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Publications

Journal Article Epublish

PubMed: 42729172 DOI: 10.3389/fneur.2026.1819534

Baseline prolonged venous transit on CT perfusion predicts the post-treatment Brush Sign after successful reperfusion in acute ischemic stroke patients.

Front Neurol 17:1819534

Authors: Derek A Tsang, Mona Gad, Andrew Cho, Karthik Lalwani, Hamza Salim, Dhairya Lakhani, Cynthia Greene, Manisha Koneru, Adam Dmytriw, Adrien Guenego, Ferdinand Hui, Jeremy Heit, Tobias Faizy, Greg Albers, Hanzhang Lu, Yasmin Aziz, Aakanksha Sriwastaw, Vivek Yedavalli

Affiliations

  • Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medicine, Baltimore, MD, United States.
  • Department of Neuroradiology, MD Anderson Medical Center, Houston, TX, United States.
  • WVU Rockefeller Neuroscience Institute, Morgantown, WV, United States.
  • Cooper University Health Care, Camden, NJ, United States.
  • Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
  • Universite Libre de Bruxelles, Brussels, Belgium.
  • The Queen's Medical Center, Honolulu, HI, United States.
  • Division of Neuroimaging and Neurointervention, Stanford University, Stanford, CA, United States.
  • Universitatsklinikum Munster, Münster, Germany.
  • University of Cincinnati, Cincinnati, OH, United States.

Abstract

BACKGROUND

Prolonged venous transit (PVT) on computed tomography perfusion (CTP) indicates impaired macroscopic venous outflow. The Brush Sign on susceptibility-weighted imaging (SWI) reflects microvascular venous congestion and the "no-reflow" phenomenon. We investigated whether pre-treatment PVT independently predicts the post-treatment Brush Sign in patients with anterior circulation acute ischemic stroke with large-vessel occlusion (AIS-LVO) following successful mechanical thrombectomy (MT).

METHODS

We retrospectively analyzed patients with anterior-circulation acute ischemic stroke due to large-vessel occlusion who achieved successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] 2b-3) and underwent post-treatment magnetic resonance imaging (MRI). Pre-treatment PVT positivity (Tmax ≥10 s in the superior sagittal sinus and/or torcula) was evaluated on baseline CTP. The primary outcome was the presence of the Brush Sign on follow-up SWI. A multivariable logistic regression model evaluated the independent association between PVT and the Brush Sign, adjusting for age, admission National Institutes of Health Stroke Scale (NIHSS), intravenous thrombolysis, final infarct volume, mTICI score, and baseline Alberta Stroke Program Early CT Score (ASPECTS).

RESULTS

Of 187 included patients, 29 (15.5%) demonstrated the Brush Sign. Pre-treatment PVT + was significantly more prevalent in patients who developed the Brush Sign (48.3% vs. 27.2%, p = 0.02). In the adjusted multivariable model (N = 130), PVT + remained a strong, independent predictor of the Brush Sign (OR 3.82, 95% CI 1.32-11.77, p = 0.02). The association remained robust across sensitivity analyses accounting for MRI timing, complete reperfusion, occlusion segment, and suspected stroke etiology.

CONCLUSION

Pre-treatment PVT independently predicts the post-treatment Brush Sign in AIS-LVO patients despite successful macrovascular reperfusion. This finding links macroscopic venous congestion to downstream microvascular failure, highlighting PVT as an easily accessible imaging biomarker for anticipating the no-reflow phenotype.

MeSH

Ischemic Stroke, Stroke, Reperfusion, Therapeutics