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Venous attenuation was quantified in predefined cortical and deep venous structures using centerline-based segmentations and automated extraction of intraluminal Hounsfield units. Quantitative measures were compared with established visual venous outflow scores using Spearman correlation. Receiver operating characteristic (ROC) analyses assessed discrimination of visually defined opacification categories.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      A total of 242 patients were analyzed (median age 75 years; median NIHSS 14.5). Quantitative venous attenuation showed strong correlations with visual venous scores at the segment level for cortical veins (\n                      <jats:italic>\u03c1<\/jats:italic>\n                      \u2009=\u20090.72\u20130.77; all\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001). Correlations for deep venous structures were moderate overall but increased substantially in proximal occlusions. Composite quantitative metrics demonstrated moderate correlations with corresponding visual scores (\n                      <jats:italic>\u03c1<\/jats:italic>\n                      \u2009=\u20090.62\u20130.64;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001). ROC analyses showed high discrimination of venous opacification states at the segment level (AUC 0.81\u20130.95; 95% CI 0.74\u20130.97). Quantitative attenuation values remained measurable in visually non-opacified segments, indicating additional continuous information beyond ordinal grading. Results were consistent across centers and robust to arterial normalization.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Quantitative venous attenuation derived from routine CTA enables reproducible, observer-independent assessment of cerebral venous outflow, closely reflecting established visual scoring while providing additional continuous information. This approach represents a scalable imaging biomarker with direct applicability to routine stroke imaging workflows.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Key Points<\/jats:title>\n                    <jats:p>\n                      <jats:bold>\n                        <jats:italic>Question<\/jats:italic>\n                      <\/jats:bold>\n                      <jats:italic>Visual assessment of cerebral venous outflow is observer-dependent and limited to ordinal grading.<\/jats:italic>\n                    <\/jats:p>\n                    <jats:p>\n                      <jats:bold>\n                        <jats:italic>Findings<\/jats:italic>\n                      <\/jats:bold>\n                      <jats:italic>Quantitative venous attenuation derived from routine CT angiography closely reflects established visual venous outflow scores at the segment level.<\/jats:italic>\n                    <\/jats:p>\n                    <jats:p>\n                      <jats:bold>\n                        <jats:italic>Clinical relevance<\/jats:italic>\n                      <\/jats:bold>\n                      <jats:italic>Quantitative assessment of venous outflow from routine CT angiography is feasible and scalable, with direct applicability to clinical stroke imaging workflows<\/jats:italic>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00330-026-12913-w","type":"journal-article","created":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T07:44:38Z","timestamp":1790754278000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Quantitative assessment of cerebral venous outflow on routine CT angiography in acute ischemic stroke"],"prefix":"10.1007","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1631-2020","authenticated-orcid":false,"given":"Tobias D.","family":"Faizy","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Henk","family":"van Voorst","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gregory W.","family":"Albers","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vivek","family":"Yedavalli","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dhairya A.","family":"Lakhani","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maarten G.","family":"Lansberg","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Helge","family":"Kniep","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christian","family":"Heitkamp","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexander","family":"Heitkamp","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul Christian","family":"Stracke","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hermann","family":"Kr\u00e4hling","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ren\u00e9","family":"Werner","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gabriel","family":"Broocks","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jens","family":"Fiehler","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Max","family":"Wintermark","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeremy J.","family":"Heit","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,9,30]]},"reference":[{"key":"12913_CR1","doi-asserted-by":"publisher","first-page":"1259","DOI":"10.1056\/NEJMoa2214403","volume":"388","author":"A Sarraj","year":"2023","unstructured":"Sarraj A, Hassan AE, Abraham MG et al (2023) Trial of endovascular thrombectomy for large ischemic strokes. 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Stroke 50:189\u2013192","journal-title":"Stroke"}],"container-title":["European Radiology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00330-026-12913-w.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s00330-026-12913-w","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00330-026-12913-w.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T07:44:40Z","timestamp":1790754280000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s00330-026-12913-w"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,30]]},"references-count":50,"alternative-id":["12913"],"URL":"https:\/\/doi.org\/10.1007\/s00330-026-12913-w","relation":{},"ISSN":["1432-1084"],"issn-type":[{"value":"1432-1084","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,30]]},"assertion":[{"value":"8 April 2026","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"3 August 2026","order":2,"name":"revised","label":"Revised","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"4 September 2026","order":3,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"30 September 2026","order":4,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"The scientific guarantor of this publication is Tobias D. Faizy.","order":1,"name":"Ethics","label":"Guarantor","group":{"name":"EthicsHeading","label":"Compliance with ethical standards"}},{"value":"Dr. Tobias FAIZY received research funding from the Else Kr\u00f6ner-Fresenius-Stiftung (grant number 2023_EKES.02) for the submitted work. He serves as a consultant for EppData GmbH and RapidAI and as an advisory board member for Takeda, outside the submitted work. Dr. Gregory W. ALBERS reports equity and consulting for iSchemaView and consulting from Medtronic. Dr. Helge KNIEP reports compensation as a speaker from Asklepios Kliniken, travel funding from Penumbra and Terumo Neuro, an ownership stake in Eppdata GmbH, and compensation from Eppdata GmbH for consulting services. Dr. Christian HEITKAMP reports compensation from Eppdata GmbH for consultant services. Dr. Ren\u00e9 WERNER reports grants and funding from the DFG, BMFTR, BMWE, and Siemens Healthineers outside the submitted work. Dr. Dhairya A. LAKHANI is a consultant for iSchemaView, RapidAI and DocPanel Technologies, and serves on the Scientific Advisory Board for Upstream Vision. Dr. Max WINTERMARK reports grants and funding from the NIH under the grant numbers (1U01 NS086872-01, 1U01 NS087748-01 and 1R01 NS104094). He reports compensation from Subtle Medical, Magnetic Insight, Icometrix and EMTensor for consultant services and employment by the University of Texas MD Anderson Cancer Center. Dr. Jens FIEHLER reports stock holdings in Tegus Medical and grants and personal fees from Acandis, Cerenovus, MicroVention, Medtronic, Stryker, Phenox and grants from Route 92 outside the submitted work. Dr. Jeremy J. HEIT reports consulting for Medtronic, MicroVention and Medical and Scientific Advisory Board membership for iSchemaView. Dr. Henk van VOORST is a member of the scientific editorial board of European Radiology and, as such, did not participate in the selection or review processes for this article. All other authors report no relevant disclosures.","order":2,"name":"Ethics","label":"Conflict of interest","group":{"name":"EthicsHeading","label":"Compliance with ethical standards"}},{"value":"Dhairya Lakhani, Tobias D. Faizy and Gabriel have significant statistical expertise. No complex statistical methods were necessary for this paper.","order":3,"name":"Ethics","label":"Statistics and biometry","group":{"name":"EthicsHeading","label":"Compliance with ethical standards"}},{"value":"Only if the study involves human subjects: Written informed consent was not required for this study because of its retrospective design. Informed consent was waived by both local Institutional Review\/Ethics boards (please see the methods section of our manuscript).","order":4,"name":"Ethics","label":"Informed consent","group":{"name":"EthicsHeading","label":"Compliance with ethical standards"}},{"value":"Institutional Review Board approval was obtained. (IRB No. 689-15 (Hamburg); IRB No. 37209 (Stanford)).","order":5,"name":"Ethics","label":"Ethical approval","group":{"name":"EthicsHeading","label":"Compliance with ethical standards"}},{"value":"None of these subjects has been reported within this specific analysis pathway.","order":6,"name":"Ethics","label":"Study subjects or cohorts overlap","group":{"name":"EthicsHeading","label":"Compliance with ethical standards"}},{"order":7,"name":"Ethics","label":"Methodology","group":{"name":"EthicsHeading","label":"Compliance with ethical standards"}}]}}