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Prolonged Venous Transit Is Associated with Unfavorable Functional Outcomes in Large-Core Stroke

Hamza Adel Salim1,2, Dhairya A Lakhani1,3, Janet Mei1

  • 1From the Department of Radiology (H.A.S., D.A.L., J.M., M.S., M.H., E.B.M., H.L., R.X., R. Leigh, A.E.H., R. Llinas, V.Y.), Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland.

AJNR. American Journal of Neuroradiology
|October 16, 2025
PubMed

Insights

Prolonged venous transit (PVT) is linked to poor outcomes in large core acute ischemic stroke (AIS) with large vessel occlusion (LVO). This finding suggests PVT may help predict patient recovery after stroke treatment.

Area of Science:

  • Neurology
  • Radiology
  • Cardiovascular Research

Background:

  • Large core acute ischemic stroke (AIS) due to large vessel occlusion (LVO) often results in significant disability, even after mechanical thrombectomy (MT).
  • Prolonged venous transit (PVT), identified on CT perfusion scans, indicates impaired venous drainage and is a potential prognostic marker.
  • The prognostic value of PVT in patients with large core AIS-LVO requires further clarification.

Purpose of the Study:

  • To investigate the association between prolonged venous transit (PVT) and functional outcomes in patients with large core AIS-LVO.
  • To test the hypothesis that PVT is an independent predictor of unfavorable outcomes in this patient cohort.

Main Methods:

  • Retrospective cohort study of 100 patients with AIS-LVO and large ischemic core volumes (ASPECTS <6 or rCBF <30% volume ≥50 mL) between September 2016 and September 2024.
  • PVT was assessed on pretreatment CT perfusion using time-to-maximum (Tmax) maps, defined as Tmax ≥10 seconds in the superior sagittal sinus or torcula.
  • The primary outcome was unfavorable functional recovery at 90 days (modified Rankin Scale score 4-6).

Main Results:

  • 41% of patients exhibited PVT. Unfavorable functional outcomes were significantly more common in patients with PVT (59% vs. 37%, p=0.036).
  • Multivariable analysis revealed PVT as an independent predictor of unfavorable outcomes (adjusted OR 4.07, p=0.03), even when controlling for penumbra and core volumes.
  • Other independent predictors included older age, higher admission NIHSS, and larger low relative cerebral blood flow (rCBF <30%) volumes.

Conclusions:

  • Prolonged venous transit (PVT) is independently associated with unfavorable functional outcomes in patients with large core AIS-LVO.
  • PVT may serve as a valuable prognostic marker for guiding treatment decisions in this high-risk stroke population.
  • Further prospective studies are warranted to validate these findings and their clinical utility.
Abstract

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