Prolonged venous transit on perfusion imaging predicts discharge Cog-4 scores in anterior-circulation large-vessel occlusion stroke

Post-stroke cognitive impairment is common after acute ischemic stroke, yet early cognitive deficits are often underrecognized in routine care. Prolonged venous transit (PVT) on perfusion imaging reflects impaired venous drainage and has been linked to worse functional outcomes in large-vessel occlusion (LVO) stroke, but its relationship with early cognitive impairment remains unclear. In this retrospective study, we evaluated consecutive patients with anterior-circulation LVO who underwent baseline perfusion imaging and had a documented discharge Cog-4 score (derived from four NIHSS items: orientation, command following, language, and attention/neglect). PVT was defined as a Tmax delay ≥10 s within the posterior superior sagittal sinus or torcula. The primary outcome was discharge Cog-4 score. Among 253 patients, 85 (34%) had PVT. Patients with PVT had higher Cog-4 scores than those without PVT (median, 2 vs 0; P < 0.001). In multivariable linear regression adjusting for age, admission NIHSS score, occlusion laterality, and follow-up infarct volume, PVT remained independently associated with higher Cog-4 scores (β, 0.63; 95% CI, 0.07–1.2; P = 0.029). A multivariable model demonstrated good discrimination for identifying normal or minimal impairment (Cog-4 score 0–1) with an area under the curve of 0.86 (95% CI, 0.81–0.90). These findings suggest that venous outflow impairment on baseline perfusion imaging is independently associated with early cognitive dysfunction at hospital discharge and may serve as a practical imaging marker for early cognitive risk stratification in anterior-circulation LVO stroke.