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Venous imaging-based biomarkers in acute ischaemic stroke
  1. Josep Munuera1,
  2. Gerard Blasco2,3,
  3. María Hernández-Pérez4,
  4. Pepus Daunis-i-Estadella5,
  5. Antoni Dávalos4,
  6. David S Liebeskind6,
  7. Max Wintermark7,
  8. Andrew Demchuk8,
  9. Bijoy K Menon8,
  10. Götz Thomalla9,
  11. Kambiz Nael10,
  12. Salvador Pedraza3,11,
  13. Josep Puig2,3
  1. 1Diagnostic Imaging Institute (IDI), Germans Trias i Pujol University Hospital, Badalona, Spain
  2. 2Institute of Diagnostic Imaging (IDI)—Research Unit (IDIR), Girona, Spain
  3. 3Girona Biomedical Research Institute (IDIBGI)—Medical Imaging, Girona, Spain
  4. 4Stroke Unit, Germans Trias i Pujol University Hospital, Badalona, Spain
  5. 5Department of Computer Science, Applied Mathematics and Statistics, University of Girona, Girona, Spain
  6. 6Neurovascular Imaging Research Core and UCLA Stroke Center, Los Angeles, California, USA
  7. 7Department of Radiology, Neuroradiology Division, Stanford University, Stanford, California, USA
  8. 8Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
  9. 9Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
  10. 10Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  11. 11Institute of Diagnostic Imaging (IDI)—Dr. Josep Trueta University Hospital, Girona, Spain
  1. Correspondence to Dr Josep Munuera, Diagnostic Imaging Institute (IDI), Germans Trias i Pujol University Hospital, Crta. de Canyet, s/n Badalona 08916, Spain; josep.munuera{at}


Vascular neuroimaging plays a decisive role in selecting the best therapy in patients with acute ischaemic stroke. However, compared with the arterial system, the role of veins has not been thoroughly studied. In this review, we present the major venous imaging-based biomarkers in ischaemic stroke. First, the presence of hypodense veins in the monophasic CT angiography ipsilateral to the arterial occlusion. Second, the asymmetry of venous drainage in the pathological cerebral hemisphere on CT and MRI dynamic angiography. Finally, the presence of hypodense veins on T2* -based MRI. From the physiological point of view, the venous imaging-based biomarkers would detect the alteration of brain perfusion (flow), as well as the optimisation of extraction oxygen mechanisms (misery perfusion). Several studies have correlated the venous imaging-based biomarkers with grade of collateral circulation, the ischaemic penumbra and clinical functional outcome. Although venous imaging-based biomarkers still have to be validated, growing evidence highlights a potential complementary role in the acute stroke clinical decision-making process.

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  • Contributors JM, AD and JP had the idea for the article. JM wrote the article. JM and MH-P performed the literature search. GB, MH-P, PD-i-E, AD, DSL, MW, AD, BKM, GT, KN and SP drafted and revised the manuscript. JP is the guarantor.

  • Competing interests JM reports other from Guerbet, outside the submitted work. DSL reports grants from NIH, other from Stryker, other from Medtronic, outside the submitted work. In addition, DSL has a patent PCT/US2008/082161 pending, and a patent 20120136240 pending. GT reports grants from European Commission, personal fees from Acandis, grants and personal fees from Bayer Healthcare, personal fees from Boehringer Ingelheim, personal fees from BMS/Pfizer, personal fees from Daichii-Sankyo, personal fees from GSK, outside the submitted work. MW reports personal fees from GE NFL Advisory Board, outside the submitted work.

  • Provenance and peer review Not commissioned; externally peer reviewed.