Physiologic predictors of collateral circulation and infarct growth during anesthesia - Detailed analyses of the GOLIATH trial

Abstract

Collateral circulation plays a pivotal role in acute ischemic stroke due to large vessel occlusion (LVO) and may be affected by multiple variables during sedation for endovascular therapy (EVT). We conducted detailed analyses of the GOLIATH trial to identify predictors of collateral circulation grade and infarct growth. We also modified the ASITN collateral grading scale and sought to determine its impact on clinical outcome and infarct growth. Multivariable analysis was used to identify predictors of collaterals and infarct growth. Ordinal analysis demonstrated nominal, but non-significant association between modified ASITN scale and infarct growth. Among all analyzed baseline clinical and procedural variables, the most significant predictors of infarct growth at 24 h were phenylephrine dose (estimate 6.78; p = 0.014) and baseline infarct volume (estimate 0.93; p = 0.03). The most significant predictors of worse collateral grade were mean arterial pressure (MAP) <70 mmHg (OR 0.35; p = 0.048) and baseline infarct volume (OR 0.96; p = 0.003). Hypotension during sedation for EVT for LVO negatively impacts collateral circulation, while higher pressor dose is a strong predictor of infarct growth. Avoidance of anesthesia-induced hypotension and consequent need for pressor therapy may prevent collateral failure and minimize infarct growth.

Keywords: Anesthesia; collaterals; hypotension; stroke; thrombectomy.

Figure 1.

Lateral projection angiographic images obtained in the venous phase in setting of M1 occlusions in three different patients. The images demonstrate examples of different collateral grades according to the modified ASITN grading scale: (a) Rapid collaterals to the periphery of the ischemic site with filling in <50% of the MCA territory, corresponding to ASITN grade 2−. (b) Rapid collaterals to the periphery of the ischemic site with filling in ≧50% of the MCA territory, corresponding to ASITN grade 2+ (c). Collaterals with slow but complete angiographic flow of the ischemic bed, corresponding to ASITN grade 3.

Figure 2.

Modified ASITN grades distribution according to ETCO₂ values. Numbers within each colored region represent the percentage of patients with the corresponding modified ASITN grades.

Figure 3.

Ninety-day mRS outcomes according to modified ASITN grading scale. Stacked bar graphs demonstrate full mRS outcome distributions for the examined cohort divided into four groups based on modified ASITN grading scale. Numbers within each colored region represent the percentage of patients with the corresponding mRS outcome grade for that group.

Figure 4.

Infarct growth according to modified ASITN collateral grade. Bar plots represent infarct growth volume in each collateral grade category.