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Hua X, Liu M, Wu S. Definition, prediction, prevention and management of patients with severe ischemic stroke and large infarction. Chin Med J (Engl) 2023; 136:2912-2922. [PMID: 38030579 PMCID: PMC10752492 DOI: 10.1097/cm9.0000000000002885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Indexed: 12/01/2023] Open
Abstract
ABSTRACT Severe ischemic stroke carries a high rate of disability and death. The severity of stroke is often assessed by the degree of neurological deficits or the extent of brain infarct, defined as severe stroke and large infarction, respectively. Critically severe stroke is a life-threatening condition that requires neurocritical care or neurosurgical intervention, which includes stroke with malignant brain edema, a leading cause of death during the acute phase, and stroke with severe complications of other vital systems. Early prediction of high-risk patients with critically severe stroke would inform early prevention and treatment to interrupt the malignant course to fatal status. Selected patients with severe stroke could benefit from intravenous thrombolysis and endovascular treatment in improving functional outcome. There is insufficient evidence to inform dual antiplatelet therapy and the timing of anticoagulation initiation after severe stroke. Decompressive hemicraniectomy (DHC) <48 h improves survival in patients aged <60 years with large hemispheric infarction. Studies are ongoing to provide evidence to inform more precise prediction of malignant brain edema, optimal indications for acute reperfusion therapies and neurosurgery, and the individualized management of complications and secondary prevention. We present an evidence-based review for severe ischemic stroke, with the aims of proposing operational definitions, emphasizing the importance of early prediction and prevention of the evolution to critically severe status, summarizing specialized treatment for severe stroke, and proposing directions for future research.
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Affiliation(s)
- Xing Hua
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Ming Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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Suzuki K, Liebeskind DS, Nishi Y, Kutsuna A, Katano T, Sakamoto Y, Saito T, Aoki J, Matsumoto N, Nishiyama Y, Kimura K. A differential detailed diffusion-weighted imaging-ASPECTS for cerebral infarct volume measurement and outcome prediction. Int J Stroke 2023; 18:1202-1208. [PMID: 37332178 DOI: 10.1177/17474930231185468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
BACKGROUND Diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) has been used to estimate infarct core volume in acute stroke. However, the same and indiscriminate score deduction for punctate or confluent DWI high-intensity lesion might lead to variation in performance. AIMS To develop and evaluate a differential detailed DWI-ASPECTS method in comparison with the conventional DWI-ASPECTS in core infarct volume measurement and clinical outcome prediction. METHODS We retrospectively recruited patients with acute ischemic stroke (AIS) treated with endovascular treatment between April 2013 and October 2019. In differential detailed DWI-ASPECTS, restricted diffusion lesion that was punctate or less than half of a cortical region (M1-M6) would not lead to subtraction of point. A favorable outcome was modified Rankin Scale score ⩽2 at 90 days after stroke onset. RESULTS Among 298 AIS patients, mean age was 75 years (interquartile range (IQR) 67-82), and 194 patients (65%) were males. Mean infarct core volume was 11 mL (IQR 3-37). Overall, the score by detailed DWI-ASPECTS was significantly higher than conventional DWI-ASPECTS (8 (7-9) vs. 7 (5-9); P < 0.01). The detailed DWI-ASPECTS resulted in a higher correlation coefficient (r) for core infarct volume estimation than the conventional DWI-ASPECTS (r = 0.832 vs. 0.773; P < 0.01). Upon re-classification of those scored ⩽6 in conventional DWI-ASPECTS (n = 134) by detailed DWI-ASPECTS, the rate of favorable outcome in patients with detailed DWI-ASPECTS >6 was significantly higher than those with ⩽6 (29 (48%) vs. 14 (19%); P < 0.01). CONCLUSIONS Detailed DWI-ASPECTS appeared to provide a more accurate infarct core volume measurement and clinical outcome correlation than conventional DWI-ASPECTS among AIS patients treated with endovascular therapy.
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Affiliation(s)
- Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
- Department of Neurology and UCLA Stroke Center, University of California, Los Angeles, CA, USA
| | - David S Liebeskind
- Department of Neurology and UCLA Stroke Center, University of California, Los Angeles, CA, USA
| | - Yuji Nishi
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Akihito Kutsuna
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Takehiro Katano
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Yuki Sakamoto
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Tomonari Saito
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Junya Aoki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | | | | | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
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Li M, Lv Y, Wang M, Zhang Y, Pan Z, Luo Y, Zhang H, Wang J. Magnetic Resonance Perfusion-Weighted Imaging in Predicting Hemorrhagic Transformation of Acute Ischemic Stroke: A Retrospective Study. Diagnostics (Basel) 2023; 13:3404. [PMID: 37998540 PMCID: PMC10670343 DOI: 10.3390/diagnostics13223404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 11/25/2023] Open
Abstract
Hemorrhagic transformation (HT) is one of the common complications in patients with acute ischemic stroke (AIS). This study aims to investigate the value of different thresholds of Tmax generated from perfusion-weighted MR imaging (PWI) and the apparent diffusion coefficient (ADC) value in the prediction of HT in AIS. A total of 156 AIS patients were enrolled in this study, with 55 patients in the HT group and 101 patients in non-HT group. The clinical baseline data and multi-parametric MRI findings were compared between HT and non-HT groups to identify indicators related to HT. The optimal parameters for predicting HT and the corresponding cutoff values were obtained using the receiver operating characteristic curve analysis of the volumes of ADC < 620 × 10-6 mm2/s and Tmax > 6 s, 8 s, and 10 s. The results showed that the volumes of ADC < 620 × 10-6 mm2/s and Tmax > 6 s, 8 s, and 10 s in the HT group were all significantly larger than that in the non-HT group and were all independent risk factors for HT. Early measurement of the volume of Tmax > 10 s had the highest value, with a cutoff lesion volume of 10.5 mL.
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Affiliation(s)
- Ming Li
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; (M.L.); (Z.P.)
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
| | - Yifan Lv
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
| | - Mingming Wang
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
| | - Yaying Zhang
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
| | - Zilai Pan
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; (M.L.); (Z.P.)
| | - Yu Luo
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
| | - Haili Zhang
- Southeast University Hospital, Southeast University, Nanjing 210096, China
| | - Jing Wang
- Department of Radiology, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai 200434, China; (Y.L.); (M.W.); (Y.Z.); (Y.L.)
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Kawano H, Hirano T. Minimal Imaging Requirements. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:243-256. [PMID: 38025254 PMCID: PMC10657732 DOI: 10.5797/jnet.ra.2023-0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 08/09/2023] [Indexed: 12/01/2023]
Abstract
The minimal requirements for imaging studies prior to endovascular treatment (EVT) of acute ischemic stroke are those that can provide the information necessary to determine the indication for treatment (treatment triage) and procedural strategies without being time-consuming. An important notion is to determine whether the patient can benefit from EVT. We should recognize that the perfect diagnostic imaging technique does not yet exist, and each has advantages and disadvantages. Generally, stroke imaging protocols to triage for EVT include the following three options: 1) non-contrast CT and CTA, 2) CT perfusion and CTA, and 3) MRI and MRA. It is not known if perfusion imaging or MRI is mandatory for patients with stroke presenting within 6 hours of onset, although non-contrast CT alone has less power to obtain the necessary information. Dual-energy CT can distinguish between post-EVT hemorrhage and contrast agent leakage immediately after EVT.
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Affiliation(s)
- Hiroyuki Kawano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Mitaka, Tokyo, Japan
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Mitaka, Tokyo, Japan
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Lee MH, Im SH, Jo KW, Yoo DS. Recanalization Rate and Clinical Outcomes of Intravenous Tissue Plasminogen Activator Administration for Large Vessel Occlusion Stroke Patients. J Korean Neurosurg Soc 2023; 66:144-154. [PMID: 36825298 PMCID: PMC10009240 DOI: 10.3340/jkns.2022.0120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 09/17/2022] [Indexed: 02/25/2023] Open
Abstract
OBJECTIVE Stroke caused from large vessel occlusion (LVO) has emerged as the most common stroke subtype worldwide. Intravenous tissue plasminogen activator administration (IV-tPA) and additional intraarterial thrombectomy (IA-Tx) is regarded as standard treatment. In this study, the authors try to find the early recanalization rate of IV-tPA in LVO stroke patients. METHODS Total 300 patients undertook IA-Tx with confirmed anterior circulation LVO, were analyzed retrospectively. Brain computed tomography angiography (CTA) was the initial imaging study and acute stroke magnetic resonance angiography (MRA) followed after finished IV-tPA. Early recanalization rate was evaluated by acute stroke MRA within 2 hours after the IV-tPA. In 167 patients undertook IV-tPA only and 133 non-recanalized patients by IV-tPA, additional IA-Tx tried (IV-tPA + IA-Tx group). And 131 patients, non-recanalized by IV-tPA (IV-tPA group) additional IA-Tx recommend and tried according to the patient condition and compliance. RESULTS Early recanalization rate of LVO after IV-tPA was 12.0% (36/300). In recanalized patients, favorable outcome (modified Rankin Scale, 0-2) was 69.4% (25/36) while it was 32.1% (42/131, p<0.001) in non-recanalized patients. Among 133 patients, nonrecanalized after intravenous recombinant tissue plasminogen activator and undertook additional IA-Tx, the clinical outcome was better than not undertaken additional IA-Tx (favorable outcome was 42.9% vs. 32.1%, p=0.046). Analysis according to the perfusion/diffusion (P/D)-mismatching or not, in patient with IV-tPA with IA-Tx (133 patients), favorable outcome was higher in P/ D-mismatching patient (52/104; 50.0%) than P/D-matching patients (5/29; 17.2%; p=0.001). Which treatment tired, P/D-mismatching was favored in clinical outcome (iv-tPA only, p=0.008 and IV-tPA with IA-Tx, p=0.001). CONCLUSION The P/D-mismatching influences on the recanalization and clinical outcomes of IV-tPA and IA-Tx. The authors would like to propose that we had better prepare IA-Tx when LVO is diagnosed on initial diagnostic imaging. Furthermore, if the patient shows P/D-mismatching on MRA after IV-tPA, additional IA-Tx improves treatment results and lessen the futile recanalization.
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Affiliation(s)
- Min-Hyung Lee
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang-Hyuk Im
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kwang Wook Jo
- Department of Neurosurgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Do-Sung Yoo
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Maes M, Brinholi FF, Michelin AP, Matsumoto AK, de Oliveira Semeão L, Almulla AF, Supasitthumrong T, Tunvirachaisakul C, Barbosa DS. In Mild and Moderate Acute Ischemic Stroke, Increased Lipid Peroxidation and Lowered Antioxidant Defenses Are Strongly Associated with Disabilities and Final Stroke Core Volume. Antioxidants (Basel) 2023; 12:antiox12010188. [PMID: 36671047 PMCID: PMC9854933 DOI: 10.3390/antiox12010188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/06/2023] [Accepted: 01/06/2023] [Indexed: 01/15/2023] Open
Abstract
In acute ischemic stroke (AIS), there are no data on whether oxidative stress biomarkers have effects above and beyond known risk factors and measurements of stroke volume. This study was conducted in 122 mild-moderate AIS patients and 40 controls and assessed the modified ranking scale (mRS) at baseline, and 3 and 6 months later. We measured lipid hydroperoxides (LOOH), malondialdehyde (MDA), advanced oxidation protein products, paraoxonase 1 (PON1) activities and PON1 Q192R genotypes, high density lipoprotein cholesterol (HDL), sulfhydryl (-SH) groups), and diffusion-weighted imaging (DWI) stroke volume and fluid-attenuated inversion recovery (FLAIR) signal intensity. We found that (a) AIS is characterized by lower chloromethyl acetate CMPAase PON1 activity, HDL and -SH groups and increased LOOH and neurotoxicity (a composite of LOOH, inflammatory markers and glycated hemoglobin); (b) oxidative and antioxidant biomarkers strongly and independently predict mRS scores 3 and 6 months later, DWI stroke volume and FLAIR signal intensity; and (c) the PON1 Q192R variant has multiple effects on stroke outcomes that are mediated by its effects on antioxidant defenses and lipid peroxidation. Lipid peroxidation and lowered -SH and PON1-HDL activity are drug targets to prevent AIS and consequent neurodegenerative processes and increased oxidative reperfusion mediators due to ischemia-reperfusion injury.
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Affiliation(s)
- Michael Maes
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, 1873 Rama 4 Rd., Phayathai Road, Pathumwan, Bangkok 10330, Thailand
- Cognitive Fitness and Technology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- Department of Psychiatry, Medical University of Plovdiv, 4000 Plovdiv, Bulgaria
- Research Institute, Medical University Plovdiv, 4000 Plovdiv, Bulgaria
- Deakin University, IMPACT-the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, VIC 3220, Australia
- Correspondence:
| | - Francis F. Brinholi
- Health Sciences Graduate Program, Health Sciences Center, State University of Londrina, Londrina 86057-970, PR, Brazil
| | - Ana Paula Michelin
- Health Sciences Graduate Program, Health Sciences Center, State University of Londrina, Londrina 86057-970, PR, Brazil
| | - Andressa K. Matsumoto
- Health Sciences Graduate Program, Health Sciences Center, State University of Londrina, Londrina 86057-970, PR, Brazil
| | - Laura de Oliveira Semeão
- Health Sciences Graduate Program, Health Sciences Center, State University of Londrina, Londrina 86057-970, PR, Brazil
| | - Abbas F. Almulla
- Medical Laboratory Technology Department, College of Medical Technology, The Islamic University, Najaf 54001, Iraq
| | - Thitiporn Supasitthumrong
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, 1873 Rama 4 Rd., Phayathai Road, Pathumwan, Bangkok 10330, Thailand
| | - Chavit Tunvirachaisakul
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, 1873 Rama 4 Rd., Phayathai Road, Pathumwan, Bangkok 10330, Thailand
| | - Decio S. Barbosa
- Health Sciences Graduate Program, Health Sciences Center, State University of Londrina, Londrina 86057-970, PR, Brazil
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Cerebral perfusion imaging predicts final infarct volume after basilar artery thrombectomy. J Stroke Cerebrovasc Dis 2023; 32:106866. [PMID: 36427471 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/19/2022] [Accepted: 10/25/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Cerebral perfusion imaging may be used to identify the ischemic core in acute ischemic stroke (AIS) patients with a large vessel occlusion of the anterior circulation; however, perfusion parameters that predict the ischemic core in AIS patients with a basilar artery occlusion (BAO) are poorly described. We determined which cerebral perfusion parameters best predict the ischemic core after successful endovascular thrombectomy (EVT) in BAO patients. MATERIALS AND METHODS We performed multicenter retrospective study of BAO patients with perfusion imaging before EVT and a DWI after successful EVT. The ischemic core was defined as regions on CTP, which were co-registered to the final DWI infarct. Various time-to-maximum (Tmax) and cerebral blood flow (CBF) thresholds were compared to final infarct volume to determine the best predictor of the final infarct. RESULTS 28 patients were included in the analysis for this study. Tmax >8s (r2: 0.56; median absolute error, 16.0 mL) and Tmax >10s (r2: 0.73; median absolute error, 11.3 mL) showed the strongest agreement between the pre-EVT CTP study and the final DWI. CBF <38% (r2: 0.76; median absolute error, 8.2 mL) and CBF <34% (r2: 0.76; median absolute error, 9.1 mL) also correlated well with final infarct volume on DWI. CONCLUSIONS Pre-EVT CT perfusion imaging is useful to predict the final ischemic infarct volume in BAO patients. Tmax >8s and Tmax >10s were the strongest predictors of the post-EVT final infarct volume.
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Nontraumatic Neurosurgical Emergencies. Crit Care Nurs Q 2023; 46:2-16. [DOI: 10.1097/cnq.0000000000000434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Garcia-Esperon C, Bivard A, Johns H, Chen C, Churilov L, Lin L, Butcher K, Kleinig TJ, Choi PMC, Cheng X, Dong Q, Aviv RI, Miteff F, Spratt NJ, Levi CR, Parsons MW. Association of Endovascular Thrombectomy With Functional Outcome in Patients With Acute Stroke With a Large Ischemic Core. Neurology 2022; 99:e1345-e1355. [PMID: 35803723 DOI: 10.1212/wnl.0000000000200908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 05/16/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Endovascular thrombectomy (EVT) is effective for patients with large vessel occlusion (LVO) stroke with smaller volumes of CT perfusion (CTP)-defined ischemic core. However, the benefit of EVT is unclear in those with a core volume >70 mL. We aimed to compare outcomes of EVT and non-EVT patients with an ischemic core volume ≥70 mL, hypothesizing that there would be a benefit from EVT for fair outcome (3-month modified Rankin scale [mRS] 0-3) after stroke. METHODS A retrospective analysis of patients enrolled into a multicenter (Australia, China, and Canada) registry (2012-2020) who underwent CTP within 24 hours of stroke onset and had a baseline ischemic core volume ≥70 mL was performed. The primary outcome was the estimation of the association of EVT in patients with core volume ≥70 mL and within 70-100 and ≥100 mL subgroups with fair outcome. RESULTS Of the 3,283 patients in the registry, 299 had CTP core volume ≥70 mL and 269 complete data (135 had core volume between 70 and 100 mL and 134 had core volume ≥100 mL). EVT was performed in 121 (45%) patients. EVT-treated patients were younger (median 69 vs 75 years; p = 0.011), had lower prestroke mRS, and smaller median core volumes (92 [79-116.5] mL vs 105.5 [85.75-138] mL, p = 0.004). EVT-treated patients had higher odds of achieving fair outcome in adjusted analysis (30% vs 13.9% in the non-EVT group; adjusted odds ratio [aOR] 2.1, 95% CI 1-4.2, p = 0.038). The benefit was seen predominantly in those with 70-100 mL core volume (71/135 [52.6%] EVT-treated), with 54.3% in the EVT-treated vs 21% in the non-EVT group achieving a fair outcome (aOR 2.5, 95% CI 1-6.2, p = 0.005). Of those with a core volume ≥100 mL, 50 of the 134 (37.3%) underwent EVT. Proportions of fair outcome were very low in both groups (8.1% vs 8.7%; p = 0.908). DISCUSSION We found a positive association of EVT with the 3-month outcome after stroke in patients with a baseline CTP ischemic core volume 70-100 mL but not in those with core volume ≥100 mL. Randomized data to confirm these findings are required. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that EVT is associated with better motor outcomes 3 months after CTP-defined ischemic stroke with a core volume of 70-100 mL.
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Affiliation(s)
- Carlos Garcia-Esperon
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia.
| | - Andrew Bivard
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Hannah Johns
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Chushuang Chen
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Leonid Churilov
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Longting Lin
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Kenneth Butcher
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Timothy J Kleinig
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Philip M C Choi
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Xin Cheng
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Qiang Dong
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Richard I Aviv
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Ferdinand Miteff
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Neil J Spratt
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Christopher R Levi
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Mark W Parsons
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
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Correlation between Hypoperfusion Intensity Ratio and Functional Outcome in Large-Vessel Occlusion Acute Ischemic Stroke: Comparison with Multi-Phase CT Angiography. J Clin Med 2022; 11:jcm11185274. [PMID: 36142924 PMCID: PMC9503156 DOI: 10.3390/jcm11185274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 08/27/2022] [Accepted: 09/01/2022] [Indexed: 11/16/2022] Open
Abstract
Background and purpose: Previous studies have shown that Hypoperfusion Intensity Ratio (HIR) derived from Perfusion Imaging (PWI) associated with collateral status in large-vessel occlusion (LVO) acute ischemic stroke (AIS) and could predict the rate of collateral flow, speed of infarct growth, and clinical outcome after endovascular treatment (EVT). We hypothesized that HIR derived from CT Perfusion (CTP) imaging could relatively accurately predict the functional outcome in LVO AIS patients receiving different types of treatment. Methods: Imaging and clinical data of consecutive patients with LVO AIS were retrospectively reviewed. Multi-phase CT angiography (mCTA) scoring was performed by 2 blinded neuroradiologists. CTP images were processed using an automatic post-processing analysis software. Correlation between the HIR and the functional outcome was calculated using the Spearman correlation. The efficacy of the HIR and the CTA collateral scores for predicting prognosis were compared. The optimal threshold of the HIR for predicting favorable functional outcome was determined using receiver operating characteristic (ROC) curve analysis. Results: 235 patients with LVO AIS were included. Patients with favorable functional outcome had lower HIR (0.1 [interquartile range (IQR), 0.1−0.2]) vs. 0.4 (IQR, 0.4−0.5)) and higher mCTA collateral scores (3 [IQR, 3−4] vs. 3 [IQR, 2−3]; p < 0.001) along with smaller infarct core volume (2.1 [IQR, 1.0−4.5]) vs. (15.2 [IQR, 5.5−39.3]; p < 0.001), larger mismatch ratio (22.9 [IQR, 11.6−45.6]) vs. (5.8 [IQR, 2.6−14]); p < 0.001), smaller ischemic volume (59.0 [IQR, 29.7−89.2]) vs. (97.5 [IQR, 68.7−142.2]; p < 0.001), and smaller final infarct volume (12.6 [IQR, 7.5−18.4]) vs. (78.9 [IQR, 44.5−165.0]; p < 0.001) than those with unfavorable functional outcome. The HIR was significantly positively correlated with the functional outcome [r = 0.852; 95% confidence interval (CI): 0.813−0.884; p < 0.0001]. The receiver operating characteristic (ROC) analysis showed that the optimal threshold for predicting a favorable functional outcome was HIR ≤ 0.3 [area under the curve (AUC) 0.968; sensitivity 88.89%; specificity 99.21%], which was higher than the mCTA collateral score [AUC 0.741; sensitivity 82.4%; specificity 48.8%]. Conclusions: HIR was associated with the functional outcome of LVO AIS patients, and the correlation coefficient was higher than mCTA collateral score. HIR outperformed mCTA collateral score in predicting functional outcome.
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Fainardi E, Busto G, Rosi A, Scola E, Casetta I, Bernardoni A, Saletti A, Arba F, Nencini P, Limbucci N, Mangiafico S, Demchuk A, Almekhlafi MA, Goyal M, Lee TY, Menon BK, Morotti A. T max Volumes Predict Final Infarct Size and Functional Outcome in Ischemic Stroke Patients Receiving Endovascular Treatment. Ann Neurol 2022; 91:878-888. [PMID: 35285078 PMCID: PMC9322332 DOI: 10.1002/ana.26354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 03/01/2022] [Accepted: 03/07/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The objective of this paper was to explore the utility of time to maximum concentration (Tmax )-based target mismatch on computed tomography perfusion (CTP) in predicting radiological and clinical outcomes in patients with acute ischemic stroke (AIS) with anterior circulation large vessel occlusion (LVO) selected for endovascular treatment (EVT). METHODS Patients with AIS underwent CTP within 24 hours from onset followed by EVT. Critically hypoperfused tissue and ischemic core volumes were automatically calculated using Tmax thresholds >9.5 seconds and >16 seconds, respectively. The difference between Tmax > 9.5 seconds and Tmax > 16 seconds volumes and the ratio between Tmax > 9.5 seconds and Tmax > 16 seconds volumes were considered ischemic penumbra and Tmax mismatch ratio, respectively. Final infarct volume (FIV) was measured on follow-up non-contrast computed tomography (CT) at 24 hours. Favorable clinical outcome was defined as 90-day modified Rankin Scale 0 to 2. Predictors of FIV and outcome were assessed with multivariable logistic regression. Optimal Tmax volumes for identification of good outcome was defined using receiver operating curves. RESULTS A total of 393 patients were included, of whom 298 (75.8%) achieved successful recanalization and 258 (65.5%) achieved good outcome. In multivariable analyses, all Tmax parameters were independent predictors of FIV and outcome. Tmax > 16 seconds volume had the strongest association with FIV (beta coefficient = 0.596 p <0.001) and good outcome (odds ratio [OR] = 0.96 per 1 ml increase, 95% confidence interval [CI] = 0.95-0.97, p < 0.001). Tmax > 16 seconds volume had the highest discriminative ability for good outcome (area under the curve [AUC] = 0.88, 95% CI = 0.842-0.909). A Tmax > 16 seconds volume of ≤67 ml best identified subjects with favorable outcome (sensitivity = 0.91 and specificity = 0.73). INTERPRETATION Tmax target mismatch predicts radiological and clinical outcomes in patients with AIS with LVO receiving EVT within 24 hours from onset. ANN NEUROL 2022;91:878-888.
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Affiliation(s)
- Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”University of FlorenceFlorence
| | - Giorgio Busto
- Neuroradiology Unit, Department of RadiologyCareggi University HospitalFlorenceItaly
| | - Andrea Rosi
- Division of Diagnostic and Interventional Neuroradiology, Department of DiagnosticsGeneva University HospitalsGenevaSwitzerland
| | - Elisa Scola
- Neuroradiology Unit, Department of RadiologyCareggi University HospitalFlorenceItaly
| | - Ilaria Casetta
- Section of Neurological, Psychiatric, and Psychological Sciences, Department of Biomedical and Specialist Surgical SciencesUniversity of FerraraFerraraItaly
| | - Andrea Bernardoni
- Neuroradiology Unit, Department of RadiologyArcispedale S. AnnaFerraraItaly
| | - Andrea Saletti
- Neuroradiology Unit, Department of RadiologyArcispedale S. AnnaFerraraItaly
| | | | | | - Nicola Limbucci
- Interventional Neuroradiology Unit, Department of RadiologyCareggi University HospitalFlorenceItaly
| | - Salvatore Mangiafico
- Neuroradiologia Diagnostica ed Interventisitca, IRCCS Neuromed, Istituto Neurologico MediterraneoPozzilliItaly
| | - Andrew Demchuk
- The Calgary Stroke Program, Department of Clinical NeurosciencesUniversity of CalgaryCalgaryAlbertaCanada,Department of RadiologyUniversity of CalgaryCalgaryAlbertaCanada,Hotchkiss Brain Institute, University of CalgaryCalgaryAlbertaCanada
| | - Mohammed A Almekhlafi
- The Calgary Stroke Program, Department of Clinical NeurosciencesUniversity of CalgaryCalgaryAlbertaCanada,Department of RadiologyUniversity of CalgaryCalgaryAlbertaCanada,Hotchkiss Brain Institute, University of CalgaryCalgaryAlbertaCanada
| | - Mayank Goyal
- The Calgary Stroke Program, Department of Clinical NeurosciencesUniversity of CalgaryCalgaryAlbertaCanada,Department of RadiologyUniversity of CalgaryCalgaryAlbertaCanada,Hotchkiss Brain Institute, University of CalgaryCalgaryAlbertaCanada
| | - Ting Y. Lee
- Lawson Health Research Institute and Robarts Research InstituteLondonOntarioCanada
| | - Bijoy K. Menon
- The Calgary Stroke Program, Department of Clinical NeurosciencesUniversity of CalgaryCalgaryAlbertaCanada,Department of RadiologyUniversity of CalgaryCalgaryAlbertaCanada,Hotchkiss Brain Institute, University of CalgaryCalgaryAlbertaCanada
| | - Andrea Morotti
- Department of Clinical and Experimental Sciences, Neurology UnitUniversity of BresciaBresciaItaly
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Fladt J, d'Esterre CD, Joundi R, McDougall C, Gensicke H, Barber P. Acute stroke imaging selection for mechanical thrombectomy in the extended time window: is it time to go back to basics? A review of current evidence. J Neurol Neurosurg Psychiatry 2022; 93:238-245. [PMID: 35115388 DOI: 10.1136/jnnp-2021-328000] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 01/05/2022] [Indexed: 12/15/2022]
Abstract
Treatment with endovascular therapy in the extended time window for acute ischaemic stroke with large vessel occlusion involves stringent selection criteria based on the two landmark studies DAWN and DEFUSE3. Current protocols typically include the requirement of advanced perfusion imaging which may exclude a substantial proportion of patients from receiving a potentially effective therapy. Efforts to offer endovascular reperfusion therapies to all appropriate candidates may be facilitated by the use of simplified imaging selection paradigms with widely available basic imaging techniques, such as non-contrast CT and CT angiography. Currently available evidence from our literature review suggests that patients meeting simplified imaging selection criteria may benefit as much as those patients selected using advanced imaging techniques (CT perfusion or MRI) from endovascular therapy in the extended time window. A comprehensive understanding of the role of imaging in patient selection is critical to optimising access to endovascular therapy in the extended time window and improving outcomes in acute stroke. This article provides an overview on current developments and future directions in this emerging area.
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Affiliation(s)
- Joachim Fladt
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Christopher D d'Esterre
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Raed Joundi
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Connor McDougall
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Henrik Gensicke
- Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Philip Barber
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Lansberg MG, Wintermark M, Kidwell CS, Albers GW. Magnetic Resonance Imaging of Cerebrovascular Diseases. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00048-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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MacLellan A, Mlynash M, Kemp S, Ortega-Gutierrez S, Heit JJ, Marks MP, Lansberg MG, Albers GW. Perfusion Imaging Collateral Scores Predict Infarct Growth in Non-Reperfused DEFUSE 3 Patients. J Stroke Cerebrovasc Dis 2021; 31:106208. [PMID: 34823091 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106208] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 10/08/2021] [Accepted: 10/24/2021] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE This study evaluated the associations of perfusion imaging collateral profiles with radiographic and clinical outcome in late presenting, non-reperfused patients in the DEFUSE 3 clinical trial. METHODS Non-reperfused patients in both treatment arms were included. Baseline ischemic core, Tmax >6s, and Tmax >10s perfusion volumes were calculated with RAPID software; infarct volumes obtained 24 hours after randomization were manually determined from DWI or CT. Substantial infarct growth was defined as a >25mL increase between baseline and 24-hour follow-up. Hypoperfusion Intensity Ratio (HIR) was defined as the proportion of the Tmax >6s lesion with Tmax >10s delay; CBV index was calculated by RAPID from mean CBV values within the Tmax >6s lesion compared to regions of normal CBV. RESULTS Eighty-four patients were included. ROC analysis showed HIR ≥0.34 (AUC=0.68) and CBV index ≤0.74 (AUC=0.72) optimally predicted substantial infarct growth in follow-up. Median growth was 23.4 versus 73.2mL with HIR threshold of 0.34 (p=0.005), and 24.3 versus 58.7mL with CBV index threshold of 0.74 (p=0.004). If baseline HIR and CBV index were both favorable, median growth was 21.7mL, 40.9mL if one was favorable, and 108.2mL if both were unfavorable (p<0.001). Baseline perfusion profile was not associated with 90-day functional outcome. CONCLUSIONS Perfusion collateral scores forecast infarct growth in late presenting, non-reperfused ischemic stroke patients. These parameters may be useful for guiding transfer decisions, such as need for repeat imaging upon thrombectomy center arrival, and may help identify slow progressing patients more likely to have persistent salvageable ischemic tissue beyond 24 hours.
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Abstract
Ischemic stroke affects 2.5% of the population of the United States and is the leading cause of disability. This article outlines the evidence to support intravenous thrombolysis with alteplase and tenecteplase, thrombolysis in the setting of DWI/flair mismatch, endovascular treatment in the 6-hour and 6- to 24-hour window, and the use of telemedicine in acute stroke. Current controversies and ongoing trials within endovascular treatment are also detailed. Case presentations are included to provide clinical context and the application of data to practice.
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Affiliation(s)
- Stephanie Lyden
- Department of Neurology, University of Utah School of Medicine, 175 North Medical Drive, Salt Lake City, UT 84132, USA
| | - Jana Wold
- Department of Neurology, University of Utah School of Medicine, 175 North Medical Drive, Salt Lake City, UT 84132, USA.
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16
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Cereda CW, Bianco G, Mlynash M, Yuen N, Qureshi AY, Hinduja A, Dehkharghani S, Goldman-Yassen AE, Hsieh KLC, Giurgiutiu DV, Gibson D, Carrera E, Alemseged F, Faizy TD, Fiehler J, Pileggi M, Campbell B, Albers GW, Heit JJ. Perfusion Imaging Predicts Favorable Outcomes after Basilar Artery Thrombectomy. Ann Neurol 2021; 91:23-32. [PMID: 34786756 DOI: 10.1002/ana.26272] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 11/13/2021] [Accepted: 11/14/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Perfusion imaging identifies anterior circulation stroke patients who respond favorably to endovascular thrombectomy (ET), but its role in basilar artery occlusion (BAO) is unknown. We hypothesized that BAO patients with limited regions of severe hypoperfusion (time to reach maximum concentration in seconds [Tmax] > 10) would have a favorable response to ET compared to patients with more extensive regions involved. METHODS We performed a multicenter retrospective cohort study of BAO patients with perfusion imaging prior to ET. We prespecified a Critical Area Perfusion Score (CAPS; 0-6 points), which quantified severe hypoperfusion (Tmax > 10) in cerebellum (1 point/hemisphere), pons (2 points), and midbrain and/or thalamus (2 points). Patients were dichotomized into favorable (CAPS ≤ 3) and unfavorable (CAPS > 3) groups. The primary outcome was a favorable functional outcome 90 days after ET (modified Rankin Scale = 0-3). RESULTS One hundred three patients were included. CAPS ≤ 3 patients (87%) had a lower median National Institutes of Health Stroke Scale score (NIHSS; 12.5, interquartile range [IQR] = 7-22) compared to CAPS > 3 patients (13%; 23, IQR = 19-36; p = 0.01). Reperfusion was achieved in 84% of all patients, with no difference between CAPS groups (p = 0.42). Sixty-four percent of reperfused CAPS ≤ 3 patients had a favorable outcome compared to 8% of nonreperfused CAPS ≤ 3 patients (odds ratio [OR] = 21.0, 95% confidence interval [CI] = 2.6-170; p < 0.001). No CAPS > 3 patients had a favorable outcome, regardless of reperfusion. In a multivariate regression analysis, CAPS ≤ 3 was a robust independent predictor of favorable outcome after adjustment for reperfusion, age, and pre-ET NIHSS (OR = 39.25, 95% CI = 1.34->999, p = 0.04). INTERPRETATION BAO patients with limited regions of severe hypoperfusion had a favorable response to reperfusion following ET. However, patients with more extensive regions of hypoperfusion in critical brain regions did not benefit from endovascular reperfusion. ANN NEUROL 2021.
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Affiliation(s)
- Carlo W Cereda
- Neurology, Stroke Center, Medico Caposervizio, Neurocentro (EOC) della Svizzera Italiana, Lugano, Switzerland
| | - Giovanni Bianco
- Neurology, Stroke Center, Medico Caposervizio, Neurocentro (EOC) della Svizzera Italiana, Lugano, Switzerland
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Nicole Yuen
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Abid Y Qureshi
- Department of Neurology, Kansas University Medical Center, Kansas City, KS
| | - Archana Hinduja
- Department of Neurology, Ohio State Wexner Medical Center, Columbus, OH
| | - Seena Dehkharghani
- Departments of Radiology and Neurology, New York University Langone Medical Center, New York, NY
| | | | - Kevin Li-Chun Hsieh
- Department of Medical Imaging, Taipei Medical University Hospital, Taipei, Taiwan
| | | | - Dan Gibson
- Department of Neurointerventional Surgery, Ascension Columbia St Mary's Hospital, Milwaukee, WI
| | - Emmanuel Carrera
- Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - Fana Alemseged
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marco Pileggi
- Department of Neuroradiology, Neurocenter of Southern Switzerland, Cantonal Hospital Corporation, Lugano, Switzerland
| | - Bruce Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
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17
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Krishnan R, Mays W, Elijovich L. Complications of Mechanical Thrombectomy in Acute Ischemic Stroke. Neurology 2021; 97:S115-S125. [PMID: 34785610 DOI: 10.1212/wnl.0000000000012803] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 06/23/2021] [Indexed: 01/01/2023] Open
Abstract
Multiple randomized clinical trials have supported the use of mechanical thrombectomy (MT) as standard of care in the treatment of large vessel occlusion acute ischemic stroke. Optimal outcomes depend not only on early reperfusion therapy but also on post thrombectomy care. Early recognition of post MT complications including reperfusion hemorrhage, cerebral edema and large space occupying infarcts, and access site complications can guide early initiation of lifesaving therapies that can improve neurologic outcomes. Knowledge of common complications and their management is essential for stroke neurologists and critical care providers to ensure optimal outcomes. We present a review of the available literature evaluating the common complications in patients undergoing MT with emphasis on early recognition and management.
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Affiliation(s)
- Rashi Krishnan
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis
| | - William Mays
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis
| | - Lucas Elijovich
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis.
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18
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Advanced Imaging in the Era of Tissue-Based Treatment for Acute Ischemic Stroke—a Practical Review. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00685-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Cerebral Perfusion Imaging for Intravenous Thrombolysis Treatment. Top Magn Reson Imaging 2021; 30:205-209. [PMID: 34397970 DOI: 10.1097/rmr.0000000000000284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Intravenous thrombolysis is the cornerstone of acute ischemic stroke treatment. However, the benefits of recanalization and reperfusion must be balanced against the risk of intracranial hemorrhage. Time from symptom onset was previously the most important selection tool for identifying patients who would benefit from treatment without prohibitive risk for secondary hemorrhage. Enhanced techniques in noncontrast computed tomography followed by computed tomography and magnetic resonance perfusion imaging led to the expansion of treatment eligibility for intravenous thrombolysis. Perfusion imaging allows for more precise evaluation of tissue at-risk to identify patients who would benefit from treatment many hours beyond symptom onset.
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20
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Hypoperfusion Index Ratio as a Surrogate of Collateral Scoring on CT Angiogram in Large Vessel Stroke. J Clin Med 2021; 10:jcm10061296. [PMID: 33801050 PMCID: PMC8003946 DOI: 10.3390/jcm10061296] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 01/14/2023] Open
Abstract
Background: This study was to evaluate the correlation of the hypoperfusion intensity ratio (HIR) with the collateral score from multiphase computed tomography angiography (mCTA) among patients with large vessel stroke. Method: From February 2019 to May 2020, we retrospectively reviewed the patients with large vessel strokes (intracranial carotid artery or proximal middle cerebral artery occlusion). HIR was defined as a Tmax > 10 s lesion volume divided by a Tmax > 6 s lesion volume, which was calculated by automatic software (Syngo.via, Siemens). The correlation between the HIR and mCTA score was evaluated by Pearson’s correlation. The cutoff value predicting the mCTA score was evaluated by receiver operating characteristic analysis. Result: Ninety-four patients were enrolled in the final analysis. The patients with good collaterals had a smaller core volume (37.3 ± 24.7 vs. 116.5 ± 70 mL, p < 0.001) and lower HIR (0.51 ± 0.2 vs. 0.73 ± 0.13, p < 0.001) than those with poor collaterals. A higher HIR was correlated with a poorer collateral score by Pearson’s correlation. (r = −0.64, p < 0.001). The receiver operating characteristic (ROC) analysis suggested that the best HIR value for predicting a good collateral score was 0.68 (area under curve: 0.82). Conclusion: HIR is a good surrogate of collateral circulation in patients with acute large artery occlusion.
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21
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Dundamadappa S, Iyer K, Agrawal A, Choi DJ. Multiphase CT Angiography: A Useful Technique in Acute Stroke Imaging-Collaterals and Beyond. AJNR Am J Neuroradiol 2020; 42:221-227. [PMID: 33384289 DOI: 10.3174/ajnr.a6889] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 08/21/2020] [Indexed: 11/07/2022]
Abstract
Multiphase CTA offers several important advantages over the traditional single-phase CTA technique in acute ischemic stroke, including improved detection of large-vessel occlusion, improved characterization of collateral status, improved tolerance of patient motion and poor hemodynamics, and higher interrater reliability. These benefits are gleaned at little additional cost in terms of time, risk to the patient, and capital expense. Existing data suggest that there are important benefits to using multiphase CTA in lieu of single-phase CTA in the initial vessel assessment of patients with acute stroke.
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Affiliation(s)
- S Dundamadappa
- From the Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts
| | - K Iyer
- From the Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts
| | - A Agrawal
- From the Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts
| | - D J Choi
- From the Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts.
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22
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Yoshimoto T, Inoue M, Tanaka K, Kanemaru K, Koge J, Shiozawa M, Kamogawa N, Kimura S, Chiba T, Satow T, Takahashi JC, Toyoda K, Koga M, Ihara M. Identifying large ischemic core volume ranges in acute stroke that can benefit from mechanical thrombectomy. J Neurointerv Surg 2020; 13:1081-1087. [PMID: 33323502 PMCID: PMC8606466 DOI: 10.1136/neurintsurg-2020-016934] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/19/2020] [Accepted: 11/24/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND We aimed to identify the large ischemic core (LIC) volume ranges in acute ischemic stroke patients that can benefit from mechanical thrombectomy (MT). METHODS Consecutive patients within 24 hours of onset of anterior circulation ischemic stroke with large vessel occlusion and ischemic core volumes of 70-300 mL were included from our single-center prospective database from March 2014 to December 2019. Subjects were divided into three groups by baseline ischemic core volume (A: 70-100 mL; B: 101-130 mL; C: >130 mL). We compared modified Rankin Scale (mRS) score 0-2 at 3 months and parenchymal hematoma between patients receiving MT and standard medical treatment (SMT), and determined clinically treatable core volume ranges for MT. RESULTS Of 157 patients (86 women; median age, 81 years; median ischemic core volume, 123 mL), 49 patients underwent MT. In Group A (n=52), MT patients (n=31) showed a higher proportion of mRS 0-2 at 3 months (52% vs 5%, P<0.05) versus SMT, respectively. Group B (n=36) MT patients (n=14) also had a higher proportion of mRS 0-2 at 3 months (29% vs 9%, P=0.13) versus SMT, respectively. In Group C (n=69), only four patients received MT. The 95% confidence intervals for the probability of mRS 0-2 at 3 months in patients with MT (n=49) versus SMT (n=108) intersected at 120-130 mL. CONCLUSIONS Ischemic core volumes between 70 and 100 mL may benefit from MT. The treatable upper core limit is approximately 120 mL in selected patients with LIC of 70-300 mL.
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Affiliation(s)
- Takeshi Yoshimoto
- Neurology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Manabu Inoue
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan .,Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kanta Tanaka
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kodai Kanemaru
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Junpei Koge
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masayuki Shiozawa
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Naruhiko Kamogawa
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Shunsuke Kimura
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Tetsuya Chiba
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Tetsu Satow
- Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Jun C Takahashi
- Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kazunori Toyoda
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masatoshi Koga
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masafumi Ihara
- Neurology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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23
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Hypoperfusion Intensity Ratio Predicts Malignant Edema and Functional Outcome in Large-Vessel Occlusive Stroke with Poor Revascularization. Neurocrit Care 2020; 35:79-86. [PMID: 33200332 DOI: 10.1007/s12028-020-01152-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/03/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND OBJECTIVE Malignant cerebral edema (MCE) is a well-known complication in patients with acute ischemic stroke with core infarcts ≥ 80 mL caused by large-vessel occlusions. MCE can also develop in patients with smaller infarcts with moderate -to-large volume of tissue at risk who do not achieve successful revascularization with endovascular thrombectomy (ET). Features that predict the development of MCE in this population are not well-described. We aim to identify predictors of MCE and 90-day functional outcome in stroke patients with an anterior circulation large vessel occlusion (LVO) and a < 80 mL ischemic core who do not achieve complete reperfusion. METHODS We reviewed our institutional stroke registry and included patients who achieved unsuccessful revascularization, mTICI 0-2a, after ET and whose baseline imaging was notable for a core infarct < 80 mL, a Tmax > 6 s volume ≥ 80 mL, and a mismatch ratio ≥ 1.8. MCE was defined as ≥ 5 mm of midline shift on follow-up imaging, obtained 6-48 h after the pre-ET perfusion scan. RESULTS Thirty-six patients met inclusion criteria. Unadjusted analysis demonstrated that younger age, higher systolic blood pressure, larger core volume, and higher hypoperfusion intensity ratio (HIR) were associated with MCE (all p < 0.02). In multivariate logistic regression analysis, age, HIR, and core infarct volume were independent predictors of MCE. The optimal HIR threshold to predict MCE was ≥ 0.54 (OR 14.7, 95% CI 2.4-78.0, p = 0.003). HIR was also associated with 3-month mRS (HIR ≥ 0.54 for mRS of 3-6: OR 10.8, 95% CI 1.9-44.0, p = 0.02). CONCLUSIONS Younger age, larger core infarct volume, and higher HIR are predictive of MCE in patients with anterior circulation LVO, moderate-to-large tissue at risk, and suboptimal revascularization. HIR is correlated with three-month functional outcomes.
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24
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Ramos LA, Kappelhof M, van Os HJA, Chalos V, Van Kranendonk K, Kruyt ND, Roos YBWEM, van der Lugt A, van Zwam WH, van der Schaaf IC, Zwinderman AH, Strijkers GJ, van Walderveen MAA, Wermer MJH, Olabarriaga SD, Majoie CBLM, Marquering HA. Predicting Poor Outcome Before Endovascular Treatment in Patients With Acute Ischemic Stroke. Front Neurol 2020; 11:580957. [PMID: 33178123 PMCID: PMC7593486 DOI: 10.3389/fneur.2020.580957] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 09/07/2020] [Indexed: 12/31/2022] Open
Abstract
Background: Although endovascular treatment (EVT) has greatly improved outcomes in acute ischemic stroke, still one third of patients die or remain severely disabled after stroke. If we could select patients with poor clinical outcome despite EVT, we could prevent futile treatment, avoid treatment complications, and further improve stroke care. We aimed to determine the accuracy of poor functional outcome prediction, defined as 90-day modified Rankin Scale (mRS) score ≥5, despite EVT treatment. Methods: We included 1,526 patients from the MR CLEAN Registry, a prospective, observational, multicenter registry of ischemic stroke patients treated with EVT. We developed machine learning prediction models using all variables available at baseline before treatment. We optimized the models for both maximizing the area under the curve (AUC), reducing the number of false positives. Results: From 1,526 patients included, 480 (31%) of patients showed poor outcome. The highest AUC was 0.81 for random forest. The highest area under the precision recall curve was 0.69 for the support vector machine. The highest achieved specificity was 95% with a sensitivity of 34% for neural networks, indicating that all models contained false positives in their predictions. From 921 mRS 0–4 patients, 27–61 (3–6%) were incorrectly classified as poor outcome. From 480 poor outcome patients in the registry, 99–163 (21–34%) were correctly identified by the models. Conclusions: All prediction models showed a high AUC. The best-performing models correctly identified 34% of the poor outcome patients at a cost of misclassifying 4% of non-poor outcome patients. Further studies are necessary to determine whether these accuracies are reproducible before implementation in clinical practice.
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Affiliation(s)
- Lucas A Ramos
- Department of Biomedical Engineering and Physics, University of Amsterdam, Amsterdam, Netherlands.,Department of Clinical Epidemiology and Biostatistics, University of Amsterdam, Amsterdam, Netherlands
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, University of Amsterdam, Amsterdam, Netherlands
| | | | - Vicky Chalos
- Department of Neurology, Erasmus MC - University Medical Center, Rotterdam, Netherlands.,Department of Public Health, Erasmus MC - University Medical Center, Rotterdam, Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus MC - University Medical Center, Rotterdam, Netherlands
| | - Katinka Van Kranendonk
- Department of Radiology and Nuclear Medicine, University of Amsterdam, Amsterdam, Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC - University Medical Center, Rotterdam, Netherlands
| | - Wim H van Zwam
- Department of Radiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | | | - Aeilko H Zwinderman
- Department of Clinical Epidemiology and Biostatistics, University of Amsterdam, Amsterdam, Netherlands
| | - Gustav J Strijkers
- Department of Biomedical Engineering and Physics, University of Amsterdam, Amsterdam, Netherlands.,Department of Radiology and Nuclear Medicine, University of Amsterdam, Amsterdam, Netherlands
| | | | - Mariekke J H Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Silvia D Olabarriaga
- Department of Clinical Epidemiology and Biostatistics, University of Amsterdam, Amsterdam, Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, University of Amsterdam, Amsterdam, Netherlands
| | - Henk A Marquering
- Department of Biomedical Engineering and Physics, University of Amsterdam, Amsterdam, Netherlands.,Department of Radiology and Nuclear Medicine, University of Amsterdam, Amsterdam, Netherlands
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25
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Wen X, Li Y, He X, Xu Y, Shu Z, Hu X, Chen J, Jiang H, Gong X. Prediction of Malignant Acute Middle Cerebral Artery Infarction via Computed Tomography Radiomics. Front Neurosci 2020; 14:708. [PMID: 32733197 PMCID: PMC7358521 DOI: 10.3389/fnins.2020.00708] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/11/2020] [Indexed: 12/23/2022] Open
Abstract
Malignant middle cerebral artery infarction (mMCAi) is a serious complication of cerebral infarction usually associated with poor patient prognosis. In this retrospective study, we analyzed clinical information as well as non-contrast computed tomography (NCCT) and computed tomography angiography (CTA) data from patients with cerebral infarction in the middle cerebral artery (MCA) territory acquired within 24 h from symptoms onset. Then, we aimed to develop a model based on the radiomics signature to predict the development of mMCAi in cerebral infarction patients. Patients were divided randomly into training (n = 87) and validation (n = 39) sets. A total of 396 texture features were extracted from each NCCT image from the 126 patients. The least absolute shrinkage and selection operator regression analysis was used to reduce the feature dimension and construct an accurate radiomics signature based on the remaining texture features. Subsequently, we developed a model based on the radiomics signature and Alberta Stroke Program Early CT Score (ASPECTS) based on NCCT to predict mMCAi. Our prediction model showed a good predictive performance with an AUC of 0.917 [95% confidence interval (CI), 0.863-0.972] and 0.913 [95% CI, 0.795-1] in the training and validation sets, respectively. Additionally, the decision curve analysis (DCA) validated the clinical efficacy of the combined risk factors of radiomics signature and ASPECTS based on NCCT in the prediction of mMCAi development in patients with acute stroke across a wide range of threshold probabilities. Our research indicates that radiomics signature can be an instrumental tool to predict the risk of mMCAi.
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Affiliation(s)
- Xuehua Wen
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Yumei Li
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Xiaodong He
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Yuyun Xu
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Zhenyu Shu
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Xingfei Hu
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Junfa Chen
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Hongyang Jiang
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Xiangyang Gong
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China.,Institute of Artificial Intelligence and Remote Imaging, Hangzhou Medical College, Hangzhou, China
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26
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Cimflova P, Volny O, Mikulik PR, Tyshchenko B, Belaskova S, Vinklarek J, Cervenak V, Krivka T, Vanicek APJ, Krajina PA. Detection of ischemic changes on baseline multimodal computed tomography: expert reading vs. Brainomix and RAPID software. J Stroke Cerebrovasc Dis 2020; 29:104978. [PMID: 32807415 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104978] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/29/2020] [Accepted: 05/17/2020] [Indexed: 11/18/2022] Open
Abstract
PURPOSE The aim of the study was to compare the assessment of ischemic changes by expert reading and available automated software for non-contrast CT (NCCT) and CT perfusion on baseline multimodal imaging and demonstrate the accuracy for the final infarct prediction. METHODS Early ischemic changes were measured by ASPECTS on the baseline neuroimaging of consecutive patients with anterior circulation ischemic stroke. The presence of early ischemic changes was assessed a) on NCCT by two experienced raters, b) on NCCT by e-ASPECTS, and c) visually on derived CT perfusion maps (CBF<30%, Tmax>10s). Accuracy was calculated by comparing presence of final ischemic changes on 24-hour follow-up for each ASPECTS region and expressed as sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). The subanalysis for patients with successful recanalization was conducted. RESULTS Of 263 patients, 81 fulfilled inclusion criteria. Median baseline ASPECTS was 9 for all tested modalities. Accuracy was 0.76 for e-ASPECTS, 0.79 for consensus, 0.82 for CBF<30%, 0.80 for Tmax>10s. e-ASPECTS, consensus, CBF<30%, and Tmax>10s had sensitivity 0.41, 0.46, 0.49, 0.57, respectively; specificity 0.91, 0.93, 0.95, 0.91, respectively; PPV 0.66, 0.75, 0.82, 0.73, respectively; NPV 0.78, 0.80, 0.82, 0.83, respectively. Results did not differ in patients with and without successful recanalization. CONCLUSION This study demonstrated high accuracy for the assessment of ischemic changes by different CT modalities with the best accuracy for CBF<30% and Tmax>10s. The use of automated software has a potential to improve the detection of ischemic changes.
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Affiliation(s)
- Petra Cimflova
- Department of Medical Imaging, St. Anne´s University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic; International Clinical Research Centre, Stroke Research Program, St. Anne´s University Hospital, Brno, Czech Republic.
| | - Ondrej Volny
- International Clinical Research Centre, Stroke Research Program, St. Anne´s University Hospital, Brno, Czech Republic; Departments of Clinical Neurosciences, Calgary Stroke Program, Cumming School of Medicine, University of Calgary, Calgary, Canada; Department of Neurology, Faculty Hospital Ostrava, Ostrava, Czech Republic.
| | - Prof Robert Mikulik
- International Clinical Research Centre, Stroke Research Program, St. Anne´s University Hospital, Brno, Czech Republic; Department of Neurology, St. Anne´s University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Bohdan Tyshchenko
- International Clinical Research Centre, Stroke Research Program, St. Anne´s University Hospital, Brno, Czech Republic.
| | - Silvie Belaskova
- International Clinical Research Centre, Stroke Research Program, St. Anne´s University Hospital, Brno, Czech Republic.
| | - Jan Vinklarek
- Department of Neurology, Faculty Hospital Ostrava, Ostrava, Czech Republic.
| | - Vladimir Cervenak
- Department of Medical Imaging, St. Anne´s University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Tomas Krivka
- Department of Medical Imaging, St. Anne´s University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Assoc Prof Jiri Vanicek
- Department of Medical Imaging, St. Anne´s University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Prof Antonin Krajina
- Department of Radiology, Charles University, Faculty of Medicine and University Hospital, Hradec Kralove, Czech Republic.
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27
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Conrad J, Ertl M, Oltmanns MH, Zu Eulenburg P. Prediction contribution of the cranial collateral circulation to the clinical and radiological outcome of ischemic stroke. J Neurol 2020; 267:2013-2021. [PMID: 32206898 PMCID: PMC7320948 DOI: 10.1007/s00415-020-09798-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 03/13/2020] [Accepted: 03/16/2020] [Indexed: 10/31/2022]
Abstract
BACKGROUND AND AIM The extent of penumbra tissue and outcome in stroke patients depend on the collateral cranial vasculature. To provide optimal individualized care for stroke patients in the emergency room setting we investigated the predictive capability of a stringent evaluation of the collateral vessels in ischemic stroke on clinical outcome and infarct size. METHODS We retrospectively studied uniform clinical and radiological data of 686 consecutive patients admitted to the emergency department with suspected acute ischemic stroke. Cranial collateral vasculature status was graded using the initial CT-angiography. Outcome was measured by mRS, NIHSS and final infarct size at hospital discharge. All data were used to build a linear regression model to predict the patients´ outcome. RESULTS Univariate and multivariate analyses showed significant effects of the whole brain collateral vessel score on all outcome variables. Atherosclerosis and piale collateral status were associated with the final infarct volume (FIV). Atherosclerosis and age were associated with the NIHSS at discharge. The presence of atherosclerosis, glucose level on admission and age were associated with the mRS at discharge. The multivariate models were able to predict 29% of the variance of the mRS at discharge, 24% of the variance in FIV and 17% of the variance of the NIHSS at discharge. The whole brain collateral status and the presence of atherosclerosis were the most relevant predictors for the clinical and radiological outcome. CONCLUSION The whole brain collateral vasculature status is clearly associated with clinical and radiological outcome but in a multivariate model seems not sufficiently predictive for FIV, mRS and NIHSS outcome at discharge in non-preselected patients admitted to the emergency department with ischemic stroke.
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Affiliation(s)
- Julian Conrad
- Department of Neurology, LMU Munich, Marchioninistr.15, 81377, Munich, Germany. .,German Center for Vertigo and Balance Disorders (DSGZ), LMU Munich, Munich, Germany.
| | - Matthias Ertl
- German Center for Vertigo and Balance Disorders (DSGZ), LMU Munich, Munich, Germany.,Department of Psychology, University of Bern, Bern, Switzerland
| | - Meret H Oltmanns
- Department of Neuroradiology, Johannes Gutenberg-University, Mainz, Germany
| | - Peter Zu Eulenburg
- German Center for Vertigo and Balance Disorders (DSGZ), LMU Munich, Munich, Germany.,Institute for Neuroradiology, LMU Munich, Munich, Germany
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28
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Byrne D, Walsh JP, Sugrue G, Nicolaou S, Rohr A. CT Imaging of Acute Ischemic Stroke [Formula: see text]. Can Assoc Radiol J 2020; 71:266-280. [PMID: 32157894 DOI: 10.1177/0846537120902068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Although acute ischemic stroke remains one of the most common causes of death and disability worldwide, it is a potentially treatable condition if appropriately managed in a timely manner. The goals of acute stroke imaging include establishing a diagnosis as fast as possible with (1) accurate infarct quantification, (2) intracranial and cervical vasculature assessment, and (3) brain perfusion analysis for detection of infarct core and potentially salvageable penumbra allowing optimal patient selection for appropriate therapy. Given the extensive number of images generated from acute stroke imaging studies and as "time is brain," this article aims to highlight a logical approach for the radiologist in acute stroke computed tomography imaging in order to accurately interpret and communicate results in a timely manner.
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Affiliation(s)
- D Byrne
- Division of Neuroradiology, Vancouver General Hospital, Vancouver, British Columbia, Canada.,University of British Columbia, Vancouver, British Columbia, Canada
| | - J P Walsh
- University of British Columbia, Vancouver, British Columbia, Canada.,Division of Emergency Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - G Sugrue
- University of British Columbia, Vancouver, British Columbia, Canada.,Division of Emergency Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - S Nicolaou
- University of British Columbia, Vancouver, British Columbia, Canada.,Division of Emergency Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - A Rohr
- Division of Neuroradiology, Vancouver General Hospital, Vancouver, British Columbia, Canada.,University of British Columbia, Vancouver, British Columbia, Canada
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29
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Demeestere J, Wouters A, Christensen S, Lemmens R, Lansberg MG. Review of Perfusion Imaging in Acute Ischemic Stroke: From Time to Tissue. Stroke 2020; 51:1017-1024. [PMID: 32008460 DOI: 10.1161/strokeaha.119.028337] [Citation(s) in RCA: 116] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jelle Demeestere
- From the Department of Neurosciences, Experimental Neurology, KU Leuven - University of Leuven, Belgium (J.D., A.W., R.L.).,VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium (J.D., A.W., R.L.).,Department of Neurology, University Hospitals Leuven, Belgium (J.D., A.W., R.L.)
| | - Anke Wouters
- From the Department of Neurosciences, Experimental Neurology, KU Leuven - University of Leuven, Belgium (J.D., A.W., R.L.).,VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium (J.D., A.W., R.L.).,Department of Neurology, University Hospitals Leuven, Belgium (J.D., A.W., R.L.)
| | - Soren Christensen
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA (S.C., M.G.L.)
| | - Robin Lemmens
- From the Department of Neurosciences, Experimental Neurology, KU Leuven - University of Leuven, Belgium (J.D., A.W., R.L.).,VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium (J.D., A.W., R.L.).,Department of Neurology, University Hospitals Leuven, Belgium (J.D., A.W., R.L.)
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA (S.C., M.G.L.)
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30
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Jiang L, Peng M, Chen H, Geng W, Zhao B, Yin X, Chen YC, Su H. Diffusion-weighted imaging (DWI) ischemic volume is related to FLAIR hyperintensity-DWI mismatch and functional outcome after endovascular therapy. Quant Imaging Med Surg 2020; 10:356-367. [PMID: 32190562 DOI: 10.21037/qims.2019.12.05] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND We assessed whether diffusion-weighted imaging (DWI) volume was associated with fluid-attenuated inversion recovery vascular hyperintensities (FVH)-DWI mismatch and functional outcome in patients with acute stroke who received endovascular therapy (EVT). METHODS Fifty-three acute stroke patients who received EVT were enrolled. FVH-DWI mismatch, DWI volume on admission, DWI volume on follow-up, DWI volume growth, the functional outcome at 3 months (mRS) and other clinical data were collected. Receiver operating characteristic (ROC) analysis was performed to evaluate the value of DWI volume in predicting functional outcome after stroke. RESULTS The FVH-DWI mismatch group had a smaller DWI volume on admission (13.86±19.58 vs. 65.07±52.21; t=-4.301, P=0.000), a smaller DWI volume on follow-up (29.88±33.52 vs. 112.43±87.19; t=-4.143, P=0.000), and a lower DWI volume growth (16.02±19.90 vs. 47.36±40.06; t=-3.326, P=0.003) than those of the no FVH-DWI mismatch group. The good functional outcome group had a smaller DWI volume on admission (13.30±13.26 vs. 68.56±54.28; t=-5.611, P=0.000), a smaller DWI volume on follow-up (27.65±18.80 vs. 120.25±90.37; t=-5.720, P=0.000), lower DWI volume growth (14.35±15.06 vs. 51.69±41.17; t=-4.737, P=0.001) and a higher FVH-DWI mismatch ratio (75.76% vs. 35%; t=8.647; P=0.004) than those of the poor functional outcome group. ROC analysis showed that the sensitivity and specificity of DWI volume on admission for predicting functional outcome were 65% and 96.97%, respectively (the optimal cut-off value: 33.50 mL); DWI volume on follow-up was 48.6 mL, with a sensitivity and specificity of 80% and 87.88%, respectively; DWI volume growth was 22.25 mL, with a sensitivity and specificity of 70% and 87.88%, respectively. CONCLUSIONS DWI volume and DWI volume growth can provide the prognostic information of acute stroke patients after thrombectomy.
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Affiliation(s)
- Liang Jiang
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China
| | - Mingyang Peng
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China
| | - Huiyou Chen
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China
| | - Wen Geng
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China
| | - Boxiang Zhao
- Department of Intervention, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China
| | - Xindao Yin
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China
| | - Yu-Chen Chen
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China
| | - Haobo Su
- Department of Intervention, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China
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Sarraj A, Hassan AE, Grotta J, Sitton C, Cutter G, Cai C, Chen PR, Imam B, Pujara D, Arora A, Reddy S, Parsha K, Riascos RF, Vora N, Abraham M, Edgell R, Hellinger F, Haussen DC, Blackburn S, Kamal H, Barreto AD, Martin-Schild S, Lansberg M, Gupta R, Savitz S, Albers GW. Optimizing Patient Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT): A Prospective, Multicenter Cohort Study of Imaging Selection. Ann Neurol 2020; 87:419-433. [PMID: 31916270 DOI: 10.1002/ana.25669] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 01/03/2020] [Accepted: 01/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The primary imaging modalities used to select patients for endovascular thrombectomy (EVT) are noncontrast computed tomography (CT) and CT perfusion (CTP). However, their relative utility is uncertain. We prospectively assessed CT and CTP concordance/discordance and correlated the imaging profiles on both with EVT treatment decisions and clinical outcomes. METHODS A phase 2, multicenter, prospective cohort study of large-vessel occlusions presented up to 24 hours from last known well was conducted. Patients received a unified prespecified imaging evaluation (CT, CT angiography, and CTP with Rapid Processing of Perfusion and Diffusion software mismatch determination). The treatment decision, EVT versus medical management, was nonrandomized and at the treating physicians' discretion. An independent, blinded, neuroimaging core laboratory adjudicated favorable profiles based on predefined criteria (CT:Alberta Stroke Program Early CT Score ≥ 6, CTP:regional cerebral blood flow (<30%) < 70ml with mismatch ratio ≥ 1.2 and mismatch volume ≥ 10ml). RESULTS Of 4,722 patients screened from January 2016 to February 2018, 361 patients were included. Two hundred eighty-five (79%) received EVT, of whom 87.0% had favorable CTs, 91% favorable CTPs, 81% both favorable profiles, 16% discordant, and 3% both unfavorable. Favorable profiles on the 2 modalities correlated similarly with 90-day functional independence rates (favorable CT = 56% vs favorable CTP = 57%, adjusted odds ratio [aOR] = 1.91, 95% confidence interval [CI] = 0.40-9.01, p = 0.41). Having a favorable profile on both modalities significantly increased the odds of receiving thrombectomy as compared to discordant profiles (aOR = 3.97, 95% CI = 1.97-8.01, p < 0.001). Fifty-eight percent of the patients with favorable profiles on both modalities achieved functional independence as compared to 38% in discordant profiles and 0% when both were unfavorable (p < 0.001 for trend). In favorable CT/unfavorable CTP profiles, EVT was associated with high symptomatic intracranial hemorrhage (sICH) (24%) and mortality (53%) rates. INTERPRETATION Patients with favorable imaging profiles on both modalities had higher odds of receiving EVT and high functional independence rates. Patients with discordant profiles achieved reasonable functional independence rates, but those with an unfavorable CTP had higher adverse outcomes. Ann Neurol 2020;87:419-433.
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Affiliation(s)
- Amrou Sarraj
- Department of Neurology, University of Texas at Houston, Houston, TX
| | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX
| | - James Grotta
- Department of Neurology, University of Texas at Houston, Houston, TX
| | - Clark Sitton
- Department of Radiology, University of Texas at Houston, Houston, TX
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham School of Public Health, Birmingham, AL
| | - Chunyan Cai
- Department of Clinical and Translational Science, University of Texas at Houston, Houston, TX
| | - Peng R Chen
- Department of Neurosurgery, University of Texas at Houston, Houston, TX
| | - Bita Imam
- Department of Neurology, University of Texas at Houston, Houston, TX
| | - Deep Pujara
- Department of Neurology, University of Texas at Houston, Houston, TX
| | | | - Sujan Reddy
- Department of Neurology, University of Texas at Houston, Houston, TX
| | - Kaushik Parsha
- Department of Neurology, University of Texas at Houston, Houston, TX
| | - Roy F Riascos
- Department of Radiology, University of Texas at Houston, Houston, TX
| | - Nirav Vora
- Department of Neurology, OhioHealth-Riverside Methodist Hospital, Columbus, OH
| | - Michael Abraham
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS
| | - Randall Edgell
- Department of Neurology, Saint Louis University, St. Louis, MO
| | | | | | - Spiros Blackburn
- Department of Neurosurgery, University of Texas at Houston, Houston, TX
| | - Haris Kamal
- Department of Neurology, University of Texas at Houston, Houston, TX
| | - Andrew D Barreto
- Department of Neurology, University of Texas at Houston, Houston, TX
| | - Sheryl Martin-Schild
- Department of Neurology, Touro Infirmary and New Orleans East Hospital, New Orleans, LA
| | | | - Rishi Gupta
- Department of Neurology, WellStar Health System, Atlanta, GA
| | - Sean Savitz
- Department of Neurology, University of Texas at Houston, Houston, TX
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32
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Toyoda K, Koga M, Iguchi Y, Itabashi R, Inoue M, Okada Y, Ogasawara K, Tsujino A, Hasegawa Y, Hatano T, Yamagami H, Iwama T, Shiokawa Y, Terayama Y, Minematsu K. Guidelines for Intravenous Thrombolysis (Recombinant Tissue-type Plasminogen Activator), the Third Edition, March 2019: A Guideline from the Japan Stroke Society. Neurol Med Chir (Tokyo) 2019; 59:449-491. [PMID: 31801934 PMCID: PMC6923159 DOI: 10.2176/nmc.st.2019-0177] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine
| | | | - Manabu Inoue
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center
| | | | - Akira Tsujino
- Department of Neurology and Strokology, Nagasaki University Hospital
| | | | - Taketo Hatano
- Department of Neurosurgery, Kokura Memorial Hospital
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital
| | - Toru Iwama
- Department of Neurosurgery, Gifu University School of Medicine
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33
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Diffusion-weighted imaging volume and diffusion-weighted imaging volume growth in acute stroke: associations with fluid-attenuated inversion recovery hyperintensities-diffusion-weighted imaging mismatch and functional outcome. Neuroreport 2019; 30:875-881. [PMID: 31373966 DOI: 10.1097/wnr.0000000000001291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE This study assessed the association between diffusion-weighted imaging (DWI) volume and fluid-attenuated inversion recovery vascular hyperintensity (FVH)-DWI mismatch, functional outcome in patients with acute stroke patients receiving endovascular therapy, as well as the value of DWI volume in predicting functional outcome with stroke patients. METHODS In 38 stroke patients who received endovascular therapy, FVH-DWI mismatch, DWI volume on admission, DWI volume on follow-up, DWI volume growth, the functional outcome at 3 months [modified Rankin scale (mRS)], and other clinical data were collected. Statistical analysis was performed to compare the associations with the above variables and predict functional outcome after stroke. RESULTS Compared with no FVH-DWI mismatch group (n = 15), FVH-DWI mismatch group (n = 23) had a smaller DWI volume on admission (t = -2.980; P = 0.008), smaller DWI volume on follow-up (t = -2.911; P = 0.009), lower DWI volume growth (t = -2.328; P = 0.031). The 3-month outcome (1.87 ± 0.92) in patients with FVH-DWI mismatch was better than that (2.93 ± 1.62) of patients with no FVH-DWI mismatch (t = -2.307; P = 0.032). Spearman's rank correlation analysis revealed that FVH-DWI mismatch (r = 0.327; P = 0.045), DWI volume on admission (r = 0.414; P = 0.010), DWI volume on follow-up (r = 0.486; P = 0.002), and DWI volume growth (r = 0.467; P = 0.003) were positively correlated with mRS at 3 months. ROC analysis showed when the optimal cutoff value of DWI volume on admission was 33.50, the sensitivity and specificity for predicting functional outcome was 60 and 95.65%, respectively. CONCLUSIONS Evaluating DWI volume on admission, DWI volume on follow-up as well as DWI volume growth comprehensively may be useful in predicting the functional outcome of acute stroke patients after thrombectomy.
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Shazeeb MS, King RM, Brooks OW, Puri AS, Henninger N, Boltze J, Gounis MJ. Infarct Evolution in a Large Animal Model of Middle Cerebral Artery Occlusion. Transl Stroke Res 2019; 11:468-480. [PMID: 31478129 DOI: 10.1007/s12975-019-00732-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/19/2019] [Accepted: 08/21/2019] [Indexed: 11/26/2022]
Abstract
Mechanical thrombectomy for the treatment of ischemic stroke shows high rates of recanalization; however, some patients still have a poor clinical outcome. A proposed reason for this relates to the fact that the ischemic infarct growth differs significantly between patients. While some patients demonstrate rapid evolution of their infarct core (fast evolvers), others have substantial potentially salvageable penumbral tissue even hours after initial vessel occlusion (slow evolvers). We show that the dog middle cerebral artery occlusion model recapitulates this key aspect of human stroke rendering it a highly desirable model to develop novel multimodal treatments to improve clinical outcomes. Moreover, this model is well suited to develop novel image analysis techniques that allow for improved lesion evolution prediction; we provide proof-of-concept that MRI perfusion-based time-to-peak maps can be utilized to predict the rate of infarct growth as validated by apparent diffusion coefficient-derived lesion maps allowing reliable classification of dogs into fast versus slow evolvers enabling more robust study design for interventional research.
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Affiliation(s)
- Mohammed Salman Shazeeb
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, MA, 01655, USA.
- Image Processing and Analysis Core, Department of Radiology, University of Massachusetts Medical School, Worcester, MA, 01655, USA.
| | - Robert M King
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, MA, 01655, USA
- Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, MA, 01609, USA
| | - Olivia W Brooks
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, MA, 01655, USA
- St. George's University School of Medicine, St. George's, West Indies, Grenada
| | - Ajit S Puri
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, MA, 01655, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, 01655, USA
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, 01655, USA
| | - Johannes Boltze
- School of Life Sciences, University of Warwick, Coventry, CV4 7AL, UK
| | - Matthew J Gounis
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, MA, 01655, USA
- Image Processing and Analysis Core, Department of Radiology, University of Massachusetts Medical School, Worcester, MA, 01655, USA
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Ng FC, Campbell BCV. Imaging After Thrombolysis and Thrombectomy: Rationale, Modalities and Management Implications. Curr Neurol Neurosci Rep 2019; 19:57. [PMID: 31278596 DOI: 10.1007/s11910-019-0970-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Urgent reperfusion treatment with intravenous thrombolysis or mechanical thrombectomy reduces disability after ischaemic stroke. Imaging plays an important role in identifying patients who benefit, particularly in extended time windows. However, the role of post-treatment neuroimaging is less well established. We review recent advances in neuroimaging after reperfusion treatment and provide a practical guide to the options and management implications. RECENT FINDINGS Post-treatment imaging is critical to identify patients with reperfusion-related haemorrhage and oedema requiring intervention. It also can guide the timing and intensity of antithrombotic medication. The degree of reperfusion on post-thrombectomy angiography and infarct volume and topography using CT or MRI carry important prognostic significance. Perfusion-weighted MRI and permeability analysis may help detect persistent perfusion abnormalities post-treatment and predict haemorrhagic complications. Post-treatment neuroimaging provides clinically relevant information to identify complications, assess prognosis and perform quality assurance after acute ischaemic stroke. Recent advances in neuroimaging represent a potential avenue to explore post-reperfusion pathophysiology and uncover therapeutic targets for secondary ischaemic and haemorrhagic injury.
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Affiliation(s)
- Felix C Ng
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Grattan Street, Parkville, VIC, 3050, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Grattan Street, Parkville, VIC, 3050, Australia.
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Panni P, Gory B, Xie Y, Consoli A, Desilles JP, Mazighi M, Labreuche J, Piotin M, Turjman F, Eker OF, Bracard S, Anxionnat R, Richard S, Hossu G, Blanc R, Lapergue B, Redjem H, Escalard S, Redjem H, Ciccio G, Smajda S, Fahed R, Obadia M, Sabben C, Corabianu O, de Broucker T, Smadja D, Alamowitch S, Ille O, Manchon E, Garcia PY, Taylor G, Maacha MB, Bourdain F, Decroix JP, Wang A, Evrard S, Tchikviladze M, Coskun O, Di Maria F, Rodesh G, Leguen M, Tisserand M, Pico F, Rakotoharinandrasana H, Tassan P, Poll R, Nighoghossian N, Labeyrie PE, Riva R, Derex L, Cho TH, Mechtouff L, Claire Lukaszewicz A, Philippeau F, Cakmak S, Blanc-Lasserre K, Vallet AE. Acute Stroke With Large Ischemic Core Treated by Thrombectomy. Stroke 2019; 50:1164-1171. [DOI: 10.1161/strokeaha.118.024295] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Pietro Panni
- From the Department of Neuroradiology, Division of Interventional Neuroradiology, Department of Neurosurgery, San Raffaele University Hospital, Milan, Italy (P.P.)
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, INSERM U12542, University Hospital of Nancy, France (B.G., S.B., R.A.)
| | - Yu Xie
- Department of Neuroradiology, University of Lorraine, IADI, INSERM U1254, Nancy, F-54000, France (Y.X., G.H.)
| | - Arturo Consoli
- Department of Diagnostic and Interventional Neuroradiology, Foch Hospital, Suresnes, France (A.C.)
| | - Jean-Philippe Desilles
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.-P.D., M.M., M.P., R.B.)
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.-P.D., M.M., M.P., R.B.)
| | - Julien Labreuche
- Department of Biostatistics, EA2694-Santé publique: épidémiologie et qualité des soins, Lille University, France (J.L.)
| | - Michel Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.-P.D., M.M., M.P., R.B.)
| | - Francis Turjman
- Department of Interventional Neuroradiology, Hospices Civils de Lyon, France (F.T., O.F.E.)
| | - Omer Faruk Eker
- Department of Interventional Neuroradiology, Hospices Civils de Lyon, France (F.T., O.F.E.)
| | - Serge Bracard
- Department of Diagnostic and Therapeutic Neuroradiology, INSERM U12542, University Hospital of Nancy, France (B.G., S.B., R.A.)
| | - René Anxionnat
- Department of Diagnostic and Therapeutic Neuroradiology, INSERM U12542, University Hospital of Nancy, France (B.G., S.B., R.A.)
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, INSERM U1116, University Hospital of Nancy, France (S.R.)
| | - Gabriela Hossu
- Department of Neuroradiology, University of Lorraine, IADI, INSERM U1254, Nancy, F-54000, France (Y.X., G.H.)
| | - Raphael Blanc
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.-P.D., M.M., M.P., R.B.)
| | - Bertrand Lapergue
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France (B.L.)
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Keenan KJ, Christensen S, Inoue M, Mlynash M, Albers GW, Smith WS. Validation and iteration of CT perfusion defined malignant profile thresholds for acute ischemic stroke. Int J Stroke 2019; 15:55-60. [PMID: 30794104 DOI: 10.1177/1747493019832987] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Malignant profile computed tomography perfusion (CTP) lesions are associated with poor outcomes after administration of intravenous tissue-plasminogen activator (IV-tPA) for ischemic stroke. AIMS To determine whether published CTP-based lesion thresholds predictive of poor outcomes in a predominantly 8 cm of CTP anatomic coverage cohort would predict poor outcomes in an independent 4 cm of CTP anatomic coverage cohort and to generate optimized 4 cm CTP thresholds. METHODS Ischemic stroke patients with baseline CTP imaging with 4 cm of anatomic coverage before receiving IV-tPA at a single institution were retrospectively studied. Perfusion lesion time to maximum of tissue residue function (Tmax) and cerebral blood flow (CBF) volumes were determined using RAPID automated software. Fisher's exact tests assessed associations between lesion thresholds and outcomes. Receiver operating characteristic (ROC) curves generated optimized thresholds for 4 cm of CTP coverage. RESULTS Sixty-three patients were included. Poor outcomes were associated with published thresholds of Tmax >6 s > 103 mL, Tmax > 8 s > 86 mL, and Tmax > 10 s > 78 mL but not CBF core >53 mL. Thresholds optimized for 4 cm of CTP coverage and associated with poor outcomes were Tmax > 6 s > 100 mL, Tmax > 8 s > 65 mL, Tmax >10 s > 46 mL, and CBF core >39 mL. CONCLUSIONS We validated the ability of published CTP Tmax lesion volume thresholds to predict poor outcomes despite IV-tPA in an independent cohort using only 4 cm of CTP anatomical coverage. A CBF > 39 mL threshold, rather than the predominantly 8 cm CTP coverage derived CBF threshold of >53 mL, was associated with poor outcomes in this 4 cm CTP coverage cohort.
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Affiliation(s)
- Kevin J Keenan
- Department of Neurology, University of California, San Francisco, CA, USA
| | | | | | | | | | - Wade S Smith
- Department of Neurology, University of California, San Francisco, CA, USA
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Farr GW, Hall CH, Farr SM, Wade R, Detzel JM, Adams AG, Buch JM, Beahm DL, Flask CA, Xu K, LaManna JC, McGuirk PR, Boron WF, Pelletier MF. Functionalized Phenylbenzamides Inhibit Aquaporin-4 Reducing Cerebral Edema and Improving Outcome in Two Models of CNS Injury. Neuroscience 2019; 404:484-498. [PMID: 30738082 DOI: 10.1016/j.neuroscience.2019.01.034] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 01/18/2019] [Accepted: 01/21/2019] [Indexed: 01/23/2023]
Abstract
Cerebral edema in ischemic stroke can lead to increased intracranial pressure, reduced cerebral blood flow and neuronal death. Unfortunately, current therapies for cerebral edema are either ineffective or highly invasive. During the development of cytotoxic and subsequent ionic cerebral edema water enters the brain by moving across an intact blood brain barrier and through aquaporin-4 (AQP4) at astrocyte endfeet. Using AQP4-expressing cells, we screened small molecule libraries for inhibitors that reduce AQP4-mediated water permeability. Additional functional assays were used to validate AQP4 inhibition and identified a promising structural series for medicinal chemistry. These efforts improved potency and revealed a compound we designated AER-270, N-[3,5-bis (trifluoromethyl)phenyl]-5-chloro-2-hydroxybenzamide. AER-270 and a prodrug with enhanced solubility, AER-271 2-{[3,5-Bis(trifluoromethyl) phenyl]carbamoyl}-4-chlorophenyl dihydrogen phosphate, improved neurological outcome and reduced swelling in two models of CNS injury complicated by cerebral edema: water intoxication and ischemic stroke modeled by middle cerebral artery occlusion.
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Affiliation(s)
- George W Farr
- Aeromics, Inc., Cleveland, OH 44106, USA; Department of Physiology and Biophysics, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA.
| | | | | | - Ramon Wade
- Aeromics, Inc., Cleveland, OH 44106, USA
| | | | | | | | - Derek L Beahm
- Department of Biology, Buffalo State College, Buffalo, NY 14222, USA
| | - Christopher A Flask
- Departments of Radiology, Biomedical Engineering and Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - Kui Xu
- Department of Physiology and Biophysics, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - Joseph C LaManna
- Department of Physiology and Biophysics, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | | | - Walter F Boron
- Department of Physiology and Biophysics, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
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An acute stroke CT imaging algorithm incorporating automated perfusion analysis. Emerg Radiol 2019; 26:319-329. [PMID: 30706257 DOI: 10.1007/s10140-019-01675-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 01/15/2019] [Indexed: 12/16/2022]
Abstract
In this paper, we propose a CT imaging algorithm for patients presenting with suspected acute stroke that incorporates automated CT perfusion (CTP) imaging. The algorithm details evaluation of the non-contrast CT (NCCT) for hemorrhage and acute ischemia, calculation of ASPECTS, with performance and interpretation of CTP if appropriate. In particular, we consider the key steps in expeditious interpretation of non-contrast CT and CT angiography in the context of suspected acute ischemic stroke. Given the recent expansion of the "imaging based" treatment window for thrombectomy from 6 to 24 h in the 2018 American Heart Association stroke guidelines, we consider the key criteria in the decision to perform CT perfusion and the patient cohorts in which this might be most helpful. We also describe how imaging findings might be incorporated into the treatment paradigm for suspected with acute ischemic stroke and we allude to some of the most frequently encountered pitfalls associated with CTP which we think will be particularly helpful for radiologists and stroke physicians who are considering adding CT perfusion to their work-up for acute stroke.
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Chen Z, Zhang R, Zhou Y, Gong X, Zhang M, Shi F, Yu X, Lou M. Patients With Ischemic Core ≥70 ml Within 6 h of Symptom Onset May Still Benefit From Endovascular Treatment. Front Neurol 2018; 9:933. [PMID: 30455665 PMCID: PMC6230959 DOI: 10.3389/fneur.2018.00933] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 10/15/2018] [Indexed: 01/01/2023] Open
Abstract
Background: Large core is associated with poor outcome in acute ischemic stroke (AIS) patients. It is unclear whether endovascular treatment (EVT) could bring benefits to patients with core volume ≥70 ml before treatment. We aimed to compare the impact of EVT with intravenous thrombolysis (IVT) on the outcome in patients with core volume ≥70 ml. Methods: We included consecutive anterior circulation AIS patients who underwent MR or CT perfusion within 6 h post stroke onset, which revealed a core ≥70 ml before reperfusion therapy. Good outcome was defined by modified Rankin Scale of 0 to 2 at 90-day. Reperfusion was defined as a reduction in hypoperfusion volume of ≥70% between baseline and 24 h. Results: One hundred four patients were included. Among them, 76 received IVT only, and 28 received EVT. After adjusting for age, NIHSS score, baseline core volume and onset to imaging time, patients in EVT group were more likely to achieve good outcome compared to IVT patients (OR, 3.875; 95% Cl 1.068-14.055, p = 0.039). More patients in EVT group achieved recanalization (84.0 vs. 58.5%, p = 0.027) and reperfusion (66.7 vs. 33.3%, p = 0.010) than in IVT group. Reperfusion also independently predicted good outcome (OR, 7.718; 95% Cl 1.713-34.772, p = 0.008). All patients with good outcome achieved recanalization at 24 h. Conclusions: Our data indicated that patients with core volume ≥70 ml might still benefit from EVT, which was related to its high reperfusion rate.
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Affiliation(s)
- Zhicai Chen
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Ruiting Zhang
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Ying Zhou
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Xiaoxian Gong
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Meixia Zhang
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Feina Shi
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Xinfeng Yu
- Department of Radiology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Min Lou
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
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41
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Rabinstein AA, Albers GW, Brinjikji W, Koch S. Factors that may contribute to poor outcome despite good reperfusion after acute endovascular stroke therapy. Int J Stroke 2018; 14:23-31. [DOI: 10.1177/1747493018799979] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Endovascular therapy with mechanical thrombectomy is a formidable treatment for severe acute ischemic stroke caused by occlusion of a proximal intracranial artery. Its strong beneficial effect is explained by the high rates of very good and excellent reperfusion achieved with current endovascular techniques. However, there is a sizable proportion of patients who do not experience clinical improvement despite successful recanalization of the occluded artery and reperfusion of the ischemic territory. Factors such as baseline reserve, collateral flow, anesthesia and systemic factors have been identified as potential culprits for lack of improvement in the setting of timely and successful revascularization. Older age, baseline disability and perhaps radiological markers of chronic brain injury can affect the prognosis of patients treated with endovascular therapy. Collateral flow is a major determinant of outcome after endovascular therapy and it is manifested by the size of the core in relation to the volume of the salvageable tissue. Parenchymal and vascular imaging can help assess the quality of collateral flow, but the optimal radiological strategy for daily practice (i.e. the optimal combination of rapid availability and diagnostic precision) has not been established. A sizable body of observational evidence indicates that acute hypertension, hyperglycemia and fever are associated with worse outcomes after a stroke even after optimal reperfusion with endovascular therapy. Lastly, current randomized controlled trials in anesthesia for stroke demonstrate similar rates of good functional outcome between general anesthesia and conscious sedation suggesting equipoise exists.
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Affiliation(s)
| | | | | | - Sebastian Koch
- Department of Neurology, University of Miami, Coral Gables, FL, USA
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Leigh R, Knutsson L, Zhou J, van Zijl PC. Imaging the physiological evolution of the ischemic penumbra in acute ischemic stroke. J Cereb Blood Flow Metab 2018; 38:1500-1516. [PMID: 28345479 PMCID: PMC6125975 DOI: 10.1177/0271678x17700913] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We review the hemodynamic, metabolic and cellular parameters affected during early ischemia and their changes as a function of approximate cerebral blood flow ( CBF) thresholds. These parameters underlie the current practical definition of an ischemic penumbra, namely metabolically affected but still viable brain tissue. Such tissue is at risk of infarction under continuing conditions of reduced CBF, but can be rescued through timely intervention. This definition will be useful in clinical diagnosis only if imaging techniques exist that can rapidly, and with sufficient accuracy, visualize the existence of a mismatch between such a metabolically affected area and regions that have suffered cell depolarization. Unfortunately, clinical data show that defining the outer boundary of the penumbra based solely on perfusion-related thresholds may not be sufficiently accurate. Also, thresholds for CBF and cerebral blood volume ( CBV) differ for white and gray matter and evolve with time for both inner and outer penumbral boundaries. As such, practical penumbral imaging would involve parameters in which the physiology is immediately displayed in a manner independent of baseline CBF or CBF threshold, namely pH, oxygen extraction fraction ( OEF), diffusion constant and mean transit time ( MTT). Suitable imaging technologies will need to meet this requirement in a 10-20 min exam.
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Affiliation(s)
- Richard Leigh
- 1 National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, USA
| | - Linda Knutsson
- 2 Department of Medical Radiation Physics, Lund University, Lund, Sweden.,3 Department of Radiology, Johns Hopkins University, Baltimore, MD, USA
| | - Jinyuan Zhou
- 3 Department of Radiology, Johns Hopkins University, Baltimore, MD, USA.,4 F.M. Kirby Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Peter Cm van Zijl
- 3 Department of Radiology, Johns Hopkins University, Baltimore, MD, USA.,4 F.M. Kirby Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, USA
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Rudkin S, Cerejo R, Tayal A, Goldberg MF. Imaging of acute ischemic stroke. Emerg Radiol 2018; 25:659-672. [DOI: 10.1007/s10140-018-1623-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/26/2018] [Indexed: 10/28/2022]
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Bernhardt J, Zorowitz RD, Becker KJ, Keller E, Saposnik G, Strbian D, Dichgans M, Woo D, Reeves M, Thrift A, Kidwell CS, Olivot JM, Goyal M, Pierot L, Bennett DA, Howard G, Ford GA, Goldstein LB, Planas AM, Yenari MA, Greenberg SM, Pantoni L, Amin-Hanjani S, Tymianski M. Advances in Stroke 2017. Stroke 2018; 49:e174-e199. [DOI: 10.1161/strokeaha.118.021380] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 03/02/2018] [Accepted: 03/12/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Julie Bernhardt
- From the Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia (J.B.)
| | - Richard D. Zorowitz
- MedStar National Rehabilitation Network and Department of Rehabilitation Medicine, Georgetown University School of Medicine, Washington, DC (R.D.Z.)
| | - Kyra J. Becker
- Department of Neurology, University of Washington, Seattle (K.J.B.)
| | - Emanuela Keller
- Division of Internal Medicine, University Hospital of Zurich, Switzerland (E.K.)
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Central Hospital, Finland (D.S.)
| | - Martin Dichgans
- Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-Universität LMU, Germany (M.D.)
- Munich Cluster for Systems Neurology (SyNergy), Germany (M.D.)
| | - Daniel Woo
- Department of Neurology, University of Cincinnati College of Medicine, OH (D.W.)
| | - Mathew Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.R.)
| | - Amanda Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (A.T.)
| | - Chelsea S. Kidwell
- Departments of Neurology and Medical Imaging, University of Arizona, Tucson (C.S.K.)
| | - Jean Marc Olivot
- Acute Stroke Unit, Toulouse Neuroimaging Center and Clinical Investigation Center, Toulouse University Hospital, France (J.M.O.)
| | - Mayank Goyal
- Department of Diagnostic and Interventional Neuroradiology, University of Calgary, AB, Canada (M.G.)
| | - Laurent Pierot
- Department of Neuroradiology, Hôpital Maison Blanche, CHU Reims, Reims Champagne-Ardenne University, France (L.P.)
| | - Derrick A. Bennett
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, United Kingdom (D.A.B.)
| | - George Howard
- Department of Biostatistics, Ryals School of Public Health, University of Alabama at Birmingham (G.H.)
| | - Gary A. Ford
- Oxford Academic Health Science Network, United Kingdom (G.A.F.)
| | | | - Anna M. Planas
- Department of Brain Ischemia and Neurodegeneration, Institute for Biomedical Research of Barcelona (IIBB), Consejo Superior de Investigaciones CIentíficas (CSIC), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (A.M.P.)
| | - Midori A. Yenari
- Department of Neurology, University of California, San Francisco (M.A.Y.)
- San Francisco Veterans Affairs Medical Center, CA (M.A.Y.)
| | - Steven M. Greenberg
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston (S.M.G.)
| | - Leonardo Pantoni
- ‘L. Sacco’ Department of Biomedical and Clinical Sciences, University of Milan, Italy (L.P.)
| | | | - Michael Tymianski
- Departments of Surgery and Physiology, University of Toronto, ON, Canada (M.T.)
- Department of Surgery, University Health Network (Neurosurgery), Toronto, ON, Canada (M.T.)
- Krembil Research Institute, Toronto Western Hospital, ON, Canada (M.T.)
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Cipolla MJ, Linfante I, Abuchowski A, Jubin R, Chan SL. Pharmacologically increasing collateral perfusion during acute stroke using a carboxyhemoglobin gas transfer agent (Sanguinate™) in spontaneously hypertensive rats. J Cereb Blood Flow Metab 2018; 38:755-766. [PMID: 28436705 PMCID: PMC5987934 DOI: 10.1177/0271678x17705567] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Similar to patients with chronic hypertension, spontaneously hypertensive rats (SHR) develop fast core progression during middle cerebral artery occlusion (MCAO) resulting in large final infarct volumes. We investigated the effect of Sanguinate™ (SG), a PEGylated carboxyhemoglobin (COHb) gas transfer agent, on changes in collateral and reperfusion cerebral blood flow and brain injury in SHR during 2 h of MCAO. SG (8 mL/kg) or vehicle ( n = 6-8/group) was infused i.v. after 30 or 90 min of ischemia with 2 h reperfusion. Multi-site laser Doppler probes simultaneously measured changes in core MCA and collateral flow during ischemia and reperfusion using a validated method. Brain injury was measured using TTC. Animals were anesthetized with choral hydrate. Collateral flow changed little in vehicle-treated SHR during ischemia (-8 ± 9% vs. prior to infusion) whereas flow increased in SG-treated animals (29 ± 10%; p < 0.05). In addition, SG improved reperfusion regardless of time of treatment; however, brain injury was smaller only with early treatment in SHR vs. vehicle (28.8 ± 3.2% vs. 18.8 ± 2.3%; p < 0.05). Limited collateral flow in SHR during MCAO is consistent with small penumbra and large infarction. The ability to increase collateral flow in SHR with SG suggests that this compound may be useful as an adjunct to endovascular therapy and extend the time window for treatment.
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Affiliation(s)
- Marilyn J Cipolla
- 1 Department of Neurological Sciences and Pharmacology, University of Vermont College of Medicine, Burlington, VT, USA
| | - Italo Linfante
- 2 Miami Cardiac and Vascular Institute and Neuroscience Center, Baptist Hospital, Miami, FL, USA
| | - Abe Abuchowski
- 3 Prolong Pharmaceuticals, LLC, South Plainfield, NJ, USA
| | - Ronald Jubin
- 3 Prolong Pharmaceuticals, LLC, South Plainfield, NJ, USA
| | - Siu-Lung Chan
- 1 Department of Neurological Sciences and Pharmacology, University of Vermont College of Medicine, Burlington, VT, USA
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46
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Tsai JP, Mlynash M, Christensen S, Kemp S, Kim S, Mishra NK, Federau C, Nogueira RG, Jovin TG, Devlin TG, Akhtar N, Yavagal DR, Bammer R, Straka M, Zaharchuk G, Marks MP, Albers GW, Lansberg MG. Time From Imaging to Endovascular Reperfusion Predicts Outcome in Acute Stroke. Stroke 2018; 49:952-957. [PMID: 29581341 DOI: 10.1161/strokeaha.117.018858] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 01/18/2018] [Accepted: 02/01/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE This study aims to describe the relationship between computed tomographic (CT) perfusion (CTP)-to-reperfusion time and clinical and radiological outcomes, in a cohort of patients who achieve successful reperfusion for acute ischemic stroke. METHODS We included data from the CRISP (Computed Tomographic Perfusion to Predict Response in Ischemic Stroke Project) in which all patients underwent a baseline CTP scan before endovascular therapy. Patients were included if they had a mismatch on their baseline CTP scan and achieved successful endovascular reperfusion. Patients with mismatch were categorized into target mismatch and malignant mismatch profiles, according to the volume of their Tmax >10s lesion volume (target mismatch, <100 mL; malignant mismatch, >100 mL). We investigated the impact of CTP-to-reperfusion times on probability of achieving functional independence (modified Rankin Scale, 0-2) at day 90 and radiographic outcomes at day 5. RESULTS Of 156 included patients, 108 (59%) had the target mismatch profile, and 48 (26%) had the malignant mismatch profile. In patients with the target mismatch profile, CTP-to-reperfusion time showed no association with functional independence (P=0.84), whereas in patients with malignant mismatch profile, CTP-to-reperfusion time was strongly associated with lower probability of functional independence (odds ratio, 0.08; P=0.003). Compared with patients with target mismatch, those with the malignant mismatch profile had significantly more infarct growth (90 [49-166] versus 43 [18-81] mL; P=0.006) and larger final infarct volumes (110 [61-155] versus 48 [21-99] mL; P=0.001). CONCLUSIONS Compared with target mismatch patients, those with the malignant profile experience faster infarct growth and a steeper decline in the odds of functional independence, with longer delays between baseline imaging and reperfusion. However, this does not exclude the possibility of treatment benefit in patients with a malignant profile.
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Affiliation(s)
- Jenny P Tsai
- From the Department of Neurology (J.P.T., M.M., S.C., S. Kemp, S. Kim, N.M., C.F., M.S., G.W.A., M.G.L.) and Department of Radiology (R.B., G.Z., M.P.M.), Stanford University, CA; Department of Neurology, Emory University, Atlanta, GA (R.G.N.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.); Department of Neurology, University of Tennessee College of Medicine, Memphis (T.G.D.); Department of Radiology, Saint Luke's Health System, Kansas City, MO (N.A.); and Department of Neurology, University of Miami, FL (D.R.Y.).
| | - Michael Mlynash
- From the Department of Neurology (J.P.T., M.M., S.C., S. Kemp, S. Kim, N.M., C.F., M.S., G.W.A., M.G.L.) and Department of Radiology (R.B., G.Z., M.P.M.), Stanford University, CA; Department of Neurology, Emory University, Atlanta, GA (R.G.N.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.); Department of Neurology, University of Tennessee College of Medicine, Memphis (T.G.D.); Department of Radiology, Saint Luke's Health System, Kansas City, MO (N.A.); and Department of Neurology, University of Miami, FL (D.R.Y.)
| | - Soren Christensen
- From the Department of Neurology (J.P.T., M.M., S.C., S. Kemp, S. Kim, N.M., C.F., M.S., G.W.A., M.G.L.) and Department of Radiology (R.B., G.Z., M.P.M.), Stanford University, CA; Department of Neurology, Emory University, Atlanta, GA (R.G.N.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.); Department of Neurology, University of Tennessee College of Medicine, Memphis (T.G.D.); Department of Radiology, Saint Luke's Health System, Kansas City, MO (N.A.); and Department of Neurology, University of Miami, FL (D.R.Y.)
| | - Stephanie Kemp
- From the Department of Neurology (J.P.T., M.M., S.C., S. Kemp, S. Kim, N.M., C.F., M.S., G.W.A., M.G.L.) and Department of Radiology (R.B., G.Z., M.P.M.), Stanford University, CA; Department of Neurology, Emory University, Atlanta, GA (R.G.N.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.); Department of Neurology, University of Tennessee College of Medicine, Memphis (T.G.D.); Department of Radiology, Saint Luke's Health System, Kansas City, MO (N.A.); and Department of Neurology, University of Miami, FL (D.R.Y.)
| | - Sun Kim
- From the Department of Neurology (J.P.T., M.M., S.C., S. Kemp, S. Kim, N.M., C.F., M.S., G.W.A., M.G.L.) and Department of Radiology (R.B., G.Z., M.P.M.), Stanford University, CA; Department of Neurology, Emory University, Atlanta, GA (R.G.N.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.); Department of Neurology, University of Tennessee College of Medicine, Memphis (T.G.D.); Department of Radiology, Saint Luke's Health System, Kansas City, MO (N.A.); and Department of Neurology, University of Miami, FL (D.R.Y.)
| | - Nishant K Mishra
- From the Department of Neurology (J.P.T., M.M., S.C., S. Kemp, S. Kim, N.M., C.F., M.S., G.W.A., M.G.L.) and Department of Radiology (R.B., G.Z., M.P.M.), Stanford University, CA; Department of Neurology, Emory University, Atlanta, GA (R.G.N.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.); Department of Neurology, University of Tennessee College of Medicine, Memphis (T.G.D.); Department of Radiology, Saint Luke's Health System, Kansas City, MO (N.A.); and Department of Neurology, University of Miami, FL (D.R.Y.)
| | - Christian Federau
- From the Department of Neurology (J.P.T., M.M., S.C., S. Kemp, S. Kim, N.M., C.F., M.S., G.W.A., M.G.L.) and Department of Radiology (R.B., G.Z., M.P.M.), Stanford University, CA; Department of Neurology, Emory University, Atlanta, GA (R.G.N.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.); Department of Neurology, University of Tennessee College of Medicine, Memphis (T.G.D.); Department of Radiology, Saint Luke's Health System, Kansas City, MO (N.A.); and Department of Neurology, University of Miami, FL (D.R.Y.)
| | - Raul G Nogueira
- From the Department of Neurology (J.P.T., M.M., S.C., S. Kemp, S. Kim, N.M., C.F., M.S., G.W.A., M.G.L.) and Department of Radiology (R.B., G.Z., M.P.M.), Stanford University, CA; Department of Neurology, Emory University, Atlanta, GA (R.G.N.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.); Department of Neurology, University of Tennessee College of Medicine, Memphis (T.G.D.); Department of Radiology, Saint Luke's Health System, Kansas City, MO (N.A.); and Department of Neurology, University of Miami, FL (D.R.Y.)
| | - Tudor G Jovin
- From the Department of Neurology (J.P.T., M.M., S.C., S. Kemp, S. Kim, N.M., C.F., M.S., G.W.A., M.G.L.) and Department of Radiology (R.B., G.Z., M.P.M.), Stanford University, CA; Department of Neurology, Emory University, Atlanta, GA (R.G.N.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.); Department of Neurology, University of Tennessee College of Medicine, Memphis (T.G.D.); Department of Radiology, Saint Luke's Health System, Kansas City, MO (N.A.); and Department of Neurology, University of Miami, FL (D.R.Y.)
| | - Thomas G Devlin
- From the Department of Neurology (J.P.T., M.M., S.C., S. Kemp, S. Kim, N.M., C.F., M.S., G.W.A., M.G.L.) and Department of Radiology (R.B., G.Z., M.P.M.), Stanford University, CA; Department of Neurology, Emory University, Atlanta, GA (R.G.N.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.); Department of Neurology, University of Tennessee College of Medicine, Memphis (T.G.D.); Department of Radiology, Saint Luke's Health System, Kansas City, MO (N.A.); and Department of Neurology, University of Miami, FL (D.R.Y.)
| | - Naveed Akhtar
- From the Department of Neurology (J.P.T., M.M., S.C., S. Kemp, S. Kim, N.M., C.F., M.S., G.W.A., M.G.L.) and Department of Radiology (R.B., G.Z., M.P.M.), Stanford University, CA; Department of Neurology, Emory University, Atlanta, GA (R.G.N.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.); Department of Neurology, University of Tennessee College of Medicine, Memphis (T.G.D.); Department of Radiology, Saint Luke's Health System, Kansas City, MO (N.A.); and Department of Neurology, University of Miami, FL (D.R.Y.)
| | - Dileep R Yavagal
- From the Department of Neurology (J.P.T., M.M., S.C., S. Kemp, S. Kim, N.M., C.F., M.S., G.W.A., M.G.L.) and Department of Radiology (R.B., G.Z., M.P.M.), Stanford University, CA; Department of Neurology, Emory University, Atlanta, GA (R.G.N.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.); Department of Neurology, University of Tennessee College of Medicine, Memphis (T.G.D.); Department of Radiology, Saint Luke's Health System, Kansas City, MO (N.A.); and Department of Neurology, University of Miami, FL (D.R.Y.)
| | - Roland Bammer
- From the Department of Neurology (J.P.T., M.M., S.C., S. Kemp, S. Kim, N.M., C.F., M.S., G.W.A., M.G.L.) and Department of Radiology (R.B., G.Z., M.P.M.), Stanford University, CA; Department of Neurology, Emory University, Atlanta, GA (R.G.N.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.); Department of Neurology, University of Tennessee College of Medicine, Memphis (T.G.D.); Department of Radiology, Saint Luke's Health System, Kansas City, MO (N.A.); and Department of Neurology, University of Miami, FL (D.R.Y.)
| | - Matus Straka
- From the Department of Neurology (J.P.T., M.M., S.C., S. Kemp, S. Kim, N.M., C.F., M.S., G.W.A., M.G.L.) and Department of Radiology (R.B., G.Z., M.P.M.), Stanford University, CA; Department of Neurology, Emory University, Atlanta, GA (R.G.N.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.); Department of Neurology, University of Tennessee College of Medicine, Memphis (T.G.D.); Department of Radiology, Saint Luke's Health System, Kansas City, MO (N.A.); and Department of Neurology, University of Miami, FL (D.R.Y.)
| | - Gregory Zaharchuk
- From the Department of Neurology (J.P.T., M.M., S.C., S. Kemp, S. Kim, N.M., C.F., M.S., G.W.A., M.G.L.) and Department of Radiology (R.B., G.Z., M.P.M.), Stanford University, CA; Department of Neurology, Emory University, Atlanta, GA (R.G.N.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.); Department of Neurology, University of Tennessee College of Medicine, Memphis (T.G.D.); Department of Radiology, Saint Luke's Health System, Kansas City, MO (N.A.); and Department of Neurology, University of Miami, FL (D.R.Y.)
| | - Michael P Marks
- From the Department of Neurology (J.P.T., M.M., S.C., S. Kemp, S. Kim, N.M., C.F., M.S., G.W.A., M.G.L.) and Department of Radiology (R.B., G.Z., M.P.M.), Stanford University, CA; Department of Neurology, Emory University, Atlanta, GA (R.G.N.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.); Department of Neurology, University of Tennessee College of Medicine, Memphis (T.G.D.); Department of Radiology, Saint Luke's Health System, Kansas City, MO (N.A.); and Department of Neurology, University of Miami, FL (D.R.Y.)
| | - Gregory W Albers
- From the Department of Neurology (J.P.T., M.M., S.C., S. Kemp, S. Kim, N.M., C.F., M.S., G.W.A., M.G.L.) and Department of Radiology (R.B., G.Z., M.P.M.), Stanford University, CA; Department of Neurology, Emory University, Atlanta, GA (R.G.N.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.); Department of Neurology, University of Tennessee College of Medicine, Memphis (T.G.D.); Department of Radiology, Saint Luke's Health System, Kansas City, MO (N.A.); and Department of Neurology, University of Miami, FL (D.R.Y.)
| | - Maarten G Lansberg
- From the Department of Neurology (J.P.T., M.M., S.C., S. Kemp, S. Kim, N.M., C.F., M.S., G.W.A., M.G.L.) and Department of Radiology (R.B., G.Z., M.P.M.), Stanford University, CA; Department of Neurology, Emory University, Atlanta, GA (R.G.N.); Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.); Department of Neurology, University of Tennessee College of Medicine, Memphis (T.G.D.); Department of Radiology, Saint Luke's Health System, Kansas City, MO (N.A.); and Department of Neurology, University of Miami, FL (D.R.Y.)
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47
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Olivot J. Which imaging before reperfusion strategy? Rev Neurol (Paris) 2017; 173:584-589. [DOI: 10.1016/j.neurol.2017.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 08/23/2017] [Accepted: 09/01/2017] [Indexed: 11/16/2022]
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Vilela P, Rowley HA. Brain ischemia: CT and MRI techniques in acute ischemic stroke. Eur J Radiol 2017; 96:162-172. [DOI: 10.1016/j.ejrad.2017.08.014] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 08/07/2017] [Accepted: 08/12/2017] [Indexed: 11/17/2022]
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Karthik R, Menaka R. Computer-aided detection and characterization of stroke lesion – a short review on the current state-of-the art methods. IMAGING SCIENCE JOURNAL 2017. [DOI: 10.1080/13682199.2017.1370879] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- R. Karthik
- School of Electronics Engineering, VIT University, Chennai, India
| | - R. Menaka
- School of Electronics Engineering, VIT University, Chennai, India
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50
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Rocha M, Jovin TG. Fast Versus Slow Progressors of Infarct Growth in Large Vessel Occlusion Stroke. Stroke 2017; 48:2621-2627. [DOI: 10.1161/strokeaha.117.017673] [Citation(s) in RCA: 162] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 07/13/2017] [Accepted: 07/20/2017] [Indexed: 12/14/2022]
Affiliation(s)
- Marcelo Rocha
- From the Department of Neurology (M.R., T.G.J.) and Department of Neurosurgery (T.G.J.), Stroke Institute, University of Pittsburgh Medical Center, PA
| | - Tudor G. Jovin
- From the Department of Neurology (M.R., T.G.J.) and Department of Neurosurgery (T.G.J.), Stroke Institute, University of Pittsburgh Medical Center, PA
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