Collateral Circulation and Outcome in Atherosclerotic Versus Cardioembolic Cerebral Large Vessel Occlusion
Authors: Guglielmi Valeria , LeCouffe Natalie E. , Zinkstok Sanne M. , Compagne Kars C.J. , Eker Reyhan , Treurniet Kilian M. , Tolhuisen Manon. L. , van der Worp H. Bart , Jansen Ivo G.H. , van Oostenbrugge Robert J. , Marquering Henk A. , Dippel Diederik W.J. , Emmer Bart J. , Majoie Charles B.L.M. , Roos Yvo B.W.E.M. , Coutinho Jonathan M. ,   on behalf of the MR-CLEAN Registry Investigators, van der Lugt Aad , van Zwam Wim H. , Boiten Jelis , Vos Jan A. , Mulder Maxim J.H.L. , Goldhoorn Robert-Jan B. , Kappelhof Manon , Schonewille Wouter J. , Vos Jan A. , Wermer Marieke J.H. , van Walderveen Marianne A.A. , Staals Julie , van Zwam Wim H. , Hofmeijer Jeannette , Martens Jasper M. , Lycklama à Nijeholt Geert J. , Boiten Jelis , Roozenbeek Bob , de Bruijn Sebastiaan F. , van Dijk Lukas C. , Lo Rob H. , van Dijk Ewoud J. , Boogaarts Hieronymus D. , de Kort Paul L.M. , Peluso Jo P. , van den Berg Jan S.P. , van Hasselt Boudewijn A.A.M. , Aerden Leo A.M. , Dallinga René J. , Uyttenboogaart Maarten , Eshghi Omid , Schreuder Tobien H.C.M.L. , Heijboer Roel J.J. , Keizer Koos , Yo Lonneke S.F. , den Hertog Heleen M. , Sturm Emiel J.C. , van Zwam Wim H. , van der Lugt Aad , Lycklama à Nijeholt Geert J. , van Walderveen Marianne A.A. , Sprengers Marieke E.S. , Jenniskens Sjoerd F.M. , van den Berg René , Yoo Albert J. , Beenen Ludo F.M. , Postma Alida A. , Roosendaal Stefan D. , van der Kallen Bas F.W. , van den Wijngaard Ido R. , van Es Adriaan C.G.M. , Martens Jasper M. , Yo Lonneke S.F. , Vos Jan A. , Bot Joost , van Doormaal Pieter-Jan , van der Lugt Aad , van Zwam Wim H. , Lycklama à Nijeholt Geert J. , Boiten Jelis , Vos Jan A. , Schonewille Wouter J. , Hofmeijer Jeannette , Martens Jasper M. , Lo Rob H. , Hofmeijer Jeannette , Flach H. Zwenneke , Lingsma Hester F. , el Ghannouti Naziha , Sterrenberg Martin , Puppels Corina , Pellikaan Wilma , Sprengers Rita , Elfrink Marjan , de Meris Joke , Vermeulen Tamara , Geerlings Annet , van Vemde Gina , Simons Tiny , van Rijswijk Cathelijn , Messchendorp Gert , Bongenaar Hester , Bodde Karin , Kleijn Sandra , Lodico Jasmijn , Droste Hanneke , Wollaert M. , Jeurrissen D. , Bos Ernas , Drabbe Yvonne , Aaldering Nicoline , Zweedijk Berber , Khalilzada Mostafa , Venema Esmee , Chalos Vicky , Geuskens Ralph R. , van Straaten Tim , Ergezen Saliha , Harmsma Roger R.M. , Muijres Daan , de Jong Anouk , Hinsenveld Wouter , Berkhemer Olvert A. , Boers Anna M.M. , Huguet J. , Groot P.F.C. , Mens Marieke A. , van Kranendonk Katinka R. , Tolhuijsen Manon L. , Alves Heitor 
Published: October 2019

Background and Purpose—
Due to chronic hypoperfusion, cervical atherosclerosis may promote cerebral collateral circulation. We hypothesized that patients with ischemic stroke due to cervical carotid atherosclerosis have a more extensive collateral circulation and better outcomes than patients with cardioembolism. We tested this hypothesis in a population of patients who underwent endovascular treatment for large vessel occlusion.

Methods—
From the MR-CLEAN Registry (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), we selected consecutive adult endovascular treatment patients (March 2014 to June 2016) with acute ischemic stroke due to anterior circulation large vessel occlusion and compared patients with cervical carotid artery stenosis >50% to those with cardioembolic etiology. The primary outcome was collateral score, graded on a 4-point scale. Secondary outcomes included the modified Rankin Scale (mRS) score and mortality at 90 days. We performed multivariable regression analyses and adjusted for potential confounders.

Results—

Of 1627 patients in the Registry, 190 patients with cervical carotid atherosclerosis and 476 with cardioembolism were included. Patients with cervical carotid atherosclerosis were younger (median 69 versus 76 years,
P
<0.001), more often male (67% versus 47%,
P
<0.001), more often had an internal carotid artery terminus occlusion (33% versus 18%,
P
<0.001), and a lower prestroke mRS (mRS score, 0–2; 96% versus 85%,
P
<0.001), than patients with cardioembolism. Stroke due to cervical carotid atherosclerosis was associated with higher collateral score (adjusted common odds ratio, 1.67 [95% CI, 1.17–2.39]) and lower median mRS at 90 days (adjusted common odds ratio, 1.45 [95% CI, 1.03–2.05]) compared with cardioembolic stroke. There was no statistically significant difference in proportion of mRS 0–2 (aOR, 1.36 [95% CI, 0.90–2.07]) or mortality at 90 days (aOR, 0.80 [95% CI, 0.48–1.34]).

Conclusions—
Patients with stroke due to cervical carotid atherosclerosis had a more extensive cerebral collateral circulation and a slightly better median mRS at 90 days than patients with cardioembolic stroke.