Clinical implications of cerebral venous outflow pattern in malignant middle cerebral artery infarction

Background: Malignant middle cerebral artery (MCA) infarction is one of the most devastating strokes. However, the role of the cerebral venous outflow pattern in malignant MCA infarction is not well established. We investigated the association between the transverse sinus (TS) shape and functional outcomes in patients with malignant MCA infarction. Methods: This retrospective cohort study included patients with malignant MCA infarction. Baseline characteristics, clinical variables, and cerebral venous outflow patterns (TS shape) were obtained. Incomplete TS shapes are referred to as unilateral TS hypoplasia, TS aplasia, or TS occlusion. We analyzed the effect of an incomplete TS shape on functional outcomes after malignant MCA infarction. The main outcome assessed was the change in ordinal shifts within the modified Rankin Scale score, indicating a deterioration in the outcome at three months. Results: Among 71 patients with malignant MCA infarction, incomplete TS shapes were observed in 33 (46.5 %). There were no significant differences in the baseline characteristics, vascular risk factors, or factors associated with malignant MCA infarction. Patients with incomplete TS shapes had a higher proportion of unfavorable functional outcomes (5.0 [4.0-5.0] vs. 5.0 [5.0-6.0], P < 0.001). Multivariable ordinal logistic regression analysis showed that patients with incomplete TS shapes (odds ratio = 6.30, 95 % confidence interval = 2.42-17.90, P < 0.001) had a substantial shift towards the unfavorable functional outcome at 3 months. Conclusions: Among patients diagnosed with malignant MCA infarction, those with incomplete TS shapes had poorer functional outcomes and higher mortality rates. This underscores the significant clinical association between cerebrovenous patterns and functional outcomes.