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Raoult H, Lassalle MV, Parat B, Rousseau C, Eugène F, Vannier S, Evain S, Le Bras A, Ronziere T, Ferre JC, Gauvrit JY, Laviolle B. DWI-Based Algorithm to Predict Disability in Patients Treated with Thrombectomy for Acute Stroke. AJNR Am J Neuroradiol 2020; 41:274-279. [PMID: 32001446 DOI: 10.3174/ajnr.a6379] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 11/14/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE The reasons for poor clinical outcome after thrombectomy for acute stroke, concerning around half of all patients, are misunderstood. We developed a hierarchic algorithm based on DWI to better identify patients at high risk of disability. MATERIALS AND METHODS Our single-center, retrospective study included consecutive patients with acute ischemic stroke who underwent thrombectomy for large anterior artery occlusion and underwent pretreatment DWI. The primary outcome was the mRS at 3 months after stroke onset. Multivariable regression was used to identify independent clinical and imaging predictors of poor prognosis (mRS > 2) at 3 months, and a hierarchic algorithm predictive of disability was developed. RESULTS A total of 149 patients were analyzed. In decreasing importance, DWI lesion volume of >80 mL, baseline NIHSS score of >14, age older than 75 years, and time from stroke onset to groin puncture of >4 hours were independent predictors of poor prognosis. The predictive hierarchic algorithm developed from the multivariate analysis predicted the risk of disability at 3 months for up to 100% of patients with a high predictive value. The area under the receiver operating characteristic curve was 0.87. CONCLUSIONS The DWI-based hierarchic algorithm we developed is highly predictive of disability at 3 months after thrombectomy and is easy to use in routine practice.
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Affiliation(s)
- H Raoult
- From the Departments of Neuroradiology (H.R., B.P., F.E., J.C.F., J.Y.G.)
| | | | - B Parat
- From the Departments of Neuroradiology (H.R., B.P., F.E., J.C.F., J.Y.G.)
| | - C Rousseau
- Clinical Pharmacology (C.R., B.L.), Institut National de la Santé et de la Recherche Médicale, Centre d'Investigation Clinique de Rennes, Centre Hospitalier Universitaire Rennes, Rennes, France
| | - F Eugène
- From the Departments of Neuroradiology (H.R., B.P., F.E., J.C.F., J.Y.G.)
| | | | - S Evain
- Departments of Neurology (S.E.)
| | - A Le Bras
- Radiology (A.L.B.), Centre Hospitalier Universitaire Bretagne Atlantique, Vannes, France
| | | | - J C Ferre
- From the Departments of Neuroradiology (H.R., B.P., F.E., J.C.F., J.Y.G.)
| | - J Y Gauvrit
- From the Departments of Neuroradiology (H.R., B.P., F.E., J.C.F., J.Y.G.)
| | - B Laviolle
- Clinical Pharmacology (C.R., B.L.), Institut National de la Santé et de la Recherche Médicale, Centre d'Investigation Clinique de Rennes, Centre Hospitalier Universitaire Rennes, Rennes, France
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103
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Rava RA, Snyder KV, Mokin M, Waqas M, Allman AB, Senko JL, Podgorsak AR, Shiraz Bhurwani MM, Hoi Y, Siddiqui AH, Davies JM, Levy EI, Ionita CN. Assessment of a Bayesian Vitrea CT Perfusion Analysis to Predict Final Infarct and Penumbra Volumes in Patients with Acute Ischemic Stroke: A Comparison with RAPID. AJNR Am J Neuroradiol 2020; 41:206-212. [PMID: 31948951 PMCID: PMC7015204 DOI: 10.3174/ajnr.a6395] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 12/04/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Brain CTP is used to estimate infarct and penumbra volumes to determine endovascular treatment eligibility for patients with acute ischemic stroke. We aimed to assess the accuracy of a Bayesian CTP algorithm in determining penumbra and final infarct volumes. MATERIALS AND METHODS Data were retrospectively collected for 105 patients with acute ischemic stroke (55 patients with successful recanalization [TICI 2b/2c/3] and large-vessel occlusions and 50 patients without interventions). Final infarct volumes were calculated using DWI and FLAIR 24 hours following CTP imaging. RAPID and the Vitrea Bayesian CTP algorithm (with 3 different settings) predicted infarct and penumbra volumes for comparison with final infarct volumes to assess software performance. Vitrea settings used different combinations of perfusion maps (MTT, TTP, CBV, CBF, delay time) for infarct and penumbra quantification. Patients with and without interventions were included for assessment of predicted infarct and penumbra volumes, respectively. RESULTS RAPID and Vitrea default setting had the most accurate final infarct volume prediction in patients with interventions ([Spearman correlation coefficient, mean infarct difference] default versus FLAIR: [0.77, 4.1 mL], default versus DWI: [0.72, 4.7 mL], RAPID versus FLAIR: [0.75, 7.5 mL], RAPID versus DWI: [0.75, 6.9 mL]). Default Vitrea and RAPID were the most and least accurate in determining final infarct volume for patients without an intervention, respectively (default versus FLAIR: [0.76, -0.4 mL], default versus DWI: [0.71, -2.6 mL], RAPID versus FLAIR: [0.68, -49.3 mL], RAPID versus DWI: [0.65, -51.5 mL]). CONCLUSIONS Compared with RAPID, the Vitrea default setting was noninferior for patients with interventions and superior in penumbra estimation for patients without interventions as indicated by mean infarct differences and correlations with final infarct volumes.
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Affiliation(s)
- R A Rava
- From the Departments of Biomedical Engineering (R.A.R., A.B.A., J.L.S., A.R.P., M.M.S.B., C.N.I.)
- Canon Stroke and Vascular Research Center (R.A.R., K.V.S., M.W., A.B.A., J.L.S., A.R.P., M.M.S.B., A.H.S., J.M.D., E.I.L., C.N.I.), Buffalo, New York
| | - K V Snyder
- Neurosurgery (K.V.S., M.W., A.R.P., A.H.S., J.M.D., E.I.L., C.N.I.)
- Canon Stroke and Vascular Research Center (R.A.R., K.V.S., M.W., A.B.A., J.L.S., A.R.P., M.M.S.B., A.H.S., J.M.D., E.I.L., C.N.I.), Buffalo, New York
| | - M Mokin
- Department of Neurosurgery (M.M.), University of South Florida, Tampa, Florida
| | - M Waqas
- Neurosurgery (K.V.S., M.W., A.R.P., A.H.S., J.M.D., E.I.L., C.N.I.)
- Canon Stroke and Vascular Research Center (R.A.R., K.V.S., M.W., A.B.A., J.L.S., A.R.P., M.M.S.B., A.H.S., J.M.D., E.I.L., C.N.I.), Buffalo, New York
| | - A B Allman
- From the Departments of Biomedical Engineering (R.A.R., A.B.A., J.L.S., A.R.P., M.M.S.B., C.N.I.)
- Canon Stroke and Vascular Research Center (R.A.R., K.V.S., M.W., A.B.A., J.L.S., A.R.P., M.M.S.B., A.H.S., J.M.D., E.I.L., C.N.I.), Buffalo, New York
| | - J L Senko
- From the Departments of Biomedical Engineering (R.A.R., A.B.A., J.L.S., A.R.P., M.M.S.B., C.N.I.)
- Canon Stroke and Vascular Research Center (R.A.R., K.V.S., M.W., A.B.A., J.L.S., A.R.P., M.M.S.B., A.H.S., J.M.D., E.I.L., C.N.I.), Buffalo, New York
| | - A R Podgorsak
- From the Departments of Biomedical Engineering (R.A.R., A.B.A., J.L.S., A.R.P., M.M.S.B., C.N.I.)
- Neurosurgery (K.V.S., M.W., A.R.P., A.H.S., J.M.D., E.I.L., C.N.I.)
- Medical Physics (A.R.P.)
- Canon Stroke and Vascular Research Center (R.A.R., K.V.S., M.W., A.B.A., J.L.S., A.R.P., M.M.S.B., A.H.S., J.M.D., E.I.L., C.N.I.), Buffalo, New York
| | - M M Shiraz Bhurwani
- From the Departments of Biomedical Engineering (R.A.R., A.B.A., J.L.S., A.R.P., M.M.S.B., C.N.I.)
- Canon Stroke and Vascular Research Center (R.A.R., K.V.S., M.W., A.B.A., J.L.S., A.R.P., M.M.S.B., A.H.S., J.M.D., E.I.L., C.N.I.), Buffalo, New York
| | - Y Hoi
- Canon Medical Systems USA (Y.H.), Tustin, California
| | - A H Siddiqui
- Neurosurgery (K.V.S., M.W., A.R.P., A.H.S., J.M.D., E.I.L., C.N.I.)
- Canon Stroke and Vascular Research Center (R.A.R., K.V.S., M.W., A.B.A., J.L.S., A.R.P., M.M.S.B., A.H.S., J.M.D., E.I.L., C.N.I.), Buffalo, New York
| | - J M Davies
- Neurosurgery (K.V.S., M.W., A.R.P., A.H.S., J.M.D., E.I.L., C.N.I.)
- Canon Stroke and Vascular Research Center (R.A.R., K.V.S., M.W., A.B.A., J.L.S., A.R.P., M.M.S.B., A.H.S., J.M.D., E.I.L., C.N.I.), Buffalo, New York
| | - E I Levy
- Neurosurgery (K.V.S., M.W., A.R.P., A.H.S., J.M.D., E.I.L., C.N.I.)
- Canon Stroke and Vascular Research Center (R.A.R., K.V.S., M.W., A.B.A., J.L.S., A.R.P., M.M.S.B., A.H.S., J.M.D., E.I.L., C.N.I.), Buffalo, New York
| | - C N Ionita
- From the Departments of Biomedical Engineering (R.A.R., A.B.A., J.L.S., A.R.P., M.M.S.B., C.N.I.)
- Neurosurgery (K.V.S., M.W., A.R.P., A.H.S., J.M.D., E.I.L., C.N.I.)
- Canon Stroke and Vascular Research Center (R.A.R., K.V.S., M.W., A.B.A., J.L.S., A.R.P., M.M.S.B., A.H.S., J.M.D., E.I.L., C.N.I.), Buffalo, New York
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104
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Mah YH, Nachev P, MacKinnon AD. Quantifying the Impact of Chronic Ischemic Injury on Clinical Outcomes in Acute Stroke With Machine Learning. Front Neurol 2020; 11:15. [PMID: 32038472 PMCID: PMC6992664 DOI: 10.3389/fneur.2020.00015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/07/2020] [Indexed: 11/13/2022] Open
Abstract
Acute stroke is often superimposed on chronic damage from previous cerebrovascular events. This background will inevitably modulate the impact of acute injury on clinical outcomes to an extent that will depend on the precise anatomical pattern of damage. Previous attempts to quantify such modulation have employed only reductive models that ignore anatomical detail. The combination of automated image processing, large-scale data, and machine learning now enables us to quantify the impact of this with high-dimensional multivariate models sensitive to individual variations in the detailed anatomical pattern. We introduce and validate a new automated chronic lesion segmentation routine for use with non-contrast CT brain scans, combining non-parametric outlier-detection score, Zeta, with an unsupervised 3-dimensional maximum-flow, minimum-cut algorithm. The routine was then applied to a dataset of 1,704 stroke patient scans, obtained at their presentation to a hyper-acute stroke unit (St George's Hospital, London, UK), and used to train a support vector machine (SVM) model to predict between low (0-2) and high (3-6) pre-admission and discharge modified Rankin Scale (mRS) scores, quantifying performance by the area under the receiver operating curve (AUROC). In this single center retrospective observational study, our SVM models were able to differentiate between low (0-2) and high (3-6) pre-admission and discharge mRS scores with an AUROC of 0.77 (95% confidence interval of 0.74-0.79), and 0.76 (0.74-0.78), respectively. The chronic lesion segmentation routine achieved a mean (standard deviation) sensitivity, specificity and Dice similarity coefficient of 0.746 (0.069), 0.999 (0.001), and 0.717 (0.091), respectively. We have demonstrated that machine learning models capable of capturing the high-dimensional features of chronic injuries are able to stratify patients-at the time of presentation-by pre-admission and discharge mRS scores. Our fully automated chronic stroke lesion segmentation routine simplifies this process, and utilizes routinely collected CT head scans, thereby facilitating future large-scale studies to develop supportive clinical decision tools.
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Affiliation(s)
- Yee-Haur Mah
- King's College Hospital NHS Foundation Trust, London, United Kingdom
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Parashkev Nachev
- High-Dimensional Neurology, Institute of Neurology, University College London, London, United Kingdom
| | - Andrew D. MacKinnon
- St George's University Hospitals NHS Foundation Trust, London, United Kingdom
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107
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Maingard J, Foo M, Chandra RV, Leslie-Mazwi TM. Endovascular Treatment of Acute Ischemic Stroke. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:89. [PMID: 31823080 DOI: 10.1007/s11936-019-0781-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Endovascular thrombectomy (ET), the standard of treatment for emergent large vessel occlusion (ELVO) strokes, has been subject to rigorous efforts to further improve its usage and delivery for optimised patient outcomes. This review aims to provide an outline and discussion about the recently established and emerging recommendations regarding endovascular treatment of stroke. RECENT FINDINGS The indications for ET have expanded continually, with perfusion imaging now enabling selection of patients presenting 6-24 h after last-known-well, and improved device and operator proficiency allowing treatment of M2-MCA occlusions and tandem occlusions. Further inclusion of paediatric patients and patients with larger infarct core or milder stroke symptoms for ET has been proposed; however, this remains unproven. This growing applicability is supported by more efficient systems of care, employing modern techniques such as telemedicine, mobile stroke units and helicopter medical services. Ongoing debate exists regarding thrombolytic agent, thrombectomy technique, anaesthesia method and the role of advanced neuroimaging, with upcoming RCTs expected to provide clarification. The journey to further improving the efficacy of ET has advanced and diversified rapidly over recent years, involving improved patient selection, increased utility of advanced neuroimaging and ongoing device redevelopment, within the setting of more efficient, streamlined systems of care. This dynamic and ongoing influx of evidence-based refinements is key to further optimising outcomes for ELVO patients.
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Affiliation(s)
- Julian Maingard
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Michelle Foo
- Department of Radiology, Austin Health, Heidelberg, Victoria, Australia
| | - Ronil V Chandra
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Victoria, Australia.,Faculty of Medicine, Nursing and Heath Sciences, Monash University, Clayton, Victoria, Australia
| | - Thabele M Leslie-Mazwi
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA. .,Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA.
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108
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Atchaneeyasakul K, Aroor S, Brunet MC, Khandelwal P, Saini V, Koch S, Yavagal D. Pearls & Oy-sters: No-cutoff large vessel occlusion stroke: An indication for thrombectomy that can be missed. Neurology 2019; 93:1014-1015. [PMID: 31792105 DOI: 10.1212/wnl.0000000000008575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Kunakorn Atchaneeyasakul
- From the Departments of Neurology (K.A., S.A., V.S., S.K., D.Y.) and Neurosurgery (M.-C.B., P.K., D.Y.), University of Miami Miller School of Medicine, FL
| | - Sushanth Aroor
- From the Departments of Neurology (K.A., S.A., V.S., S.K., D.Y.) and Neurosurgery (M.-C.B., P.K., D.Y.), University of Miami Miller School of Medicine, FL
| | - Marie-Christine Brunet
- From the Departments of Neurology (K.A., S.A., V.S., S.K., D.Y.) and Neurosurgery (M.-C.B., P.K., D.Y.), University of Miami Miller School of Medicine, FL
| | - Priyank Khandelwal
- From the Departments of Neurology (K.A., S.A., V.S., S.K., D.Y.) and Neurosurgery (M.-C.B., P.K., D.Y.), University of Miami Miller School of Medicine, FL
| | - Vasu Saini
- From the Departments of Neurology (K.A., S.A., V.S., S.K., D.Y.) and Neurosurgery (M.-C.B., P.K., D.Y.), University of Miami Miller School of Medicine, FL
| | - Sebastian Koch
- From the Departments of Neurology (K.A., S.A., V.S., S.K., D.Y.) and Neurosurgery (M.-C.B., P.K., D.Y.), University of Miami Miller School of Medicine, FL
| | - Dileep Yavagal
- From the Departments of Neurology (K.A., S.A., V.S., S.K., D.Y.) and Neurosurgery (M.-C.B., P.K., D.Y.), University of Miami Miller School of Medicine, FL.
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