adjusted OR, 1.07; 95% CI, 1.02–1.11; P ¼ .003), higher admission NIHSS (adjusted OR, 1.16; 95% CI, 1.05–1.29; P ¼ .005), and larger rCBF,30% volume (adjusted OR, 1.02; 95% CI, 1.00–1.04; P ¼ .032). CONCLUSIONS: PVT is independently associated with unfavorable outcomes in patients with large core AIS-LVO. These findings suggest that PVT may serve as a prognostic marker, warranting further investigation and validation in larger prospective studies to guide treatment decisions in this high-risk population.