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Luitse MJA, Velthuis BK, Dauwan M, Dankbaar JW, Biessels GJ, Kappelle LJ. Residual high-grade stenosis after recanalization of extracranial carotid occlusion in acute ischemic stroke. Stroke 2014; 46:12-5. [PMID: 25492908 DOI: 10.1161/strokeaha.114.007169] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Residual stenosis after recanalization of an acute symptomatic extracranial occlusion of the internal carotid artery (ICA) might be an indication for carotid endarterectomy. We evaluated the proportion of residual high-grade stenosis (≥70%, near occlusions not included) on follow-up imaging in a consecutive series of patients with an acute symptomatic occlusion of the extracranial ICA. METHODS We included patients participating in the Dutch Acute Stroke Study (DUST), who had an acute symptomatic occlusion of the extracranial ICA that was diagnosed on computed tomographic angiography within 9 hours after onset of neurological symptoms. Follow-up imaging of the carotid artery had to be available within 7 days after admission. RESULTS Of the 1021 patients participating in DUST between May 2009 and May 2013, an acute symptomatic occlusion of the extracranial ICA was found in 126 (12.3%) patients. Follow-up imaging was available in 86 (68.3%) of these patients. At follow-up, a residual stenosis of <30% was found in 15 (17.4%; 95% confidence interval, 10.8-26.9) patients, a 30% to 49% stenosis in 3 (3.5%; 95% confidence interval, 0.8-10.2) patients, a 50% to 69% stenosis in 2 (2.3%; 95% confidence interval, 0.1-8.6) patients, and a ≥70% stenosis in 14 (16.3%; 95% confidence interval, 9.8-25.6) patients. A near or persistent occlusion was present in the remaining 52 (60.5%) patients. CONCLUSIONS A residual high-grade stenosis of the extracranial ICA occurs in 1 of 6 patients with a symptomatic occlusion in the acute stage of cerebral ischemia. Because this may have implications for secondary prevention, we recommend follow-up imaging in these patients within a week after the event. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT00880113.
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Affiliation(s)
- Merel J A Luitse
- From the Department of Neurology, UMC Utrecht Stroke Center, Brain Center Rudolf Magnus (M.J.A.L., M.D., G.J.B., L.J.K.) and Department of Radiology (B.K.V., J.W.D.), University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Birgitta K Velthuis
- From the Department of Neurology, UMC Utrecht Stroke Center, Brain Center Rudolf Magnus (M.J.A.L., M.D., G.J.B., L.J.K.) and Department of Radiology (B.K.V., J.W.D.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Meenakshi Dauwan
- From the Department of Neurology, UMC Utrecht Stroke Center, Brain Center Rudolf Magnus (M.J.A.L., M.D., G.J.B., L.J.K.) and Department of Radiology (B.K.V., J.W.D.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan Willem Dankbaar
- From the Department of Neurology, UMC Utrecht Stroke Center, Brain Center Rudolf Magnus (M.J.A.L., M.D., G.J.B., L.J.K.) and Department of Radiology (B.K.V., J.W.D.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Geert Jan Biessels
- From the Department of Neurology, UMC Utrecht Stroke Center, Brain Center Rudolf Magnus (M.J.A.L., M.D., G.J.B., L.J.K.) and Department of Radiology (B.K.V., J.W.D.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - L Jaap Kappelle
- From the Department of Neurology, UMC Utrecht Stroke Center, Brain Center Rudolf Magnus (M.J.A.L., M.D., G.J.B., L.J.K.) and Department of Radiology (B.K.V., J.W.D.), University Medical Center Utrecht, Utrecht, The Netherlands
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Spectroscopy of reperfused tissue after stroke reveals heightened metabolism in patients with good clinical outcomes. J Cereb Blood Flow Metab 2014; 34:1944-50. [PMID: 25269516 PMCID: PMC4269749 DOI: 10.1038/jcbfm.2014.166] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 09/08/2014] [Accepted: 09/08/2014] [Indexed: 11/09/2022]
Abstract
The aim of acute stroke treatment is to reperfuse the penumbra. However, not all posttreatment reperfusion is associated with a good outcome. Recent arterial spin labeling (ASL) studies suggest that patients with hyperperfusion after treatment have a better clinical recovery. This study aimed to determine whether there was a distinctive magnetic resonance spectroscopy (MRS) metabolite profile in hyperperfused tissue after stroke reperfusion therapy. We studied 77 ischemic stroke patients 24 hours after treatment using MRS (single voxel spectroscopy, point resolved spectroscopy, echo time 30 ms), ASL, and diffusion-weighted imaging (DWI). Magnetic resonance spectroscopy voxels were placed in cortical tissue that was penumbral on baseline perfusion imaging but had reperfused at 24 hours (and did not progress to infarction). Additionally, 20 healthy age matched controls underwent MRS. In all, 24 patients had hyperperfusion; 36 had reperfused penumbra without hyperperfusion, and 17 were excluded due to no reperfusion. Hyperperfusion was significantly related to better 3-month clinical outcome compared with patients without hyperperfusion (P=0.007). Patients with hyperperfusion showed increased glutamate (P<0.001), increased N-Acetylaspartate (NAA) (P=0.038), and increased lactate (P<0.002) in reperfused tissue compared with contralateral tissue and healthy controls. Hyperperfused tissue has a characteristic metabolite signature, suggesting that it is more metabolically active and perhaps more capable of later neuroplasticity.
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Abstract
Neuroimaging has expanded beyond its traditional diagnostic role and become a critical tool in the evaluation and management of stroke. The objectives of imaging include prompt accurate diagnosis, treatment triage, prognosis prediction, and secondary preventative precautions. While capitalizing on the latest treatment options and expanding upon the "time is brain" doctrine, the ultimate goal of imaging is to maximize the number of treated patients and improve the outcome of one the most costly and morbid disease. A broad overview of comprehensive multimodal stroke imaging is presented here to affirm its utilization.
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Affiliation(s)
- Elizabeth Tong
- Neuroradiology Division, Department of Radiology, University of Virginia, Charlottesville, Virginia
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104
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Lum C, Ahmed ME, Patro S, Thornhill R, Hogan M, Iancu D, Lesiuk H, Dos Santos M, Dowlatshahi D. Computed tomographic angiography and cerebral blood volume can predict final infarct volume and outcome after recanalization. Stroke 2014; 45:2683-8. [PMID: 25104844 DOI: 10.1161/strokeaha.114.006163] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Recanalization rates are higher in acute anterior stroke treated with stent-retrievers when compared with older techniques. However, some still have sizeable infarcts and poor outcome. This may be related to underestimation of core infarct on nonenhanced computed tomography (NECT). CT angiography (CTA) source images (CTASI) and CT perfusion may be more informative. We hypothesize that core infarct estimation with NECT, CTA, and CT perfusion predicts infarct at 24 hours and outcome after fast recanalization. METHODS Consecutive good recanalization patients with proximal anterior circulation stroke were evaluated. We assessed Alberta Stroke Program Early CT Score (ASPECTs) on NECT for subtle early infarct, hypodensity, loss of gray-white (CTASI), and low cerebral blood volume (CBV; CT perfusion). Sensitivity and specificity for predicting infarct by region were calculated. RESULTS Of 46 patients, 36 (78%) had successful thrombectomy. Median ASPECTS was 10 for NECT early infarct and frank hypodensity; for CBV, CTASI-ASPECTS was 8. CTASI had the highest sensitivity of 71% and specificity of 82% for 24 hours NECT infarct. There was moderate correlation and concordance between CBV/24-hour NECT (Rp=0.51; Rc=0.50) and CTASI/24-hour NECT (Rp=0.54 and Rc=0.53). Thirty-four patients (74%) had good outcomes. Median ASPECTS was higher on CTASI (8 versus 5; P=0.04) and CBV (9 versus 5; P=0.03) for patients with good versus bad outcome. There were better outcomes with increasing CTASI-ASPECTS (P=0.004) and CBV-ASPECTS (P=0.02). CONCLUSIONS CTASI and CBV were better at predicting 24-hour infarct and outcome than NECT. Appropriate advanced imaged guided selection may improve outcomes in large-vessel stroke treated with the newest techniques.
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Affiliation(s)
- Cheemun Lum
- From the Interventional Neuroradiology Section, Department of Medical Imaging-Diagnostic (C.L., M.E.A., S.P., R.T., D.I., H.L., M.d.S.) and Division of Neurology, Department of Medicine (M.H., D.D.), The Ottawa Hospital, Ottawa Hospital Research Institute (OHRI), University of Ottawa, Ottawa, Ontario, Canada.
| | - Muhammad Ejaz Ahmed
- From the Interventional Neuroradiology Section, Department of Medical Imaging-Diagnostic (C.L., M.E.A., S.P., R.T., D.I., H.L., M.d.S.) and Division of Neurology, Department of Medicine (M.H., D.D.), The Ottawa Hospital, Ottawa Hospital Research Institute (OHRI), University of Ottawa, Ottawa, Ontario, Canada
| | - Satya Patro
- From the Interventional Neuroradiology Section, Department of Medical Imaging-Diagnostic (C.L., M.E.A., S.P., R.T., D.I., H.L., M.d.S.) and Division of Neurology, Department of Medicine (M.H., D.D.), The Ottawa Hospital, Ottawa Hospital Research Institute (OHRI), University of Ottawa, Ottawa, Ontario, Canada
| | - Rebecca Thornhill
- From the Interventional Neuroradiology Section, Department of Medical Imaging-Diagnostic (C.L., M.E.A., S.P., R.T., D.I., H.L., M.d.S.) and Division of Neurology, Department of Medicine (M.H., D.D.), The Ottawa Hospital, Ottawa Hospital Research Institute (OHRI), University of Ottawa, Ottawa, Ontario, Canada
| | - Matthew Hogan
- From the Interventional Neuroradiology Section, Department of Medical Imaging-Diagnostic (C.L., M.E.A., S.P., R.T., D.I., H.L., M.d.S.) and Division of Neurology, Department of Medicine (M.H., D.D.), The Ottawa Hospital, Ottawa Hospital Research Institute (OHRI), University of Ottawa, Ottawa, Ontario, Canada
| | - Daniela Iancu
- From the Interventional Neuroradiology Section, Department of Medical Imaging-Diagnostic (C.L., M.E.A., S.P., R.T., D.I., H.L., M.d.S.) and Division of Neurology, Department of Medicine (M.H., D.D.), The Ottawa Hospital, Ottawa Hospital Research Institute (OHRI), University of Ottawa, Ottawa, Ontario, Canada
| | - Howard Lesiuk
- From the Interventional Neuroradiology Section, Department of Medical Imaging-Diagnostic (C.L., M.E.A., S.P., R.T., D.I., H.L., M.d.S.) and Division of Neurology, Department of Medicine (M.H., D.D.), The Ottawa Hospital, Ottawa Hospital Research Institute (OHRI), University of Ottawa, Ottawa, Ontario, Canada
| | - Marlise Dos Santos
- From the Interventional Neuroradiology Section, Department of Medical Imaging-Diagnostic (C.L., M.E.A., S.P., R.T., D.I., H.L., M.d.S.) and Division of Neurology, Department of Medicine (M.H., D.D.), The Ottawa Hospital, Ottawa Hospital Research Institute (OHRI), University of Ottawa, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- From the Interventional Neuroradiology Section, Department of Medical Imaging-Diagnostic (C.L., M.E.A., S.P., R.T., D.I., H.L., M.d.S.) and Division of Neurology, Department of Medicine (M.H., D.D.), The Ottawa Hospital, Ottawa Hospital Research Institute (OHRI), University of Ottawa, Ottawa, Ontario, Canada
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105
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McVerry F, Dani KA, MacDougall NJ, MacLeod MJ, Wardlaw J, Muir KW. Derivation and Evaluation of Thresholds for Core and Tissue at Risk of Infarction Using CT Perfusion. J Neuroimaging 2014; 24:562-568. [DOI: 10.1111/jon.12134] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 02/06/2014] [Accepted: 03/31/2014] [Indexed: 11/25/2022] Open
Affiliation(s)
- Ferghal McVerry
- Institute of Neuroscience and Psychology; University of Glasgow; Glasgow United Kingdom
| | - Krishna Ashok Dani
- Institute of Neuroscience and Psychology; University of Glasgow; Glasgow United Kingdom
| | - Niall J.J. MacDougall
- Institute of Neuroscience and Psychology; University of Glasgow; Glasgow United Kingdom
| | - Mary Joan MacLeod
- Department of Medicine and Therapeutics; University of Aberdeen; United Kingdom
| | - Joanna Wardlaw
- Division of Clinical Neurosciences; Western General Hospital; Edinburgh United Kingdom
| | - Keith W Muir
- Institute of Neuroscience and Psychology; University of Glasgow; Glasgow United Kingdom
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106
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Jang MH, Oh HJ, Lee MW, Ku MW, Lee SH, Jung JY, Kang SY, Kim JY, Kwon KH, Cho SJ. Brain Perfusion Computed Tomography Findings of Cerebral Infarction associated with Polycythemia Vera. JOURNAL OF NEUROCRITICAL CARE 2014. [DOI: 10.18700/jnc.2014.7.1.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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107
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Lin L, Bivard A, Levi CR, Parsons MW. Comparison of Computed Tomographic and Magnetic Resonance Perfusion Measurements in Acute Ischemic Stroke. Stroke 2014; 45:1727-32. [DOI: 10.1161/strokeaha.114.005419] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Longting Lin
- From the Stroke Research Program, Hunter Medical Research Institute (L.L., A.B., C.R.L., M.W.P.) and Department of Neurology, John Hunter Hospital (C.R.L., M.W.P.), The University of Newcastle, Newcastle, New South Wales, Australia
| | - Andrew Bivard
- From the Stroke Research Program, Hunter Medical Research Institute (L.L., A.B., C.R.L., M.W.P.) and Department of Neurology, John Hunter Hospital (C.R.L., M.W.P.), The University of Newcastle, Newcastle, New South Wales, Australia
| | - Christopher R. Levi
- From the Stroke Research Program, Hunter Medical Research Institute (L.L., A.B., C.R.L., M.W.P.) and Department of Neurology, John Hunter Hospital (C.R.L., M.W.P.), The University of Newcastle, Newcastle, New South Wales, Australia
| | - Mark W. Parsons
- From the Stroke Research Program, Hunter Medical Research Institute (L.L., A.B., C.R.L., M.W.P.) and Department of Neurology, John Hunter Hospital (C.R.L., M.W.P.), The University of Newcastle, Newcastle, New South Wales, Australia
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108
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Diagnostic Accuracy of Whole-Brain Computed Tomographic Perfusion Imaging in Small-Volume Infarctions. Invest Radiol 2014; 49:236-42. [DOI: 10.1097/rli.0000000000000023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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109
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Vanicek J, Bulik M, Brichta J, Jancalek R. Utility of a rescue endovascular therapy for the treatment of major strokes refractory to full-dose intravenous thrombolysis. Br J Radiol 2014; 87:20130545. [PMID: 24641217 DOI: 10.1259/bjr.20130545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Large artery occlusion (LAO) in patients with major stroke predicts poor revascularization by intravenous thrombolysis (IVT) and more likely results in a poor outcome. We focused on the effects of intra-arterial thrombolysis (IAT) and endovascular mechanical recanalization (EMR) as rescue therapies in major strokes refractory to IVT. METHODS A retrospective analysis of 87 patients (National Institutes of Health Stroke Scale >20), who did not respond to full-dose IVT due to LAO, was performed based on their endovascular therapy status. IAT was performed as an intraclot infusion of alteplase, and EMR was provided by the Solitaire device™ (Covidien, Dubin, Ireland). The recanalization and 3-month outcome rates after IAT/EMR were correlated with a group of patients who were scheduled to receive endovascular treatment but who underwent only IVT. RESULTS We achieved successful recanalization by IAT and EMR in 68.7% and 76.1% of patients, respectively. Despite no significant differences in mortality between IAT and EMR, a trend towards better outcomes after IAT and a statistically significant increase for outcome-modified Rankin scale (mRS) 0-3 (45.7%) and mRS 0-2 (34.9%) after EMR was noted when compared with IVT. The degree of recanalization did not correlate with the functional results except for the good-moderate outcome after successful recanalization by EMR. CONCLUSION EMR by the Solitaire device is a safe and beneficial method for the rescue treatment of patients with major stroke whose neurological status does not improve and who fail to recanalize the LAO after a 1-h full dose of IVT. ADVANCES IN KNOWLEDGE The article verifies efficiency of the Solitaire device in major strokes.
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Affiliation(s)
- J Vanicek
- Department of Diagnostic Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
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110
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111
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Heiss WD, Kidwell CS. Imaging for prediction of functional outcome and assessment of recovery in ischemic stroke. Stroke 2014; 45:1195-201. [PMID: 24595589 DOI: 10.1161/strokeaha.113.003611] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Wolf-Dieter Heiss
- From the Max Planck Institute for Neurological Research, Cologne, Germany (W.-D.H.); and Departments of Neurology and Medical Imaging, University of Arizona, Tucson (C.S.K.)
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112
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Alves JE, Carneiro Â, Xavier J. Reliability of CT perfusion in the evaluation of the ischaemic penumbra. Neuroradiol J 2014; 27:91-5. [PMID: 24571838 DOI: 10.15274/nrj-2014-10010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 01/17/2014] [Indexed: 11/12/2022] Open
Abstract
CT perfusion (CTP) is part of the initial evaluation of stroke patients, allowing differentiation between infarcted tissue and the ischaemic penumbra and helping in the selection of patients for endovascular treatment. This study assessed the reliability of the qualitative evaluation CTP maps in defining the ischemic penumbra and identified potential pitfalls associated with this technique. We reviewed CTP scans of 45 consecutive patients admitted to our institution with anterior circulation acute ischaemic stroke. Two neuroradiologists performed qualitative evaluations of cerebral blood volume (CBV) and mean transit time (MTT) maps, using 24h follow-up non-contrast CT as surrogate marker for the area of definitive infarct. For each slice analyzed, the area of qualitative alteration in the CBV and MTT maps was classified as either being inferior, equal or superior to the area of infarct on the follow-up CT. Three out of 45 (7%) patients had admission CT CBV abnormalities larger than follow-up lesions; 34/45 (76%) patients had infarct areas smaller than initial MTT prolongation. In the group of patients with no recanalization 12/19 (63%) had infarct areas smaller than initial MTT lesion. CBV abnormality is a reliable marker for an irreversible ischaemic lesion, although rarely it may overestimate the ischaemic "core", possibly due to delay in contrast arrival to the brain. In the majority of patients without recanalization, MTT overestimated final infarct areas, probably because it does not differentiate true "at risk" penumbra from benign oligaemia. Qualitative evaluation of CBV and MTT maps may overestimate the real ischaemic penumbra.
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Affiliation(s)
- José Eduardo Alves
- Department of Neuroradiology, Centro Hospitalar do Porto; Porto, Portugal -
| | - Ângelo Carneiro
- Department of Neuroradiology, Centro Hospitalar do Porto; Porto, Portugal
| | - João Xavier
- Department of Neuroradiology, Centro Hospitalar do Porto; Porto, Portugal
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113
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Bivard A, Levi C, Krishnamurthy V, Hislop-Jambrich J, Salazar P, Jackson B, Davis S, Parsons M. Defining acute ischemic stroke tissue pathophysiology with whole brain CT perfusion. J Neuroradiol 2014; 41:307-15. [PMID: 24433950 DOI: 10.1016/j.neurad.2013.11.006] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 11/25/2013] [Accepted: 11/27/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND This study aimed to identify and validate whole brain perfusion computed tomography (CTP) thresholds for ischemic core and salvageable penumbra in acute stroke patients and develop a probability based model to increase the accuracy of tissue pathophysiology measurements. METHODS One hundred and eighty-three patients underwent multimodal stroke CT using a 320-slice scanner within 6hours of acute stroke onset, followed by 24hour MRI that included diffusion weighted imaging (DWI) and dynamic susceptibility weighted perfusion imaging (PWI). Coregistered acute CTP and 24hour DWI was used to identify the optimum single perfusion parameter thresholds to define penumbra (in patients without reperfusion), and ischemic core (in patients with reperfusion), using a pixel based receiver operator curve analysis. Then, these results were used to develop a sigma curve fitted probability based model incorporating multiple perfusion parameter thresholds. RESULTS For single perfusion thresholds, a time to peak (TTP) of +5seconds best defined the penumbra (area under the curve, AUC 0.79 CI 0.74-0.83) while a cerebral blood flow (CBF) of < 50% best defined the acute ischemic core (AUC 0.73, CI 0.69-0.77). The probability model was more accurate at detecting the ischemic core (AUC 0.80 SD 0.75-0.83) and penumbra (0.85 SD 0.83-0.87) and was significantly closer in volume to the corresponding reference DWI (P=0.031). CONCLUSIONS Whole brain CTP can accurately identify penumbra and ischemic core using similar thresholds to previously validated 16 or 64 slice CTP. Additionally, a novel probability based model was closer to defining the ischemic core and penumbra than single thresholds.
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Affiliation(s)
- A Bivard
- Melbourne Brain Centre, Flory Neuroscience Institute, University of Melbourne, Melbourne, Australia.
| | - C Levi
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia.
| | - V Krishnamurthy
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia.
| | | | - P Salazar
- Vital Images, Minneapolis, United States
| | - B Jackson
- Vital Images, Minneapolis, United States
| | - S Davis
- Melbourne Brain Centre, Flory Neuroscience Institute, University of Melbourne, Melbourne, Australia
| | - M Parsons
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia.
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114
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115
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Bivard A, Krishnamurthy V, Stanwell P, Levi C, Spratt NJ, Davis S, Parsons M. Arterial Spin Labeling Versus Bolus-Tracking Perfusion in Hyperacute Stroke. Stroke 2014; 45:127-33. [DOI: 10.1161/strokeaha.113.003218] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Andrew Bivard
- From the Melbourne Brain Centre, Florey Neuroscience Institute, University of Melbourne, Australia (A.B., S.D.); and Department of Neurology, Hunter New England Health (V.K., C.L., N.J.S., M.P.), and School of Health Sciences, University of Newcastle (P.S.), NSW, Australia
| | - Venkatesh Krishnamurthy
- From the Melbourne Brain Centre, Florey Neuroscience Institute, University of Melbourne, Australia (A.B., S.D.); and Department of Neurology, Hunter New England Health (V.K., C.L., N.J.S., M.P.), and School of Health Sciences, University of Newcastle (P.S.), NSW, Australia
| | - Peter Stanwell
- From the Melbourne Brain Centre, Florey Neuroscience Institute, University of Melbourne, Australia (A.B., S.D.); and Department of Neurology, Hunter New England Health (V.K., C.L., N.J.S., M.P.), and School of Health Sciences, University of Newcastle (P.S.), NSW, Australia
| | - Christopher Levi
- From the Melbourne Brain Centre, Florey Neuroscience Institute, University of Melbourne, Australia (A.B., S.D.); and Department of Neurology, Hunter New England Health (V.K., C.L., N.J.S., M.P.), and School of Health Sciences, University of Newcastle (P.S.), NSW, Australia
| | - Neil J. Spratt
- From the Melbourne Brain Centre, Florey Neuroscience Institute, University of Melbourne, Australia (A.B., S.D.); and Department of Neurology, Hunter New England Health (V.K., C.L., N.J.S., M.P.), and School of Health Sciences, University of Newcastle (P.S.), NSW, Australia
| | - Stephen Davis
- From the Melbourne Brain Centre, Florey Neuroscience Institute, University of Melbourne, Australia (A.B., S.D.); and Department of Neurology, Hunter New England Health (V.K., C.L., N.J.S., M.P.), and School of Health Sciences, University of Newcastle (P.S.), NSW, Australia
| | - Mark Parsons
- From the Melbourne Brain Centre, Florey Neuroscience Institute, University of Melbourne, Australia (A.B., S.D.); and Department of Neurology, Hunter New England Health (V.K., C.L., N.J.S., M.P.), and School of Health Sciences, University of Newcastle (P.S.), NSW, Australia
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116
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McLeod DD, Parsons MW, Hood R, Hiles B, Allen J, McCann SK, Murtha L, Calford MB, Levi CR, Spratt NJ. Perfusion computed tomography thresholds defining ischemic penumbra and infarct core: studies in a rat stroke model. Int J Stroke 2013; 10:553-9. [PMID: 24138577 DOI: 10.1111/ijs.12147] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 04/29/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Perfusion computed tomography is becoming more widely used as a clinical imaging tool to predict potentially salvageable tissue (ischemic penumbra) after ischemic stroke and guide reperfusion therapies. AIMS The study aims to determine whether there are important changes in perfusion computed tomography thresholds defining ischemic penumbra and infarct core over time following stroke. METHODS Permanent middle cerebral artery occlusion was performed in adult outbred Wistar rats (n = 6) and serial perfusion computed tomography scans were taken every 30 mins for 2 h. To define infarction thresholds at 1 h and 2 h post-stroke, separate groups of rats underwent 1 h (n = 6) and 2 h (n = 6) of middle cerebral artery occlusion followed by reperfusion. Infarct volumes were defined by histology at 24 h. Co-registration with perfusion computed tomography maps (cerebral blood flow, cerebral blood volume, and mean transit time) permitted pixel-based analysis of thresholds defining infarction, using receiver operating characteristic curves. RESULTS Relative cerebral blood flow was the perfusion computed tomography parameter that most accurately predicted penumbra (area under the curve = 0.698) and also infarct core (area under the curve = 0.750). A relative cerebral blood flow threshold of < 75% of mean contralateral cerebral blood flow most accurately predicted penumbral tissue at 0.5 h (area under the curve = 0.660), 1 h (area under the curve = 0.659), 1.5 h (area under the curve = 0.636), and 2 h (area under the curve = 0.664) after stroke onset. A relative cerebral blood flow threshold of < 55% of mean contralateral most accurately predicted infarct core at 1 h (area under the curve = 0.765) and at 2 h (area under the curve = 0.689) after middle cerebral artery occlusion. CONCLUSIONS The data provide perfusion computed tomography defined relative cerebral blood flow thresholds for infarct core and ischemic penumbra within the first two hours after experimental stroke in rats. These thresholds were shown to be stable to define the volume of infarct core and penumbra within this time window.
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Affiliation(s)
- D D McLeod
- Discipline of Human Physiology, School of Biomedical Sciences & Pharmacy, Faculty of Health, Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales, Australia
| | - M W Parsons
- Department of Neurology, John Hunter Hospital, Hunter Region M.C., New South Wales, Australia
| | - R Hood
- Discipline of Human Physiology, School of Biomedical Sciences & Pharmacy, Faculty of Health, Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales, Australia
| | - B Hiles
- Discipline of Human Physiology, School of Biomedical Sciences & Pharmacy, Faculty of Health, Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales, Australia
| | - J Allen
- Discipline of Human Physiology, School of Biomedical Sciences & Pharmacy, Faculty of Health, Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales, Australia
| | - S K McCann
- Discipline of Human Physiology, School of Biomedical Sciences & Pharmacy, Faculty of Health, Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales, Australia
| | - L Murtha
- Discipline of Human Physiology, School of Biomedical Sciences & Pharmacy, Faculty of Health, Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales, Australia
| | - M B Calford
- Discipline of Human Physiology, School of Biomedical Sciences & Pharmacy, Faculty of Health, Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales, Australia
| | - C R Levi
- Department of Neurology, John Hunter Hospital, Hunter Region M.C., New South Wales, Australia
| | - N J Spratt
- Discipline of Human Physiology, School of Biomedical Sciences & Pharmacy, Faculty of Health, Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales, Australia.,Department of Neurology, John Hunter Hospital, Hunter Region M.C., New South Wales, Australia
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Lin L, Bivard A, Parsons MW. Perfusion patterns of ischemic stroke on computed tomography perfusion. J Stroke 2013; 15:164-73. [PMID: 24396810 PMCID: PMC3859000 DOI: 10.5853/jos.2013.15.3.164] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 08/19/2013] [Accepted: 08/19/2013] [Indexed: 11/11/2022] Open
Abstract
CT perfusion (CTP) has been applied increasingly in research of ischemic stroke. However, in clinical practice, it is still a relatively new technology. For neurologists and radiologists, the challenge is to interpret CTP results properly in the context of the clinical presentation. In this article, we will illustrate common CTP patterns in acute ischemic stroke using a case-based approach. The aim is to get clinicians more familiar with the information provided by CTP with a view towards inspiring them to incorporate CTP in their routine imaging workup of acute stroke patients.
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Affiliation(s)
- Longting Lin
- Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, the University of Newcastle, Newcastle, Australia
| | - Andrew Bivard
- Department of Neurology and Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Mark W Parsons
- Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, the University of Newcastle, Newcastle, Australia
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118
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Bendinelli C, Bivard A, Nebauer S, Parsons MW, Balogh ZJ. Brain CT perfusion provides additional useful information in severe traumatic brain injury. Injury 2013; 44:1208-12. [PMID: 23642628 DOI: 10.1016/j.injury.2013.03.039] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 03/10/2013] [Accepted: 03/29/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND The role of brain CT perfusion (CTP) imaging in severe traumatic brain injury (STBI) is unclear. We hypothesised that in STBI early CTP may provide additional information beyond the non contrast CT (NCCT). METHODS Subset analysis of an ongoing prospective observational study on trauma patients with STBI who did not require craniectomy and deteriorated or failed to improve neurologically during the first 48h from trauma. Subsequently to follow-up NCCT, a CTP was obtained. Additional findings were defined as an area of altered perfusion on CTP larger than the abnormal area detected by the simultaneous NCCT. Patients who had additional finding (A-CTP) were compared with patients who did not have additional findings (NA-CTP). RESULTS Study population was 30 patients [male: 90%, mean age: 38.6 (SD 16.9), blunt trauma: 100%; prehospital intubation: 6 (20%); lowest GCS before intubation: 5.1 (SD 2.0); mean ISS: 30.5 (SD 8.3); mean head and neck AIS: 4.4 (SD 0.8). Days in ICU: 10.2 (SD 6.3). Intracranial pressure (ICP) monitored in 12 (40%). Mean highest ICP in mmHg: 30.1 (SD14.1). There were five (17%) deaths. Findings of NCCT: primarily diffuse axonal injury (DAI) pattern in seven (23%), primarily haematoma in ten (33%), and primarily intracerebral contusion in nine (30%). CTP was performed 24.9 (SD 13) hours from trauma. There were 18 (60%) patients in the A-CTP group and 12 (40.0%) in NA-CTP. The A-CTP group was older (41.7 (SD16.9) vs 27.7 (SD 12.8): P<0.02) and showed on admission NCCT presence of cerebral contusion and absence of DAI. The degree of hypoperfusion was found to be severe enough to be in the ischaemic range in eight patients (27%). CTP altered clinical management in three patients (10%), who were diagnosed with massive and unsurvivable strokes despite minimal changes on NCCT. CONCLUSION When compared to NCCT, CTP provided additional diagnostic information in 60% of patients with STBI. CTP altered clinical management in 10% of patients.
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119
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Kheradmand A, Fisher M, Paydarfar D. Ischemic stroke in evolution: predictive value of perfusion computed tomography. J Stroke Cerebrovasc Dis 2013; 23:836-43. [PMID: 23954606 DOI: 10.1016/j.jstrokecerebrovasdis.2013.07.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 07/07/2013] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Various perfusion computed tomography (PCT) parameters have been used to identify tissue at risk of infarction in the setting of acute stroke. The purpose of this study was to examine predictive value of the PCT parameters commonly used in clinical practice to define ischemic penumbra. The patient selection criterion aimed to exclude the effect of thrombolysis from the imaging data. METHODS Consecutive acute stroke patients were screened and a total of 18 patients who initially underwent PCT and CT angiogram (CTA) on presentation but did not qualify to receive thrombolytic therapy were selected. The PCT images were postprocessed using a delay-sensitive deconvolution algorithm. All the patients had follow-up noncontrast CT or magnetic resonance imaging to delineate the extent of their infarction. The extent of lesions on PCT maps calculated from mean transit time (MTT), time to peak (TTP), cerebral blood flow, and cerebral blood volume were compared and correlated with the final infarct size. A collateral grading score was used to measure collateral blood supply on the CTA studies. RESULTS The average size of MTT lesions was larger than infarct lesions (P < .05). The correlation coefficient of TTP/infarct lesions (r = .95) was better than MTT/infarct lesions (r = .66) (P = .004). CONCLUSIONS A widely accepted threshold to define MTT lesions overestimates the ischemic penumbra. In this setting, TTP with appropriate threshold is a better predictor of infarct in acute stroke patients. The MTT/TTP mismatch correlates with the status of collateral blood supply to the tissue at risk of infarction.
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Affiliation(s)
- Amir Kheradmand
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Marc Fisher
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - David Paydarfar
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts
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Wintermark M, Sanelli PC, Albers GW, Bello J, Derdeyn C, Hetts SW, Johnson MH, Kidwell C, Lev MH, Liebeskind DS, Rowley H, Schaefer PW, Sunshine JL, Zaharchuk G, Meltzer CC. Imaging recommendations for acute stroke and transient ischemic attack patients: A joint statement by the American Society of Neuroradiology, the American College of Radiology, and the Society of NeuroInterventional Surgery. AJNR Am J Neuroradiol 2013; 34:E117-27. [PMID: 23907247 DOI: 10.3174/ajnr.a3690] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
SUMMARY Stroke is a leading cause of death and disability worldwide. Imaging plays a critical role in evaluating patients suspected of acute stroke and transient ischemic attack, especially before initiating treatment. Over the past few decades, major advances have occurred in stroke imaging and treatment, including Food and Drug Administration approval of recanalization therapies for the treatment of acute ischemic stroke. A wide variety of imaging techniques has become available to assess vascular lesions and brain tissue status in acute stroke patients. However, the practical challenge for physicians is to understand the multiple facets of these imaging techniques, including which imaging techniques to implement and how to optimally use them, given available resources at their local institution. Important considerations include constraints of time, cost, access to imaging modalities, preferences of treating physicians, availability of expertise, and availability of endovascular therapy. The choice of which imaging techniques to employ is impacted by both the time urgency for evaluation of patients and the complexity of the literature on acute stroke imaging. Ideally, imaging algorithms should incorporate techniques that provide optimal benefit for improved patient outcomes without delaying treatment.
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Affiliation(s)
- M Wintermark
- Departments of Radiology, Neurology, Neurosurgery, and Biomedical Engineering, University of Virginia, Charlottesville, Virginia
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Grand S, Tahon F, Attye A, Lefournier V, Le Bas JF, Krainik A. Perfusion imaging in brain disease. Diagn Interv Imaging 2013; 94:1241-57. [PMID: 23876408 DOI: 10.1016/j.diii.2013.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Perfusion CT or MRI have been extensively developed over the last years and are accessible on most imaging machines. Perfusion CT has taken a major place in the assessment of a stroke. Its role has to be specified for the diagnosis and treatment of the vasospasm, complicating a subarachnoid hemorrhage. Perfusion MRI should be included in the assessment of any brain tumor, both at the time of the diagnosis as well as in the post-treatment monitoring. It is included in the multimodal approach required for the optimum treatment of this disease. The applications in epilepsy and the neurodegenerative diseases are in the evaluation process.
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Affiliation(s)
- S Grand
- CHU de Grenoble, Cluni BP 217, 38043 Grenoble cedex 9, France; Grenoble institut des neurosciences, chemin Fortuné-Ferrini, 38042 Grenoble cedex 9, France.
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122
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Affiliation(s)
- Mark W Parsons
- Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, University of Newcastle, New South Wales, Australia.
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Bivard A, Lin L, Parsonsb MW. Review of stroke thrombolytics. J Stroke 2013; 15:90-8. [PMID: 24324944 PMCID: PMC3779670 DOI: 10.5853/jos.2013.15.2.90] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 05/09/2013] [Accepted: 05/09/2013] [Indexed: 11/30/2022] Open
Abstract
The cornerstone of acute ischemic stroke treatment relies on rapid clearance of an offending thrombus in the cerebrovascular system. There are various drugs and different methods of assessment to select patients more likely to respond to treatment. Current clinical guidelines recommend the administration of intravenous alteplase (following a brain noncontract CT to exclude hemorrhage) within 4.5 hours of stroke onset. Because of the short therapeutic time window, the risk of hemorrhage, and relatively limited efficacy of alteplase for large clot burden, research is ongoing to find more effective and safer reperfusion therapy, as well as focussing on refinement of patient selection for acute reperfusion treatment. Studies using advanced imaging (incorporating perfusion CT or diffusion/perfusion MRI) may allow us to use thrombolytics, or possibly endovascular therapy, in an extended time window. Recent clinical trials have suggested that Tenecteplase, used in conjunction with advanced imaging selection, resulted in more effective reperfusion than alteplase, which translated into increased clinical benefit. Studies using Desmoteplase have suggested its potential benefit in a sub-group of patients with large artery occlusion and salveageable tissue, in an extended time window. Other ways to improve acute reperfusion approaches are being actively explored, including endovascular therapy, and the enhancement of thrombolysis by ultrasound insonation of the clot (sono-thrombolysis).
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Affiliation(s)
- Andrew Bivard
- Departments of Neurology and Medicine, University of Melbourne, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Biesbroek J, Niesten J, Dankbaar J, Biessels G, Velthuis B, Reitsma J, van der Schaaf I. Diagnostic Accuracy of CT Perfusion Imaging for Detecting Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Cerebrovasc Dis 2013; 35:493-501. [DOI: 10.1159/000350200] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 02/20/2013] [Indexed: 11/19/2022] Open
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Bivard A, Levi C, Spratt N, Parsons M. Perfusion CT in Acute Stroke: A Comprehensive Analysis of Infarct and Penumbra. Radiology 2013; 267:543-50. [DOI: 10.1148/radiol.12120971] [Citation(s) in RCA: 191] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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126
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Abstract
There is mounting evidence that shows how poorly noncontrast computed tomography (NCCT) Alberta Stroke Program Early CT Score (ASPECTS) performs in the first three-hours after stroke onset compared to Diffusion weighted (DWI) magnetic resonance imaging (MRI). It is time to move into the 21st century and use more advanced imaging routinely in hyper-acute stroke assessment. While a useful tool if one is limited to NCCT alone, ASPECTS becomes somewhat superfluous as we now have rapid, validated, automated infarct core and penumbra volumes with either MRI or perfusion CT.
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Affiliation(s)
- A. Bivard
- Melbourne Brain Centre Melbourne University, Florey Neuroscience Institutes, Melbourne, Victoria, Australia
| | - M. Parsons
- Department of Neurology, Hunter New England Health, Newcastle, New South Wales, Australia
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127
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Bivard A, Stanwell P, Levi C, Parsons M. Arterial Spin Labeling Identifies Tissue Salvage and Good Clinical Recovery After Acute Ischemic Stroke. J Neuroimaging 2012; 23:391-6. [DOI: 10.1111/j.1552-6569.2012.00728.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Hu S, Dong H, Zhang H, Wang S, Hou L, Chen S, Zhang J, Xiong L. Noninvasive limb remote ischemic preconditioning contributes neuroprotective effects via activation of adenosine A1 receptor and redox status after transient focal cerebral ischemia in rats. Brain Res 2012; 1459:81-90. [DOI: 10.1016/j.brainres.2012.04.017] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 04/07/2012] [Accepted: 04/10/2012] [Indexed: 12/01/2022]
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Parsons M, Spratt N, Bivard A, Campbell B, Chung K, Miteff F, O'Brien B, Bladin C, McElduff P, Allen C, Bateman G, Donnan G, Davis S, Levi C. A randomized trial of tenecteplase versus alteplase for acute ischemic stroke. N Engl J Med 2012; 366:1099-107. [PMID: 22435369 DOI: 10.1056/nejmoa1109842] [Citation(s) in RCA: 442] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Intravenous alteplase is the only approved treatment for acute ischemic stroke. Tenecteplase, a genetically engineered mutant tissue plasminogen activator, is an alternative thrombolytic agent. METHODS In this phase 2B trial, we randomly assigned 75 patients to receive alteplase (0.9 mg per kilogram of body weight) or tenecteplase (0.1 mg per kilogram or 0.25 mg per kilogram) less than 6 hours after the onset of ischemic stroke. To favor the selection of patients most likely to benefit from thrombolytic therapy, the eligibility criteria were a perfusion lesion at least 20% greater than the infarct core on computed tomographic (CT) perfusion imaging at baseline and an associated vessel occlusion on CT angiography. The coprimary end points were the proportion of the perfusion lesion that was reperfused at 24 hours on perfusion-weighted magnetic resonance imaging and the extent of clinical improvement at 24 hours as assessed on the National Institutes of Health Stroke Scale (NIHSS, a 42-point scale on which higher scores indicate more severe neurologic deficits). RESULTS The three treatment groups each comprised 25 patients. The mean (±SD) NIHSS score at baseline for all patients was 14.4±2.6, and the time to treatment was 2.9±0.8 hours. Together, the two tenecteplase groups had greater reperfusion (P=0.004) and clinical improvement (P<0.001) at 24 hours than the alteplase group. There were no significant between-group differences in intracranial bleeding or other serious adverse events. The higher dose of tenecteplase (0.25 mg per kilogram) was superior to the lower dose and to alteplase for all efficacy outcomes, including absence of serious disability at 90 days (in 72% of patients, vs. 40% with alteplase; P=0.02). CONCLUSIONS Tenecteplase was associated with significantly better reperfusion and clinical outcomes than alteplase in patients with stroke who were selected on the basis of CT perfusion imaging. (Funded by the Australian National Health and Medical Research Council; Australia New Zealand Clinical Trials Registry number, ACTRN12608000466347.).
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Affiliation(s)
- Mark Parsons
- Department of Neurology, John Hunter Hospital-Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia.
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Aviv R, Lee T, Sharma M. Reply. AJNR Am J Neuroradiol 2012. [DOI: 10.3174/ajnr.a3051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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