101
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Hui FK, Obuchowski NA, John S, Toth G, Katzan I, Wisco D, Cheng-Ching E, Uchino K, Man SM, Hussain S. ASPECTS discrepancies between CT and MR imaging: analysis and implications for triage protocols in acute ischemic stroke. J Neurointerv Surg 2016; 9:240-243. [PMID: 26888953 DOI: 10.1136/neurintsurg-2015-012188] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/28/2016] [Accepted: 01/29/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Optimal imaging triage for intervention for large vessel occlusions remains unclear. MR-based imaging provides ischemic core volumes at the cost of increased imaging time. CT Alberta Stroke Program Early CT Score (ASPECTS) estimates are faster, but may be less sensitive. OBJECTIVE To assesses the rate at which MRI changed management in comparison with CT imaging alone. METHODS Retrospective analysis of patients with acute ischemic stroke undergoing imaging triage for endovascular therapy was performed between 2008 and 2013. Univariate and multivariate analyses were performed. Multivariate logistic regression was used to evaluate the effect of time on disagreement in MRI and CT ASPECTS scores. RESULTS A total of 241 patients underwent both diffusion-weighted imaging (DWI) and CT. Six patients with DWI ASPECTS ≥6 and CT ASPECTS <6 were omitted, leaving 235 patients. For 47 patients, disagreement between the two modalities resulted in different treatment recommendations. The estimated probability of disagreement was 20.0% (95% CI 15.4% to 25.6%). In a multivariate logistic regression, CT ASPECTS >7 (p=0.004) and admission National Institutes of Health Stroke Scale (NIHSS) score <16 (p=0.008) were simultaneously significant predictors of agreement in ASPECTS. The time between modalities was a marginally significant predictor (p=0.080). CONCLUSIONS The study suggests that patients with NIHSS scores at admission of <16 and patients with CT ASPECTS >7 have a higher likelihood of agreement between CT and DWI based on an ASPECTS cut-off value of 6. Additional MRI for triage in patients with NIHSS at admission of >16, and ASPECTS of 6 or 7 may be more likely to change management. Unsurprisingly, patients with low CT ASPECTS had good correlation with MRI ASPECTS.
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Affiliation(s)
- Ferdinand K Hui
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Seby John
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gabor Toth
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Irene Katzan
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Dolora Wisco
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Esteban Cheng-Ching
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shu-Mei Man
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shazam Hussain
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
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102
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Campbell BCV, Donnan GA, Mitchell PJ, Davis SM. Endovascular thrombectomy for stroke: current best practice and future goals. Stroke Vasc Neurol 2016; 1:16-22. [PMID: 28959994 PMCID: PMC5435188 DOI: 10.1136/svn-2015-000004] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 01/19/2016] [Indexed: 12/02/2022] Open
Abstract
Endovascular thrombectomy for large vessel ischaemic stroke substantially reduces disability, with recent positive randomised trials leading to guideline changes worldwide. This review discusses in detail the evidence provided by recent randomised trials and meta-analyses, the remaining areas of uncertainty and the future directions for research. The data from existing trials have demonstrated the robust benefit of endovascular thrombectomy for internal carotid and proximal middle cerebral artery occlusions. Uncertainty remains for more distal occlusions where the efficacy of alteplase is greater, less tissue is at risk and the safety of endovascular procedures is less established. Basilar artery occlusion was excluded from the trials, but with a dire natural history and proof of principle that rapid reperfusion is effective, it seems reasonable to continue treating these patients pending ongoing trial results. There has been no evidence of heterogeneity in treatment effect in clinically defined subgroups by age, indeed, those aged >80 years have at least as great an overall reduction in disability and reduced mortality. Similarly there was no heterogeneity across the range of baseline stroke severities included in the trials. Evidence that routine use of general anaesthesia reduces the benefit of endovascular thrombectomy is increasing and conscious sedation is generally preferred unless severe agitation or airway compromise is present. The impact of time delays has become clearer with description of onset to imaging and imaging to reperfusion epochs. Delays in the onset to imaging reduce the proportion of patients with salvageable brain tissue. However, in the presence of favourable imaging, rapid treatment appears beneficial regardless of the onset to imaging time elapsed. Imaging to reperfusion delays lead to decay in the clinical benefit achieved, particularly in those with less robust collateral flow. The brain imaging options to assess prognosis have various advantages and disadvantages, but whatever strategy is employed must be fast. Ongoing trials are investigating extended time windows, using advanced brain imaging selection. There is also a need for further technical advances to maximise rates of complete reperfusion in the minimum time.
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Affiliation(s)
- Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Geoffrey A Donnan
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
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103
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Good Clinical and Radiological Correlation from Standard Perfusion Computed Tomography Accurately Identifies Salvageable Tissue in Ischemic Stroke. J Stroke Cerebrovasc Dis 2016; 25:1062-1069. [PMID: 26856462 DOI: 10.1016/j.jstrokecerebrovasdis.2016.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 10/26/2015] [Accepted: 01/02/2016] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION It has been debated whether the penumbral pattern, as identified using multimodal imaging, is a specific marker of tissue viability in ischemic stroke. We assessed whether perfusion computed tomography (PCT) accurately identifies salvageable tissue and helps predict postreperfusion outcomes. METHODS A retrospective study of patients with anterior circulation stroke undergoing reperfusion therapies who had a PCT before treatment and an assessment of vessel recanalization post treatment was conducted. Tissue at risk was considered as that with reduced cerebral blood flow, whereas the infarct core was the region of reduced cerebral blood volume, the mismatch region being salvageable tissue. The volume of hypodensity in slices corresponding to perfusion acquisition cage in 24-hour computed tomography (partial lesion volume [PLV]) was measured. Outcome variables were the amount of preserved tissue, that is, the difference between volumes of tissue at risk and PLV expressed as a percentage, and the modified Rankin Scale (mRS) score at 3 months. RESULTS Patients (n = 34) meeting the inclusion criteria were included. Vessel recanalization was associated with a larger amount of tissue at risk preserved from definite lesion (89% [interquartile range {IQR}: 76-94] versus 46% [IQR: 23-86], P < .005). The amount of preserved tissue correlated with clinical outcome at 24 hours: for each 10% of preserved tissue, the National Institutes of Health Stroke Scale score improved by 3 points (95% confidence interval [CI]: -4.9 to -.8, P = .007) and was the only predictor of independency (mRS score 0-2) following adjustment for covariates (odds ratio 1.15, 95% CI: 1.04-1.28, P = .005). CONCLUSIONS PCT provides accurate markers of viability of tissue in acute ischemic stroke and could help predict the degree of improvement following reperfusion.
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104
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Magnetic Resonance Imaging of Cerebrovascular Diseases. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00048-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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105
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Nogueira RG, Haussen DC, Dehkharghani S, Rebello LC, Lima A, Bowen M, Belagaje S, Anderson A, Frankel M. Large Volumes of Critically Hypoperfused Penumbral Tissue Do Not Preclude Good Outcomes After Complete Endovascular Reperfusion. Stroke 2016; 47:94-8. [DOI: 10.1161/strokeaha.115.011360] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 10/21/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Acute ischemic stroke patients with large volumes of severe hypoperfusion (
T
max
>10 s>100 mL) on magnetic resonance imaging have a higher likelihood of intracranial hemorrhage and poor outcomes after reperfusion. We aim to evaluate the impact of the extent of
T
max
>10 s CTP lesions in patients undergoing successful treatment.
Methods—
Retrospective database review of endovascular acute ischemic stroke treatment between September 2010 and March 2015 for patients with anterior circulation occlusions with baseline RAPID CTP and full reperfusion (mTICI 3). The primary outcome was the impact of the
T
max
>10 s lesion spectrum on infarct growth. Secondary safety and efficacy outcomes included parenchymal hematomas and good clinical outcomes (90-day modified Rankin Scale score, 0–2).
Results—
Of 684 treated patients, 113 patients fit the inclusion criteria.
T
max
>10 s>100 mL patients (n=37) had significantly higher baseline National Institutes of Health Stroke Scale (20.7±3.8 versus 17.0±5.9;
P
<0.01), more internal carotid artery terminus occlusions (29% versus 9%;
P
=0.02), and larger baseline (38.6±29.6 versus 11.7±15.8 mL;
P
<0.01) and final (60.7±60.0 versus 29.4±33.9 mL;
P
<0.01) infarct volumes when compared with patients without
T
max
>10 s>100 mL (n=76); however, the 2 groups were otherwise well balanced. There were no significant differences in infarct growth (22.1±51.6 versus 17.8±32.4 mL;
P
=0.78), severe intracranial hemorrhage (PH2: 2% versus 4%;
P
=0.73), good outcomes (90-day mRS score, 0–2: 56% versus 59%;
P
=0.83), or 90-day mortality (16% versus 7%;
P
=0.28). On multivariate analysis, only baseline National Institutes of Health Stroke Scale (odds ratio, 1.19; 95% confidence interval, 1.06–1.34;
P
<0.01) and baseline infarct core volume (odds ratio, 1.05; 95% confidence interval, 1.02–1.08;
P
<0.01) were independently associated with
T
max
>10 s>100 mL. There was no association between
T
max
>10 s>100 mL with any PH, good outcome, or infarct growth.
Conclusions—
In the setting of limited baseline ischemic cores, large
T
max
>10 s lesions on computed tomographic perfusion do not seem to be associated with a higher risk of parenchymal hematomas and do not preclude good outcomes in patients undergoing endovascular reperfusion with contemporary technology.
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Affiliation(s)
- Raul G. Nogueira
- From the Department of Neurology (R.G.N., D.C.H., L.C.R., A.L., S.B., A.A., M.F.) and the Department of Radiology (S.D., M.B.), Emory University and Grady Memorial Hospital - Marcus Stroke and Neuroscience Center, Atlanta, GA
| | - Diogo C. Haussen
- From the Department of Neurology (R.G.N., D.C.H., L.C.R., A.L., S.B., A.A., M.F.) and the Department of Radiology (S.D., M.B.), Emory University and Grady Memorial Hospital - Marcus Stroke and Neuroscience Center, Atlanta, GA
| | - Seena Dehkharghani
- From the Department of Neurology (R.G.N., D.C.H., L.C.R., A.L., S.B., A.A., M.F.) and the Department of Radiology (S.D., M.B.), Emory University and Grady Memorial Hospital - Marcus Stroke and Neuroscience Center, Atlanta, GA
| | - Leticia C. Rebello
- From the Department of Neurology (R.G.N., D.C.H., L.C.R., A.L., S.B., A.A., M.F.) and the Department of Radiology (S.D., M.B.), Emory University and Grady Memorial Hospital - Marcus Stroke and Neuroscience Center, Atlanta, GA
| | - Andrey Lima
- From the Department of Neurology (R.G.N., D.C.H., L.C.R., A.L., S.B., A.A., M.F.) and the Department of Radiology (S.D., M.B.), Emory University and Grady Memorial Hospital - Marcus Stroke and Neuroscience Center, Atlanta, GA
| | - Meredith Bowen
- From the Department of Neurology (R.G.N., D.C.H., L.C.R., A.L., S.B., A.A., M.F.) and the Department of Radiology (S.D., M.B.), Emory University and Grady Memorial Hospital - Marcus Stroke and Neuroscience Center, Atlanta, GA
| | - Samir Belagaje
- From the Department of Neurology (R.G.N., D.C.H., L.C.R., A.L., S.B., A.A., M.F.) and the Department of Radiology (S.D., M.B.), Emory University and Grady Memorial Hospital - Marcus Stroke and Neuroscience Center, Atlanta, GA
| | - Aaron Anderson
- From the Department of Neurology (R.G.N., D.C.H., L.C.R., A.L., S.B., A.A., M.F.) and the Department of Radiology (S.D., M.B.), Emory University and Grady Memorial Hospital - Marcus Stroke and Neuroscience Center, Atlanta, GA
| | - Michael Frankel
- From the Department of Neurology (R.G.N., D.C.H., L.C.R., A.L., S.B., A.A., M.F.) and the Department of Radiology (S.D., M.B.), Emory University and Grady Memorial Hospital - Marcus Stroke and Neuroscience Center, Atlanta, GA
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106
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Goyal M, Hill MD, Saver JL, Fisher M. Challenges and Opportunities of Endovascular Stroke Therapy. Ann Neurol 2015; 79:11-7. [DOI: 10.1002/ana.24528] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 09/11/2015] [Accepted: 09/18/2015] [Indexed: 02/06/2023]
Affiliation(s)
- Mayank Goyal
- Department of Radiology and Clinical Neurosciences; Foothills Hospital, Cuming School of Medicine, University of Calgary; Calgary Alberta Canada
| | - Michael D. Hill
- Department of Radiology and Clinical Neurosciences; Foothills Hospital, Cuming School of Medicine, University of Calgary; Calgary Alberta Canada
- Department of Community Health Sciences and Medicine; Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary; Calgary Alberta Canada
| | - Jeffrey L. Saver
- Geffen School of Medicine at UCLA, UCLA Comprehensive Stroke Center; Los Angeles CA
| | - Marc Fisher
- Department of Neurology; Beth Israel Deaconess Medical Center, Harvard Medical School; Boston MA
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107
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Albers GW, Goyal M, Jahan R, Bonafe A, Diener HC, Levy EI, Pereira VM, Cognard C, Cohen DJ, Hacke W, Jansen O, Jovin TG, Mattle HP, Nogueira RG, Siddiqui AH, Yavagal DR, Baxter BW, Devlin TG, Lopes DK, Reddy VK, de Rochemont RDM, Singer OC, Bammer R, Saver JL. Ischemic core and hypoperfusion volumes predict infarct size in SWIFT PRIME. Ann Neurol 2015; 79:76-89. [PMID: 26476022 DOI: 10.1002/ana.24543] [Citation(s) in RCA: 130] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 10/01/2015] [Accepted: 10/15/2015] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Within the context of a prospective randomized trial (SWIFT PRIME), we assessed whether early imaging of stroke patients, primarily with computed tomography (CT) perfusion, can estimate the size of the irreversibly injured ischemic core and the volume of critically hypoperfused tissue. We also evaluated the accuracy of ischemic core and hypoperfusion volumes for predicting infarct volume in patients with the target mismatch profile. METHODS Baseline ischemic core and hypoperfusion volumes were assessed prior to randomized treatment with intravenous (IV) tissue plasminogen activator (tPA) alone versus IV tPA + endovascular therapy (Solitaire stent-retriever) using RAPID automated postprocessing software. Reperfusion was assessed with angiographic Thrombolysis in Cerebral Infarction scores at the end of the procedure (endovascular group) and Tmax > 6-second volumes at 27 hours (both groups). Infarct volume was assessed at 27 hours on noncontrast CT or magnetic resonance imaging (MRI). RESULTS A total of 151 patients with baseline imaging with CT perfusion (79%) or multimodal MRI (21%) were included. The median baseline ischemic core volume was 6 ml (interquartile range= 0-16). Ischemic core volumes correlated with 27-hour infarct volumes in patients who achieved reperfusion (r = 0.58, p < 0.0001). In patients who did not reperfuse (<10% reperfusion), baseline Tmax > 6-second lesion volumes correlated with 27-hour infarct volume (r = 0.78, p = 0.005). In target mismatch patients, the union of baseline core and early follow-up Tmax > 6-second volume (ie, predicted infarct volume) correlated with the 27-hour infarct volume (r = 0.73, p < 0.0001); the median absolute difference between the observed and predicted volume was 13 ml. INTERPRETATION Ischemic core and hypoperfusion volumes, obtained primarily from CT perfusion scans, predict 27-hour infarct volume in acute stroke patients who were treated with reperfusion therapies.
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Affiliation(s)
- Gregory W Albers
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Mayank Goyal
- Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Reza Jahan
- Division of Interventional Neuroradiology, University of California, Los Angeles, Los Angeles, CA
| | - Alain Bonafe
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France
| | | | - Elad I Levy
- Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY
| | - Vitor M Pereira
- Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France
| | - David J Cohen
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Olav Jansen
- Department of Radiology and Neuroradiology, Christian Albrechts University of Kiel, Kiel, Germany
| | - Tudor G Jovin
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Heinrich P Mattle
- Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
| | - Raul G Nogueira
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, State University of New York at Buffalo, Buffalo, NY
| | - Dileep R Yavagal
- Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL
| | - Blaise W Baxter
- Department of Radiology, Erlanger Hospital at University of Tennessee, Chattanooga, TN
| | - Thomas G Devlin
- Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga, TN
| | - Demetrius K Lopes
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL
| | - Vivek K Reddy
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Oliver C Singer
- Department of Neurology, Goethe University Hospital, Frankfurt, Germany
| | - Roland Bammer
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
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108
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Seker F, Potreck A, Möhlenbruch M, Bendszus M, Pham M. Comparison of four different collateral scores in acute ischemic stroke by CT angiography. J Neurointerv Surg 2015; 8:1116-1118. [DOI: 10.1136/neurintsurg-2015-012101] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 11/16/2015] [Indexed: 11/03/2022]
Abstract
PurposeMultiple scores have been described for the assessment of collateralization in acute ischemic stroke. Currently, there is no gold standard for collateral assessment by CT angiography (CTA). This study compared four frequently used collateral scores with regard to their correlation with early infarct core and mismatch ratio.Methods30 consecutive patients with acute occlusion of the M1 segment or terminal carotid artery were reviewed retrospectively. Collaterals were assessed using dynamic and also single-phase CTA according to grading systems by the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR), Alberta Stroke Program Early CT Score (ASPECTS) (on collaterals), Christoforidis et al and Miteff et al. The Christoforidis and ASITN/SIR scores, which were initially designed for conventional angiography, were adapted to be applicable to CTA. The scores were compared with respect to early infarct core and mismatch ratio in perfusion CT estimated by RAPID software using Spearman correlation.ResultsASITN/SIR and ASPECTS collateral scores showed good correlation with early infarct core (rho=−0.696, p<0.001 and rho=−0.677, p<0.001) and mismatch ratio (rho=0.609, p<0.001 and rho=0.581, p<0.001). In contrast, the Christoforidis and Miteff scores correlated less well with infarct core (rho=0.245, p=0.191 and rho=−0.272, p=0.145, respectively) and mismatch ratio (rho=−0.329, p=0.075 and rho=0.279, p=0.135, respectively). ASPECTS and ASITN/SIR showed excellent cross-correlation (rho=0.901, p<0.001).ConclusionsCompared with the Christoforidis and Miteff scores, the modified ASITN/SIR and ASPECTS collateral scores showed consistently higher correlation with the extent of early infarct core and mismatch volume. This is probably because these scores evaluate the extent and delay of vascular enhancement in the affected territory rather than the backflow of contrast medium to the occlusion.
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109
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Krieger DA, Dehkharghani S. Magnetic Resonance Imaging in Ischemic Stroke and Cerebral Venous Thrombosis. Top Magn Reson Imaging 2015; 24:331-352. [PMID: 26636639 DOI: 10.1097/rmr.0000000000000067] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Imaging is indispensable in the evaluation of patients presenting with central nervous system emergencies. Although computed tomography (CT) is the mainstay of initial assessment and triage, magnetic resonance imaging (MRI) has become vital in expanding diagnostic capabilities, refining management strategies, and developing our understanding of disease processes. Ischemic stroke and cerebral venous thrombosis are 2 areas wherein MRI is actively revolutionizing patient care. Familiarity with the imaging manifestations of these 2 disease processes is crucial for any radiologist reading brain MR studies. In this review, the fundamentals of image interpretation will be addressed in-depth. Furthermore, advanced imaging techniques which are redefining the role of emergency MRI will be outlined, with a focus on the pathophysiological mechanisms that underlie image interpretation. In particular, emerging data surrounding the use of MR perfusion imaging in acute stroke management portend dramatic shifts in neurointerventional management. To this end, a review of the recent stroke literature will hopefully enhance the radiologist's role in both meaningful reporting and multidisciplinary teamwork.
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Affiliation(s)
- Daniel A Krieger
- Emory University School of Medicine, Department of Radiology and Imaging Sciences, Division of Neuroradiology, Atlanta, Georgia
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110
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Acute ischemic stroke imaging: a practical approach for diagnosis and triage. Int J Cardiovasc Imaging 2015; 32:19-33. [DOI: 10.1007/s10554-015-0757-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 08/26/2015] [Indexed: 11/30/2022]
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111
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Albers GW, Goyal M, Jahan R, Bonafe A, Diener HC, Levy EI, Pereira VM, Cognard C, Yavagal DR, Saver JL. Relationships Between Imaging Assessments and Outcomes in Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke. Stroke 2015; 46:2786-94. [PMID: 26316344 DOI: 10.1161/strokeaha.115.010710] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/14/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Imaging findings can predict outcomes in patients with acute stroke. Relationships between imaging findings and clinical and imaging outcomes in patients randomized to intravenous tissue-type plasminogen activator-alone versus tissue-type plasminogen activator plus endovascular therapy (Solitaire device) in the Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) study were assessed. METHODS We evaluated associations between imaging assessments (baseline mismatch profiles/ischemic core volumes and successful reperfusion) with imaging outcomes (27-hour infarct volume/growth) and clinical outcomes (modified Rankin Scale scores at 90 days). Imaging variables that predict favorable clinical outcomes were assessed in both univariate and multivariate models. RESULTS One hundred and ninety-five patients were included. Successful reperfusion and infarct volume (assessed at 27 hours) were powerful independent predictors of favorable clinical outcomes (modified Rankin Scale score of 0-2 at 90 days). Patients with the target mismatch profile at baseline had a higher rate of reperfusion, lesser infarct growth, smaller infarct volumes, and better clinical outcomes in the Solitaire plus tissue-type plasminogen activator (intervention) group than those in the tissue-type plasminogen activator-alone (control) group. Patients with larger mismatch volumes at baseline had a trend toward better treatment response in the intervention group than patients who had smaller (<50 mL) mismatch volumes. CONCLUSIONS Patients who achieved reperfusion had substantially more favorable clinical and imaging outcomes in both the intervention and the control groups. Infarct volume at 27 hours strongly correlated with clinical outcome at 90 days in both treatment groups. SWIFT PRIME patients with the target mismatch profile had a highly favorable response to endovascular therapy on both clinical and imaging outcomes. Both reperfusion and infarct volumes at 27 hours were powerful and independent predictors of 90-day clinical outcomes. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01657461.
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Affiliation(s)
- Gregory W Albers
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo, NY (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada (V.M.P.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.).
| | - Mayank Goyal
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo, NY (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada (V.M.P.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Reza Jahan
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo, NY (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada (V.M.P.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Alain Bonafe
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo, NY (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada (V.M.P.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Hans-Christoph Diener
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo, NY (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada (V.M.P.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Elad I Levy
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo, NY (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada (V.M.P.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Vitor M Pereira
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo, NY (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada (V.M.P.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Christophe Cognard
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo, NY (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada (V.M.P.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Dileep R Yavagal
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo, NY (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada (V.M.P.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Jeffrey L Saver
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles; Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.); Department of Neurology, University Hospital of University Duisburg-Essen, Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo, NY (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada (V.M.P.); Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
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112
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Dehkharghani S, Bammer R, Straka M, Albin LS, Kass-Hout O, Allen JW, Rangaraju S, Qiu D, Winningham MJ, Nahab F. Performance and Predictive Value of a User-Independent Platform for CT Perfusion Analysis: Threshold-Derived Automated Systems Outperform Examiner-Driven Approaches in Outcome Prediction of Acute Ischemic Stroke. AJNR Am J Neuroradiol 2015; 36:1419-25. [PMID: 25999410 DOI: 10.3174/ajnr.a4363] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 01/20/2015] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND PURPOSE Treatment strategies in acute ischemic stroke aim to curtail ischemic progression. Emerging paradigms propose patient subselection using imaging biomarkers derived from CT, CTA, and CT perfusion. We evaluated the performance of a fully-automated computational tool, hypothesizing enhancements compared with qualitative approaches. The correlation between imaging variables and clinical outcomes in a cohort of patients with acute ischemic stroke is reported. MATERIALS AND METHODS Sixty-two patients with acute ischemic stroke and MCA or ICA occlusion undergoing multidetector CT, CTA, and CTP were retrospectively evaluated. CTP was processed on a fully operator-independent platform (RApid processing of PerfusIon and Diffusion [RAPID]) computing automated core estimates based on relative cerebral blood flow and relative cerebral blood volume and hypoperfused tissue volumes at varying thresholds of time-to-maximum. Qualitative analysis was assigned by 2 independent reviewers for each variable, including CT-ASPECTS, CBV-ASPECTS, CBF-ASPECTS, CTA collateral score, and CTA clot burden score. Performance as predictors of favorable clinical outcome and final infarct volume was established for each variable. RESULTS Both RAPID core estimates, CT-ASPECTS, CBV-ASPECTS, and clot burden score correlated with favorable clinical outcome (P < .05); CBF-ASPECTS and collateral score were not significantly associated with favorable outcome, while hypoperfusion estimates were variably associated, depending on the selected time-to-maximum thresholds. Receiver operating characteristic analysis demonstrated disparities among tested variables, with RAPID core and hypoperfusion estimates outperforming all qualitative approaches (area under the curve, relative CBV = 0.86, relative CBF = 0.81; P < .001). CONCLUSIONS Qualitative approaches to acute ischemic stroke imaging are subject to limitations due to their subjective nature and lack of physiologic information. These findings support the benefits of high-speed automated analysis, outperforming conventional methodologies while limiting delays in clinical management.
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Affiliation(s)
- S Dehkharghani
- From the Departments of Radiology and Imaging Sciences (S.D., L.S.A., J.W.A., D.Q.)
| | - R Bammer
- Department of Radiology (R.B.), Stanford University Hospital, Stanford, California
| | - M Straka
- Institut für Radiologie und Nuklearmedizin (M.S.), Kantonsspital Winterthur, Winterthur, Switzerland
| | - L S Albin
- From the Departments of Radiology and Imaging Sciences (S.D., L.S.A., J.W.A., D.Q.)
| | - O Kass-Hout
- Department of Neurology (O.K.-H.), Catholic Health System, Buffalo, New York
| | - J W Allen
- From the Departments of Radiology and Imaging Sciences (S.D., L.S.A., J.W.A., D.Q.)
| | - S Rangaraju
- Neurology (S.R., M.J.W., F.N.), Emory University Hospital, Atlanta, Georgia
| | - D Qiu
- From the Departments of Radiology and Imaging Sciences (S.D., L.S.A., J.W.A., D.Q.)
| | - M J Winningham
- Neurology (S.R., M.J.W., F.N.), Emory University Hospital, Atlanta, Georgia
| | - F Nahab
- Neurology (S.R., M.J.W., F.N.), Emory University Hospital, Atlanta, Georgia
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113
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Jickling GC, Sharp FR. Improving the translation of animal ischemic stroke studies to humans. Metab Brain Dis 2015; 30:461-7. [PMID: 24526567 PMCID: PMC4186910 DOI: 10.1007/s11011-014-9499-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Accepted: 01/28/2014] [Indexed: 12/18/2022]
Abstract
Despite testing more than 1,026 therapeutic strategies in models of ischemic stroke and 114 therapies in human ischemic stroke, only one agent tissue plasminogen activator has successfully been translated to clinical practice as a treatment for acute stroke. Though disappointing, this immense body of work has led to a rethinking of animal stroke models and how to better translate therapies to patients with ischemic stroke. Several recommendations have been made, including the STAIR recommendations and statements of RIGOR from the NIH/NINDS. In this commentary we discuss additional aspects that may be important to improve the translational success of ischemic stroke therapies. These include use of tissue plasminogen activator in animal studies; modeling ischemic stroke heterogeneity in terms of infarct size and cause of human stroke; addressing the confounding effect of anesthesia; use of comparable therapeutic dosage between humans and animals based on biological effect; modeling the human immune system; and developing outcome measures in animals comparable to those used in human stroke trials. With additional study and improved animal modeling of factors involved in human ischemic stroke, we are optimistic that new stroke therapies will be developed.
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Affiliation(s)
- Glen C Jickling
- Department of Neurology, MIND Institute Wet Labs Room 2415, University of California at Davis Medical Center, 2805 50th Street, Sacramento, CA, 95817, USA,
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114
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Huang X, Cheripelli BK, Lloyd SM, Kalladka D, Moreton FC, Siddiqui A, Ford I, Muir KW. Alteplase versus tenecteplase for thrombolysis after ischaemic stroke (ATTEST): a phase 2, randomised, open-label, blinded endpoint study. Lancet Neurol 2015; 14:368-76. [PMID: 25726502 DOI: 10.1016/s1474-4422(15)70017-7] [Citation(s) in RCA: 204] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND In most countries, alteplase given within 4·5 h of onset is the only approved medical treatment for acute ischaemic stroke. The newer thrombolytic drug tenecteplase has been investigated in one randomised trial up to 3 h after stroke and in another trial up to 6 h after stroke in patients selected by advanced neuroimaging. In the Alteplase-Tenecteplase Trial Evaluation for Stroke Thrombolysis (ATTEST), we aimed to assess the efficacy and safety of tenecteplase versus alteplase within 4·5 h of stroke onset in a population not selected on the basis of advanced neuroimaging, and to use imaging biomarkers to inform the design of a definitive phase 3 clinical trial. METHODS In this single-centre, phase 2, prospective, randomised, open-label, blinded end-point evaluation study, adults with supratentorial ischaemic stroke eligible for intravenous thrombolysis within 4·5 h of onset were recruited from The Institute of Neurological Sciences, Glasgow, Scotland. Patients were randomly assigned (1:1) to receive tenecteplase 0·25 mg/kg (maximum 25 mg) or alteplase 0·9 mg/kg (maximum 90 mg). Treatment allocation used a mixed randomisation and minimisation algorithm including age and National Institutes of Health Stroke Scale score, generated by an independent statistician. Patients were not informed of treatment allocation; treating clinicians were aware of allocation but those assessing the primary outcome were not. Imaging comprised baseline CT, CT perfusion, and CT angiography; and CT plus CT angiography at 24-48 h. The primary endpoint was percentage of penumbra salvaged (CT perfusion-defined penumbra volume at baseline minus CT infarct volume at 24-48 h). Analysis was per protocol. This study is registered with ClinicalTrials.gov, number NCT01472926. FINDINGS Between Jan 1, 2012, and Sept 7, 2013, 355 patients were screened, of whom 157 were eligible for intravenous thrombolysis, and 104 patients were enrolled. 52 were assigned to the alteplase group and 52 to tenecteplase. Of 71 patients (35 assigned tenecteplase and 36 assigned alteplase) contributing to the primary endpoint, no significant differences were noted for percentage of penumbral salvaged (68% [SD 28] for the tenecteplase group vs 68% [23] for the alteplase group; mean difference 1·3% [95% CI -9·6 to 12·1]; p=0·81). Neither incidence of symptomatic intracerebral haemorrhage (by SITS-MOST definition, 1/52 [2%] tenecteplase vs 2/51 [4%] alteplase, p=0·55; by ECASS II definition, 3/52 [6%] vs 4/51 [8%], p=0·59) nor total intracerebral haemorrhage events (8/52 [15%] vs 14/51 [29%], p=0·091) differed significantly. The incidence of serious adverse events did not differ between groups (32 in the tenecteplase group, three considered probably or definitely related to drug treatment; 16 in the alteplase group, five were considered drug-related). INTERPRETATION Neurological and radiological outcomes did not differ between the tenecteplase and alteplase groups. Evaluation of tenecteplase in larger trials of patients with acute stroke seems warranted. FUNDING The Stroke Association.
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Affiliation(s)
- Xuya Huang
- Institute of Neuroscience and Psychology, University of Glasgow, Southern General Hospital, Glasgow, Scotland, UK
| | - Bharath Kumar Cheripelli
- Institute of Neuroscience and Psychology, University of Glasgow, Southern General Hospital, Glasgow, Scotland, UK
| | - Suzanne M Lloyd
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland, UK
| | - Dheeraj Kalladka
- Institute of Neuroscience and Psychology, University of Glasgow, Southern General Hospital, Glasgow, Scotland, UK
| | - Fiona Catherine Moreton
- Institute of Neuroscience and Psychology, University of Glasgow, Southern General Hospital, Glasgow, Scotland, UK
| | - Aslam Siddiqui
- Department of Neuroradiology, Southern General Hospital, NHS Greater Glasgow and Clyde, Glasgow, Scotland, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland, UK
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Southern General Hospital, Glasgow, Scotland, UK.
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115
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Ramani L, Huang X, Cheripelli B, Muir KW. Intravenous thrombolysis for acute stroke: current standards and future directions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:373. [PMID: 25778425 DOI: 10.1007/s11936-015-0373-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OPINION STATEMENT Intravenous thrombolysis with the recombinant tissue plasminogen activator alteplase is the standard of care for patients with acute ischaemic stroke presenting within 4.5 h of symptom onset. The odds of independent survival decline steeply with longer time to treatment delivery, reflecting progressive ischaemic damage to the brain. Standards accordingly emphasise optimisation of patient pathways to minimise treatment delays. Observational data and international clinical guidelines support the safety and efficacy of alteplase in many patient groups currently excluded from treatment (e.g. seizure at onset, concomitant diabetes and previous stroke) on the basis of historical clinical trial criteria. Future evolution of thrombolysis will optimise dosing, apply advanced imaging to extend treatment to groups currently excluded and investigate novel drugs, and adjunctive drug and device therapies. To date, trials of novel therapeutic approaches that have been applied at later time points have failed to demonstrate benefit, suggesting that the future gains are likely to arise from applications within current time windows.
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Affiliation(s)
- Lucille Ramani
- Institute of Neuroscience and Psychology, University of Glasgow, Southern General Hospital, 1345 Govan Road, Glasgow, G51 3TF, Scotland, UK
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116
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Na DG, Sohn CH, Kim EY. Imaging-based management of acute ischemic stroke patients: current neuroradiological perspectives. Korean J Radiol 2015; 16:372-90. [PMID: 25741200 PMCID: PMC4347274 DOI: 10.3348/kjr.2015.16.2.372] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 12/02/2014] [Indexed: 01/05/2023] Open
Abstract
Advances in imaging-based management of acute ischemic stroke now provide crucial information such as infarct core, ischemic penumbra/degree of collaterals, vessel occlusion, and thrombus that helps in the selection of the best candidates for reperfusion therapy. It also predicts thrombolytic efficacy and benefit or potential hazards from therapy. Thus, radiologists should be familiar with various imaging studies for patients with acute ischemic stroke and the applicability to clinical trials. This helps radiologists to obtain optimal rapid imaging as well as its accurate interpretation. This review is focused on imaging studies for acute ischemic stroke, including their roles in recent clinical trials and some guidelines to optimal interpretation.
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Affiliation(s)
- Dong Gyu Na
- Department of Neuroradiology, Head & Neck Radiology, Thyroid Radiology Human Medical Imaging & Intervention Center, Seoul 137-902, Korea
| | - Chul-Ho Sohn
- Department of Radiology, Seoul National University Hospital, Seoul 110-744, Korea
| | - Eung Yeop Kim
- Department of Radiology, Gachon University Gil Medical Center, Incheon 405-760, Korea
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117
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An H, Ford AL, Chen Y, Zhu H, Ponisio R, Kumar G, Shanechi AM, Khoury N, Vo KD, Williams J, Derdeyn CP, Diringer MN, Panagos P, Powers WJ, Lee JM, Lin W. Defining the ischemic penumbra using magnetic resonance oxygen metabolic index. Stroke 2015; 46:982-8. [PMID: 25721017 DOI: 10.1161/strokeaha.114.008154] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Penumbral biomarkers promise to individualize treatment windows in acute ischemic stroke. We used a novel magnetic resonance imaging approach that measures oxygen metabolic index (OMI), a parameter closely related to positron emission tomography-derived cerebral metabolic rate of oxygen utilization (CMRO2), to derive a pair of ischemic thresholds: (1) an irreversible-injury threshold that differentiates ischemic core from penumbra and (2) a reversible-injury threshold that differentiates penumbra from tissue not-at-risk for infarction. METHODS Forty patients with acute ischemic stroke underwent magnetic resonance imaging at 3 time points after stroke onset: <4.5 hours (for OMI threshold derivation), 6 hours (to determine reperfusion status), and 1 month (for infarct probability determination). A dynamic susceptibility contrast method measured cerebral blood flow, and an asymmetrical spin echo sequence measured oxygen extraction fraction, to derive OMI (OMI=cerebral blood flow×oxygen extraction fraction). Putative ischemic threshold pairs were iteratively tested using a computation-intensive method to derive infarct probabilities in 3 tissue groups defined by the thresholds (core, penumbra, and not-at-risk tissue). An optimal threshold pair was chosen based on its ability to predict infarction in the core, reperfusion-dependent survival in the penumbra, and survival in not-at-risk tissue. The predictive abilities of the thresholds were then tested within the same cohort using a 10-fold cross-validation method. RESULTS The optimal OMI ischemic thresholds were found to be 0.28 and 0.42 of normal values in the contralateral hemisphere. Using the 10-fold cross-validation method, median infarct probabilities were 90.6% for core, 89.7% for nonreperfused penumbra, 9.95% for reperfused penumbra, and 6.28% for not-at-risk tissue. CONCLUSIONS OMI thresholds, derived using voxel-based, reperfusion-dependent infarct probabilities, delineated the ischemic penumbra with high predictive ability. These thresholds will require confirmation in an independent patient sample.
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Affiliation(s)
- Hongyu An
- From the Biomedical Research Imaging Center and Departments of Radiology (H.A., Y.C., W.L.), Biostatistics (H.Z.), and Neurology (W.J.P., W.L.), University of North Carolina at Chapel Hill; Department of Neurology (A.L.F., G.K., N.K., J.-M.L.), Department of Radiology (R.P., K.D.V., C.P.D., J.-M.L.), Department of Emergency Medicine (P.P.), and School of Medicine (A.L.F., G.K., N.K., J.-M.L., R.P., K.D.V., C.P.D., J.-M.L., A.M.S., P.P.), Washington University, St. Louis, MO; and Emergency Department, Barnes-Jewish Hospital, St. Louis, MO (J.W.)
| | - Andria L Ford
- From the Biomedical Research Imaging Center and Departments of Radiology (H.A., Y.C., W.L.), Biostatistics (H.Z.), and Neurology (W.J.P., W.L.), University of North Carolina at Chapel Hill; Department of Neurology (A.L.F., G.K., N.K., J.-M.L.), Department of Radiology (R.P., K.D.V., C.P.D., J.-M.L.), Department of Emergency Medicine (P.P.), and School of Medicine (A.L.F., G.K., N.K., J.-M.L., R.P., K.D.V., C.P.D., J.-M.L., A.M.S., P.P.), Washington University, St. Louis, MO; and Emergency Department, Barnes-Jewish Hospital, St. Louis, MO (J.W.)
| | - Yasheng Chen
- From the Biomedical Research Imaging Center and Departments of Radiology (H.A., Y.C., W.L.), Biostatistics (H.Z.), and Neurology (W.J.P., W.L.), University of North Carolina at Chapel Hill; Department of Neurology (A.L.F., G.K., N.K., J.-M.L.), Department of Radiology (R.P., K.D.V., C.P.D., J.-M.L.), Department of Emergency Medicine (P.P.), and School of Medicine (A.L.F., G.K., N.K., J.-M.L., R.P., K.D.V., C.P.D., J.-M.L., A.M.S., P.P.), Washington University, St. Louis, MO; and Emergency Department, Barnes-Jewish Hospital, St. Louis, MO (J.W.)
| | - Hongtu Zhu
- From the Biomedical Research Imaging Center and Departments of Radiology (H.A., Y.C., W.L.), Biostatistics (H.Z.), and Neurology (W.J.P., W.L.), University of North Carolina at Chapel Hill; Department of Neurology (A.L.F., G.K., N.K., J.-M.L.), Department of Radiology (R.P., K.D.V., C.P.D., J.-M.L.), Department of Emergency Medicine (P.P.), and School of Medicine (A.L.F., G.K., N.K., J.-M.L., R.P., K.D.V., C.P.D., J.-M.L., A.M.S., P.P.), Washington University, St. Louis, MO; and Emergency Department, Barnes-Jewish Hospital, St. Louis, MO (J.W.)
| | - Rosana Ponisio
- From the Biomedical Research Imaging Center and Departments of Radiology (H.A., Y.C., W.L.), Biostatistics (H.Z.), and Neurology (W.J.P., W.L.), University of North Carolina at Chapel Hill; Department of Neurology (A.L.F., G.K., N.K., J.-M.L.), Department of Radiology (R.P., K.D.V., C.P.D., J.-M.L.), Department of Emergency Medicine (P.P.), and School of Medicine (A.L.F., G.K., N.K., J.-M.L., R.P., K.D.V., C.P.D., J.-M.L., A.M.S., P.P.), Washington University, St. Louis, MO; and Emergency Department, Barnes-Jewish Hospital, St. Louis, MO (J.W.)
| | - Gyanendra Kumar
- From the Biomedical Research Imaging Center and Departments of Radiology (H.A., Y.C., W.L.), Biostatistics (H.Z.), and Neurology (W.J.P., W.L.), University of North Carolina at Chapel Hill; Department of Neurology (A.L.F., G.K., N.K., J.-M.L.), Department of Radiology (R.P., K.D.V., C.P.D., J.-M.L.), Department of Emergency Medicine (P.P.), and School of Medicine (A.L.F., G.K., N.K., J.-M.L., R.P., K.D.V., C.P.D., J.-M.L., A.M.S., P.P.), Washington University, St. Louis, MO; and Emergency Department, Barnes-Jewish Hospital, St. Louis, MO (J.W.)
| | - Amirali Modir Shanechi
- From the Biomedical Research Imaging Center and Departments of Radiology (H.A., Y.C., W.L.), Biostatistics (H.Z.), and Neurology (W.J.P., W.L.), University of North Carolina at Chapel Hill; Department of Neurology (A.L.F., G.K., N.K., J.-M.L.), Department of Radiology (R.P., K.D.V., C.P.D., J.-M.L.), Department of Emergency Medicine (P.P.), and School of Medicine (A.L.F., G.K., N.K., J.-M.L., R.P., K.D.V., C.P.D., J.-M.L., A.M.S., P.P.), Washington University, St. Louis, MO; and Emergency Department, Barnes-Jewish Hospital, St. Louis, MO (J.W.)
| | - Naim Khoury
- From the Biomedical Research Imaging Center and Departments of Radiology (H.A., Y.C., W.L.), Biostatistics (H.Z.), and Neurology (W.J.P., W.L.), University of North Carolina at Chapel Hill; Department of Neurology (A.L.F., G.K., N.K., J.-M.L.), Department of Radiology (R.P., K.D.V., C.P.D., J.-M.L.), Department of Emergency Medicine (P.P.), and School of Medicine (A.L.F., G.K., N.K., J.-M.L., R.P., K.D.V., C.P.D., J.-M.L., A.M.S., P.P.), Washington University, St. Louis, MO; and Emergency Department, Barnes-Jewish Hospital, St. Louis, MO (J.W.)
| | - Katie D Vo
- From the Biomedical Research Imaging Center and Departments of Radiology (H.A., Y.C., W.L.), Biostatistics (H.Z.), and Neurology (W.J.P., W.L.), University of North Carolina at Chapel Hill; Department of Neurology (A.L.F., G.K., N.K., J.-M.L.), Department of Radiology (R.P., K.D.V., C.P.D., J.-M.L.), Department of Emergency Medicine (P.P.), and School of Medicine (A.L.F., G.K., N.K., J.-M.L., R.P., K.D.V., C.P.D., J.-M.L., A.M.S., P.P.), Washington University, St. Louis, MO; and Emergency Department, Barnes-Jewish Hospital, St. Louis, MO (J.W.)
| | - Jennifer Williams
- From the Biomedical Research Imaging Center and Departments of Radiology (H.A., Y.C., W.L.), Biostatistics (H.Z.), and Neurology (W.J.P., W.L.), University of North Carolina at Chapel Hill; Department of Neurology (A.L.F., G.K., N.K., J.-M.L.), Department of Radiology (R.P., K.D.V., C.P.D., J.-M.L.), Department of Emergency Medicine (P.P.), and School of Medicine (A.L.F., G.K., N.K., J.-M.L., R.P., K.D.V., C.P.D., J.-M.L., A.M.S., P.P.), Washington University, St. Louis, MO; and Emergency Department, Barnes-Jewish Hospital, St. Louis, MO (J.W.)
| | - Colin P Derdeyn
- From the Biomedical Research Imaging Center and Departments of Radiology (H.A., Y.C., W.L.), Biostatistics (H.Z.), and Neurology (W.J.P., W.L.), University of North Carolina at Chapel Hill; Department of Neurology (A.L.F., G.K., N.K., J.-M.L.), Department of Radiology (R.P., K.D.V., C.P.D., J.-M.L.), Department of Emergency Medicine (P.P.), and School of Medicine (A.L.F., G.K., N.K., J.-M.L., R.P., K.D.V., C.P.D., J.-M.L., A.M.S., P.P.), Washington University, St. Louis, MO; and Emergency Department, Barnes-Jewish Hospital, St. Louis, MO (J.W.)
| | - Michael N Diringer
- From the Biomedical Research Imaging Center and Departments of Radiology (H.A., Y.C., W.L.), Biostatistics (H.Z.), and Neurology (W.J.P., W.L.), University of North Carolina at Chapel Hill; Department of Neurology (A.L.F., G.K., N.K., J.-M.L.), Department of Radiology (R.P., K.D.V., C.P.D., J.-M.L.), Department of Emergency Medicine (P.P.), and School of Medicine (A.L.F., G.K., N.K., J.-M.L., R.P., K.D.V., C.P.D., J.-M.L., A.M.S., P.P.), Washington University, St. Louis, MO; and Emergency Department, Barnes-Jewish Hospital, St. Louis, MO (J.W.)
| | - Peter Panagos
- From the Biomedical Research Imaging Center and Departments of Radiology (H.A., Y.C., W.L.), Biostatistics (H.Z.), and Neurology (W.J.P., W.L.), University of North Carolina at Chapel Hill; Department of Neurology (A.L.F., G.K., N.K., J.-M.L.), Department of Radiology (R.P., K.D.V., C.P.D., J.-M.L.), Department of Emergency Medicine (P.P.), and School of Medicine (A.L.F., G.K., N.K., J.-M.L., R.P., K.D.V., C.P.D., J.-M.L., A.M.S., P.P.), Washington University, St. Louis, MO; and Emergency Department, Barnes-Jewish Hospital, St. Louis, MO (J.W.)
| | - William J Powers
- From the Biomedical Research Imaging Center and Departments of Radiology (H.A., Y.C., W.L.), Biostatistics (H.Z.), and Neurology (W.J.P., W.L.), University of North Carolina at Chapel Hill; Department of Neurology (A.L.F., G.K., N.K., J.-M.L.), Department of Radiology (R.P., K.D.V., C.P.D., J.-M.L.), Department of Emergency Medicine (P.P.), and School of Medicine (A.L.F., G.K., N.K., J.-M.L., R.P., K.D.V., C.P.D., J.-M.L., A.M.S., P.P.), Washington University, St. Louis, MO; and Emergency Department, Barnes-Jewish Hospital, St. Louis, MO (J.W.)
| | - Jin-Moo Lee
- From the Biomedical Research Imaging Center and Departments of Radiology (H.A., Y.C., W.L.), Biostatistics (H.Z.), and Neurology (W.J.P., W.L.), University of North Carolina at Chapel Hill; Department of Neurology (A.L.F., G.K., N.K., J.-M.L.), Department of Radiology (R.P., K.D.V., C.P.D., J.-M.L.), Department of Emergency Medicine (P.P.), and School of Medicine (A.L.F., G.K., N.K., J.-M.L., R.P., K.D.V., C.P.D., J.-M.L., A.M.S., P.P.), Washington University, St. Louis, MO; and Emergency Department, Barnes-Jewish Hospital, St. Louis, MO (J.W.).
| | - Weili Lin
- From the Biomedical Research Imaging Center and Departments of Radiology (H.A., Y.C., W.L.), Biostatistics (H.Z.), and Neurology (W.J.P., W.L.), University of North Carolina at Chapel Hill; Department of Neurology (A.L.F., G.K., N.K., J.-M.L.), Department of Radiology (R.P., K.D.V., C.P.D., J.-M.L.), Department of Emergency Medicine (P.P.), and School of Medicine (A.L.F., G.K., N.K., J.-M.L., R.P., K.D.V., C.P.D., J.-M.L., A.M.S., P.P.), Washington University, St. Louis, MO; and Emergency Department, Barnes-Jewish Hospital, St. Louis, MO (J.W.).
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Menon BK, d'Esterre CD, Qazi EM, Almekhlafi M, Hahn L, Demchuk AM, Goyal M. Multiphase CT Angiography: A New Tool for the Imaging Triage of Patients with Acute Ischemic Stroke. Radiology 2015; 275:510-20. [PMID: 25633505 DOI: 10.1148/radiol.15142256] [Citation(s) in RCA: 440] [Impact Index Per Article: 48.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To describe the use of an imaging selection tool, multiphase computed tomographic (CT) angiography, in patients with acute ischemic stroke (AIS) and to demonstrate its interrater reliability and ability to help determine clinical outcome. MATERIALS AND METHODS The local ethics board approved this study. Data are from the pilot phase of PRoveIT, a prospective observational study analyzing utility of multimodal imaging in the triage of patients with AIS. Patients underwent baseline unenhanced CT, single-phase CT angiography of the head and neck, multiphase CT angiography, and perfusion CT. Multiphase CT angiography generates time-resolved images of pial arteries. Pial arterial filling was scored on a six-point ordinal scale, and interrater reliability was tested. Clinical outcomes included a 50% or greater decrease in National Institutes of Health Stroke Scale (NIHSS) over 24 hours and 90-day modified Rankin Scale (mRS) score of 0-2. The ability to predict clinical outcomes was compared between single-phase CT angiography, multiphase CT angiography, and perfusion CT by using receiver operating curve analysis, Akaike information criterion (AIC), and Bayesian information criterion (BIC). RESULTS A total of 147 patients were included. Interrater reliability for multiphase CT angiography is excellent (n = 30, κ = 0.81, P < .001). At receiver operating characteristic curve analysis, the ability to predict clinical outcome is modest (C statistic = 0.56, 95% confidence interval [CI]: 0.52, 0.63 for ≥50% decrease in NIHSS over 24 hours; C statistic = 0.6, 95% CI: 0.53, 0.68 for 90-day mRS score of 0-2) but better than that of models using single-phase CT angiography and perfusion CT (P < .05 overall). With AIC and BIC, models that use multiphase CT angiography are better than models that use single-phase CT angiography and perfusion CT for a decrease of 50% or more in NIHSS over 24 hours (AIC = 166, BIC = 171.7; values were lowest for multiphase CT angiography) and a 90-day mRS score of 0-2 (AIC = 132.1, BIC = 137.4; values were lowest for multiphase CT angiography). CONCLUSION Multiphase CT angiography is a reliable tool for imaging selection in patients with AIS.
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Affiliation(s)
- Bijoy K Menon
- From the Calgary Stroke Program, Department of Clinical Neurosciences (B.K.M., C.D.d.E., E.M.Q., M.A., A.M.D., M.G.), Department of Radiology (B.K.M., C.D.d.E., M.A., L.H., A.M.D., M.G.), Department of Community Health Sciences (B.K.M.), Hotchkiss Brain Institute (B.K.M., A.M.D., M.G.); and Seaman Family MR Research Centre, Foothills Medical Centre (B.K.M., C.D.d.E., A.M.D., M.G.), University of Calgary, 1403-29th St NW, Calgary, AB, Canada T2N 2T9
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Wheeler HM, Mlynash M, Inoue M, Tipirnini A, Liggins J, Bammer R, Lansberg MG, Kemp S, Zaharchuk G, Straka M, Albers GW. The growth rate of early DWI lesions is highly variable and associated with penumbral salvage and clinical outcomes following endovascular reperfusion. Int J Stroke 2015; 10:723-9. [PMID: 25580662 DOI: 10.1111/ijs.12436] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Accepted: 10/29/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND The degree of variability in the rate of early diffusion-weighted imaging expansion in acute stroke has not been well characterized. AIM We hypothesized that patients with slowly expanding diffusion-weighted imaging lesions would have more penumbral salvage and better clinical outcomes following endovascular reperfusion than patients with rapidly expanding diffusion-weighted imaging lesions. METHODS In the first part of this substudy of DEFUSE 2, growth curves were constructed for patients with >90% reperfusion and <10% reperfusion. Next, the initial growth rate was determined in all patients with a clearly established time of symptom onset, assuming a lesion volume of 0 ml just prior to symptom onset. Patients who achieved reperfusion (>50% reduction in perfusion-weighted imaging after endovascular therapy) were categorized into tertiles according to their initial diffusion-weighted imaging growth rates. For each tertile, penumbral salvage [comparison of final volume to the volume of perfusion-weighted imaging (Tmax > 6 s)/diffusion-weighted imaging mismatch prior to endovascular therapy], favorable clinical response (National Institutes of Health Stroke Scale improvement of ≥8 points or 0-1 at 30 days), and good functional outcome (90-day modified Rankin score of ≤2) were calculated. A multivariate model assessed whether infarct growth rates were an independent predictor of clinical outcomes. RESULTS Sixty-five patients were eligible for this study; the median initial growth rate was 3·1 ml/h (interquartile range 0·7-10·7). Target mismatch patients (n = 42) had initial growth rates that were significantly slower than the growth rates in malignant profile (n = 9 patients, P < 0·001). In patients who achieved reperfusion (n = 38), slower early diffusion-weighted imaging growth rates were associated with better clinical outcomes (P < 0·05) and a trend toward more penumbral salvage (n = 31, P = 0·103). A multivariate model demonstrated that initial diffusion-weighted imaging growth rate was an independent predictor of achieving a 90-day modified Rankin score of ≤2. CONCLUSIONS The growth rate of early diffusion-weighted imaging lesions in acute stroke patients is highly variable; malignant profile patients have higher growth rates than patients with target mismatch. A slower rate of early diffusion-weighted imaging growth is associated with a greater degree of penumbral salvage and improved clinical outcomes following endovascular reperfusion.
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Affiliation(s)
- Hayley M Wheeler
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Mlynash
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Manabu Inoue
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Aaryani Tipirnini
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
| | - John Liggins
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Roland Bammer
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Maarten G Lansberg
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Stephanie Kemp
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Greg Zaharchuk
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Matus Straka
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Gregory W Albers
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
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Translational Stroke Research: Where Have We Been and Where are We Going? Interviewing Dr. Marc Fisher (editor of Stroke). Can J Neurol Sci 2014; 42:2-6. [PMID: 25511193 DOI: 10.1017/cjn.2014.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Zhang S, Tang H, Yu YN, Yan SQ, Parsons MW, Lou M. Optimal magnetic resonance perfusion thresholds identifying ischemic penumbra and infarct core: a Chinese population-based study. CNS Neurosci Ther 2014; 21:289-95. [PMID: 25476071 DOI: 10.1111/cns.12367] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 10/30/2014] [Accepted: 11/01/2014] [Indexed: 12/26/2022] Open
Abstract
AIMS To validate whether the optimal magnetic resonance perfusion (MRP) thresholds for ischemic penumbra and infarct core, between voxel and volume-based analysis, are varied greatly among Chinese acute ischemic stroke patients. MATERIALS AND METHODS Acute ischemic stroke patients receiving intravenous thrombolysis within 6 h of onset that obtained acute and 24-h MRP were reviewed. Patients with either no reperfusion (<30% reperfusion at 24 h) or successful reperfusion (>70% reperfusion at 24 h) were enrolled to investigate the ischemic penumbra and infarct core, respectively. The final infarct was assessed on 24-h diffusion-weighted imaging (DWI), which was retrospectively matched to the baseline perfusion-weighted imaging (PWI) images by volume or voxel-based analysis. The optimal thresholds that determined by each approach were compared. RESULTS From June 2009 to Jan 2014, of 50 patients enrolled, 19 patients achieved no reperfusion, and 20 patients reperfused at 24 h. In patients with no reperfusion, Tmax > 6 seconds was proved of the best agreement with the final infarct in both volumetric analysis (ratio: 1.05, 95% limits of agreement:-0.23 to 2.33, P < 0.001) and voxel-by-voxel analysis (sensitivity: 72.3%, specificity: 74.3%). In patients with reperfusion, rMTT>225% (ratio:2.4, 95% limits of agreement: -6.5 to 11.4, P < 0.001) was found of the best volumetric agreement with the final infarct, while Tmax > 5.6 seconds (sensitivity: 76.8%, specificity: 70.3%) performed most accurately in voxel-based analysis. CONCLUSION Among Chinese acute stroke patients, volume of Tmax >6 seconds may precisely target ischemic penumbra tissue as good as voxel-based analysis performed, albeit no concordant MRP parameter is found to accurately predict infarct core because reperfusion occurred within 24 h after thrombolysis fails to restrain the infarct growth.
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Affiliation(s)
- Sheng Zhang
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
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Faigle R, Wozniak AW, Marsh EB, Llinas RH, Urrutia VC. Infarct volume predicts critical care needs in stroke patients treated with intravenous thrombolysis. Neuroradiology 2014; 57:171-8. [PMID: 25344632 DOI: 10.1007/s00234-014-1453-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 10/06/2014] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Patients receiving intravenous thrombolysis with recombinant tissue plasminogen activator (IVT) for ischemic stroke are monitored in an intensive care unit (ICU) or a comparable unit capable of ICU interventions due to the high frequency of standardized neurological exams and vital sign checks. The present study evaluates quantitative infarct volume on early post-IVT MRI as a predictor of critical care needs and aims to identify patients who may not require resource intense monitoring. METHODS We identified 46 patients who underwent MRI within 6 h of IVT. Infarct volume was measured using semiautomated software. Logistic regression and receiver operating characteristics (ROC) analysis were used to determine factors associated with ICU needs. RESULTS Infarct volume was an independent predictor of ICU need after adjusting for age, sex, race, systolic blood pressure, NIH Stroke Scale (NIHSS), and coronary artery disease (odds ratio 1.031 per cm(3) increase in volume, 95% confidence interval [CI] 1.004-1.058, p = 0.024). The ROC curve with infarct volume alone achieved an area under the curve (AUC) of 0.766 (95% CI 0.605-0.927), while the AUC was 0.906 (95% CI 0.814-0.998) after adjusting for race, systolic blood pressure, and NIHSS. Maximum Youden index calculations identified an optimal infarct volume cut point of 6.8 cm(3) (sensitivity 75.0%, specificity 76.7%). Infarct volume greater than 3 cm(3) predicted need for critical care interventions with 81.3% sensitivity and 66.7% specificity. CONCLUSION Infarct volume may predict needs for ICU monitoring and interventions in stroke patients treated with IVT.
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Affiliation(s)
- Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 484, Baltimore, MD, 21287, USA,
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El-Koussy M, Schroth G, Brekenfeld C, Arnold M. Imaging of Acute Ischemic Stroke. Eur Neurol 2014; 72:309-16. [DOI: 10.1159/000362719] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 04/06/2014] [Indexed: 11/19/2022]
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Goyal M, Almekhlafi M, Menon B, Hill M, Fargen K, Parsons M, Bang OY, Siddiqui A, Andersson T, Mendes V, Davalos A, Turk A, Mocco J, Campbell B, Nogueira R, Gupta R, Murphy S, Jovin T, Khatri P, Miao Z, Demchuk A, Broderick JP, Saver J. Challenges of acute endovascular stroke trials. Stroke 2014; 45:3116-22. [PMID: 25169945 DOI: 10.1161/strokeaha.114.006288] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mayank Goyal
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.).
| | - Mohammed Almekhlafi
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.)
| | - Bijoy Menon
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.)
| | - Michael Hill
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.)
| | - Kyle Fargen
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.)
| | - Mark Parsons
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.)
| | - Oh Young Bang
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.)
| | - Adnan Siddiqui
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.)
| | - Tommy Andersson
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.)
| | - Vitor Mendes
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.)
| | - Antoni Davalos
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.)
| | - Aquilla Turk
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.)
| | - J Mocco
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.)
| | - Bruce Campbell
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.)
| | - Raul Nogueira
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.)
| | - Rishi Gupta
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.)
| | - Sean Murphy
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.)
| | - Tudor Jovin
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.)
| | - Pooja Khatri
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.)
| | - Zhongrong Miao
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.)
| | - Andrew Demchuk
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.)
| | - Joseph P Broderick
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.)
| | - Jeffrey Saver
- From the Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G., M.A., B.M., M.H., A.D.); Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (M.A.); Department of Neurosurgery, University of Florida, Gainesville (K.F.); Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, Australia (M.P.); Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea (O.Y.B.); Department of Neurosurgery, Buffalo, NY (A.S.); Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden (T.A.); Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (T.A.); Department of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland (V.M.); Department of Neurology, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain (A.D.); Department of Radiology, Medical University of South Carolina, Charleston (A.T.); Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN (J.M.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia (B.C.); Department of Neurology, Emory University, Atlanta, GA (R.N.); Wellstar Neurosurgery, Wellstar Neuroscience Institute, Wellstar Health System, Marietta, GA (R.G.); The Dublin Neurological Institute, Mater Misericordiae University Hospital, Dublin 7, Ireland (S.M.); Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (T.J.); Departments of Neurology and Radiology, University of Cincinnati, OH (P.K., J.P.B.); Department of Interventional Neuroradiology, Capital University, Beijing, China (Z.M.); and Department of Neurology, University of California, Los Angeles (J.S.)
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Penumbra pattern assessment in acute stroke patients: comparison of quantitative and non-quantitative methods in whole brain CT perfusion. PLoS One 2014; 9:e105413. [PMID: 25144396 PMCID: PMC4140765 DOI: 10.1371/journal.pone.0105413] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 07/21/2014] [Indexed: 11/19/2022] Open
Abstract
Background And Purpose While penumbra assessment has become an important part of the clinical decision making for acute stroke patients, there is a lack of studies measuring the reliability and reproducibility of defined assessment techniques in the clinical setting. Our aim was to determine reliability and reproducibility of different types of three-dimensional penumbra assessment methods in stroke patients who underwent whole brain CT perfusion imaging (WB-CTP). Materials And Methods We included 29 patients with a confirmed MCA infarction who underwent initial WB-CTP with a scan coverage of 100 mm in the z-axis. Two blinded and experienced readers assessed the flow-volume-mismatch twice and in two quantitative ways: Performing a volumetric mismatch analysis using OsiriX imaging software (MMVOL) and visual estimation of mismatch (MMEST). Complementarily, the semiquantitative Alberta Stroke Programme Early CT Score for CT perfusion was used to define mismatch (MMASPECTS). A favorable penumbral pattern was defined by a mismatch of ≥30% in combination with a cerebral blood flow deficit of ≤90 ml and an MMASPECTS score of ≥1, respectively. Inter- and intrareader agreement was determined by Kappa-values and ICCs. Results Overall, MMVOL showed considerably higher inter-/intrareader agreement (ICCs: 0.751/0.843) compared to MMEST (0.292/0.749). In the subgroup of large (≥50 mL) perfusion deficits, inter- and intrareader agreement of MMVOL was excellent (ICCs: 0.961/0.942), while MMEST interreader agreement was poor (0.415) and intrareader agreement was good (0.919). With respect to penumbra classification, MMVOL showed the highest agreement (interreader agreement: 25 agreements/4 non-agreements/κ: 0.595; intrareader agreement 27/2/0.833), followed by MMEST (22/7/0.471; 23/6/0.577), and MMASPECTS (18/11/0.133; 21/8/0.340). Conclusion The evaluated approach of volumetric mismatch assessment is superior to pure visual and ASPECTS penumbra pattern assessment in WB-CTP and helps to precisely judge the extent of 3-dimensional mismatch in acute stroke patients.
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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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Altered resting-state FMRI signals in acute stroke patients with ischemic penumbra. PLoS One 2014; 9:e105117. [PMID: 25121486 PMCID: PMC4133354 DOI: 10.1371/journal.pone.0105117] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 07/20/2014] [Indexed: 11/19/2022] Open
Abstract
Background Identifying the ischemic penumbra in acute stroke subjects is important for the clinical decision making process. The aim of this study was to use resting-state functional magnetic resonance singal (fMRI) to investigate the change in the amplitude of low-frequency fluctuations (ALFF) of these subjects in three different subsections of acute stroke regions: the infarct core tissue, the penumbra tissue, and the normal brain tissue. Another aim of this study was to test the feasilbility of consistently detecting the penumbra region of the brain through ALFF analysis. Methods Sixteen subjects with first-ever acute ischemic stroke were scanned within 27 hours of the onset of stroke using magnetic resonance imaging. The core of infarct regions and penumbra regions were determined by diffusion and perfusion-weighted imaging respectively. The ALFF were measured from resting-state blood oxygen level dependent (BOLD) fMRI scans. The averaged relative ALFF value of each regions were correlated with the time after the onset of stroke. Results Relative ALFF values were significantly different in the infarct core tissue, penumbra tissue and normal brain tissue. The locations of lesions in the ALFF maps did not match perfectly with diffusion and perfusion-weighted imagings; however, these maps provide a contrast that can be used to differentiate between penumbra brain tissue and normal brain tissue. Significant correlations between time after stroke onset and the relative ALFF values were present in the penumbra tissue but not in the infarct core and normal brain tissue. Conclusion Preliminary results from this study suggest that the ALFF reflects the underlying neurovascular activity and has a great potential to estimate the brain tissue viability after ischemia. Results also show that the ALFF may contribute to acute stroke imaging for thrombolytic or neuroprotective therapies.
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The ischemic penumbra: the location rather than the volume of recovery determines outcome. Curr Opin Neurol 2014; 27:35-41. [PMID: 24275722 DOI: 10.1097/wco.0000000000000047] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The clinical efficiency of thrombolysis is explained by the rescue of ischemic penumbra areas resulting from early arterial recanalization. The perfusion-diffusion weighted imaging mismatch is a commonly used MRI surrogate of the ischemic penumbra. However, the randomized trials testing the mismatch hypothesis have been negative. We will review the 'mismatch concept' and the recent studies that aim to localize the clinically eloquent areas of penumbra in middle cerebral artery (MCA) infarcts. RECENT FINDINGS New methods of image analysis have shown that poor outcomes after MCA stroke are related to infarction of an extremely well localized area of the periventricular white matter and adjacent internal capsule, where projections and association tracts are crossing and converging. This area almost colocalizes with the area salvaged by early arterial recanalization and is located extremely close to the initial ischemic core. SUMMARY The location of the area that correlates with disability in MCA stroke patients and that is salvaged by early arterial recanalization is in the same specific region of the deep white matter, close to the initial ischemic core. These findings may have important implications for designing new recanalization trials and support the importance of basic research on white-matter neuroprotection.
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Abstract
BACKGROUND Most strokes are due to blockage of an artery in the brain by a blood clot. Prompt treatment with thrombolytic drugs can restore blood flow before major brain damage has occurred and improve recovery after stroke in some people. Thrombolytic drugs, however, can also cause serious bleeding in the brain, which can be fatal. One drug, recombinant tissue plasminogen activator (rt-PA), is licensed for use in selected patients within 4.5 hours of stroke in Europe and within three hours in the USA. There is an upper age limit of 80 years in some countries, and a limitation to mainly non-severe stroke in others. Forty per cent more data are available since this review was last updated in 2009. OBJECTIVES To determine whether, and in what circumstances, thrombolytic therapy might be an effective and safe treatment for acute ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched November 2013), MEDLINE (1966 to November 2013) and EMBASE (1980 to November 2013). We also handsearched conference proceedings and journals, searched reference lists and contacted pharmaceutical companies and trialists. SELECTION CRITERIA Randomised trials of any thrombolytic agent compared with control in people with definite ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors applied the inclusion criteria, extracted data and assessed trial quality. We verified the extracted data with investigators of all major trials, obtaining additional unpublished data if available. MAIN RESULTS We included 27 trials, involving 10,187 participants, testing urokinase, streptokinase, rt-PA, recombinant pro-urokinase or desmoteplase. Four trials used intra-arterial administration, while the rest used the intravenous route. Most data come from trials that started treatment up to six hours after stroke. About 44% of the trials (about 70% of the participants) were testing intravenous rt-PA. In earlier studies very few of the participants (0.5%) were aged over 80 years; in this update, 16% of participants are over 80 years of age due to the inclusion of IST-3 (53% of participants in this trial were aged over 80 years). Trials published more recently utilised computerised randomisation, so there are less likely to be baseline imbalances than in previous versions of the review. More than 50% of trials fulfilled criteria for high-grade concealment; there were few losses to follow-up for the main outcomes.Thrombolytic therapy, mostly administered up to six hours after ischaemic stroke, significantly reduced the proportion of participants who were dead or dependent (modified Rankin 3 to 6) at three to six months after stroke (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.78 to 0.93). Thrombolytic therapy increased the risk of symptomatic intracranial haemorrhage (OR 3.75, 95% CI 3.11 to 4.51), early death (OR 1.69, 95% CI 1.44 to 1.98; 13 trials, 7458 participants) and death by three to six months after stroke (OR 1.18, 95% CI 1.06 to 1.30). Early death after thrombolysis was mostly attributable to intracranial haemorrhage. Treatment within three hours of stroke was more effective in reducing death or dependency (OR 0.66, 95% CI 0.56 to 0.79) without any increase in death (OR 0.99, 95% CI 0.82 to 1.21; 11 trials, 2187 participants). There was heterogeneity between the trials. Contemporaneous antithrombotic drugs increased the risk of death. Trials testing rt-PA showed a significant reduction in death or dependency with treatment up to six hours (OR 0.84, 95% CI 0.77 to 0.93, P = 0.0006; 8 trials, 6729 participants) with significant heterogeneity; treatment within three hours was more beneficial (OR 0.65, 95% CI 0.54 to 0.80, P < 0.0001; 6 trials, 1779 participants) without heterogeneity. Participants aged over 80 years benefited equally to those aged under 80 years, particularly if treated within three hours of stroke. AUTHORS' CONCLUSIONS Thrombolytic therapy given up to six hours after stroke reduces the proportion of dead or dependent people. Those treated within the first three hours derive substantially more benefit than with later treatment. This overall benefit was apparent despite an increase in symptomatic intracranial haemorrhage, deaths at seven to 10 days, and deaths at final follow-up (except for trials testing rt-PA, which had no effect on death at final follow-up). Further trials are needed to identify the latest time window, whether people with mild stroke benefit from thrombolysis, to find ways of reducing symptomatic intracranial haemorrhage and deaths, and to identify the environment in which thrombolysis may best be given in routine practice.
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Affiliation(s)
- Joanna M Wardlaw
- University of EdinburghCentre for Clinical Brain SciencesThe Chancellor's Building49 Little France CrescentEdinburghUKEH16 4SB
| | - Veronica Murray
- Danderyd HospitalDepartment of Clinical Sciences, Karolinska InstitutetStockholmSwedenSE‐182 88
| | - Eivind Berge
- Oslo University HospitalDepartment of Internal MedicineOsloNorwayNO‐0407
| | - Gregory J del Zoppo
- University of WashingtonDepartment of Medicine (Division of Hematology), Department of Neurology325 Ninth AvenueBox 359756SeattleWashingtonUSA98104
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Menon RG, Walsh EG, Twieg DB, Cantrell CG, Vakil P, Jonathan SV, Batjer HH, Carroll TJ. Snapshot MR technique to measure OEF using rapid frequency mapping. J Cereb Blood Flow Metab 2014; 34:1111-6. [PMID: 24756077 PMCID: PMC4083374 DOI: 10.1038/jcbfm.2014.59] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Accepted: 03/12/2014] [Indexed: 11/09/2022]
Abstract
Magnetic resonance (MR)-based oxygen extraction fraction (OEF) measurement techniques that use blood oxygen level-dependent (BOLD)-based approaches require the measurement of the R2' decay rate and deoxygenated blood volume to derive the local oxygen saturation in vivo. We describe here a novel approach to measure OEF using rapid local frequency mapping. By modeling the MR decay process in the static dephasing regime as two separate dissipative and oscillatory effects, we calculate the OEF from local frequencies measured across the brain by assuming that the biophysical mechanisms causing OEF-related frequency changes can be determined from the oscillatory effects. The Parameter Assessment by Retrieval from Signal Encoding (PARSE) technique was used to acquire the local frequency change maps. The PARSE images were taken on 11 normal volunteers, and 1 patient exhibiting hemodynamic stress. The mean MR-OEF in 11 normal subjects was 36.66±7.82%, in agreement with positron emission tomography (PET) literature. In regions of hemodynamic stress induced by vascular steal, OEF exhibits the predicted focal increases. These preliminary results show that it is possible to measure OEF using a rapid frequency mapping technique. Such a technique has numerous advantages including speed of acquisition, is noninvasive, and has sufficient spatial and temporal resolution.
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Affiliation(s)
- Rajiv G Menon
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Edward G Walsh
- Department of Neuroscience, Brown University, Providence, Rhode Island, USA
| | - Donald B Twieg
- Deparment of Biomedical Engineering, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Charles G Cantrell
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Parmede Vakil
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sumeeth V Jonathan
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Hunt H Batjer
- Department of Neurosurgery, UT Southwestern, Dallas, Texas, USA
| | - Timothy J Carroll
- 1] Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA [2] Department of Biomedical Engineering, Northwestern University, Chicago, IL, USA
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Mishra NK, Albers GW, Christensen S, Marks M, Hamilton S, Straka M, Liggins JTP, Kemp S, Mlynash M, Bammer R, Lansberg MG. Comparison of magnetic resonance imaging mismatch criteria to select patients for endovascular stroke therapy. Stroke 2014; 45:1369-74. [PMID: 24699054 DOI: 10.1161/strokeaha.114.004772] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE The Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution 2 (DEFUSE 2) study has shown that clinical response to endovascular reperfusion differs between patients with and without perfusion-diffusion (perfusion-weighted imaging-diffusion-weighted imaging, PWI-DWI) mismatch: patients with mismatch have a favorable clinical response to reperfusion, whereas patients without mismatch do not. This study examined whether alternative mismatch criteria can also differentiate patients according to their response to reperfusion. METHODS Patients from the DEFUSE 2 study were categorized according to vessel occlusion on magnetic resonance angiography (MRA) and DWI lesion volume criteria (MRA-DWI mismatch) and symptom severity and DWI criteria (clinical-DWI mismatch). Favorable clinical response was defined as an improvement of ≥8 points on the National Institutes of Health Stroke Scale (NIHSS) by day 30 or an NIHSS score of ≤1 at day 30. We assessed, for each set of criteria, whether the association between reperfusion and favorable clinical response differed according to mismatch status. RESULTS A differential response to reperfusion was observed between patients with and without MRA-DWI mismatch defined as an internal carotid artery or M1 occlusion and a DWI lesion<50 mL. Reperfusion was associated with good functional outcome in patients who met these MRA-DWI mismatch criteria (odds ratio [OR], 8.5; 95% confidence interval [CI], 2.3-31.3), whereas no association was observed in patients who did not meet these criteria (OR, 0.5; 95% CI, 0.08-3.1; P for difference between the odds, 0.01). No differential response to reperfusion was observed with other variations of the MRA-DWI or clinical-DWI mismatch criteria. CONCLUSIONS The MRA-DWI mismatch is a promising alternative to DEFUSE 2's PWI-DWI mismatch for patient selection in endovascular stroke trials.
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Affiliation(s)
- Nishant K Mishra
- From the Department of Neurology, Stanford Stroke Center, Palo Alto, CA (N.K.M., G.W.A., S.C., S.H., M.S., J.T.P.L., S.K., M. Mlynash, R.B., M.G.L.); and Department of Radiology, Stanford University Medical Center, Palo Alto, CA (M. Marks, R.B.)
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Jeon JS, Sheen SH, Kim HC. Re-endovascular recanalization for acute middle cerebral artery reocclusion after surgical embolectomy. J Neurointerv Surg 2014; 6:e24. [PMID: 23632243 DOI: 10.1136/neurintsurg-2012-010646.rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A 62-year-old woman with atrial fibrillation underwent burr hole trephination for a chronic subdural hematoma. Two days later the patient suddenly presented with motor dysphasia and slightly decreased motor power. Time of flight MR angiography revealed distal M1 occlusion without diffusion restriction. Stent-assisted mechanical thrombectomy was attempted but failed. Post-procedure MRI illustrated a small area of diffusion restriction within the peri-insular and parietal areas. Immediate surgical embolectomy was performed but reocclusion of M1 was documented in the postoperative angiography. Stent-assisted revascularization with a Solitaire stent was conducted and immediate restoration of blood flow was observed. The patient's motor weakness and motor dysphasia recovered fully. Re-endovascular intervention can be beneficial in selected patients for acute middle cerebral artery reocclusion after surgical embolectomy when endovascular thrombectomy fails.
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Affiliation(s)
- Jin Sue Jeon
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
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Marks MP, Lansberg MG, Mlynash M, Kemp S, McTaggart RA, Zaharchuk G, Bammer R, Albers GW. Angiographic outcome of endovascular stroke therapy correlated with MR findings, infarct growth, and clinical outcome in the DEFUSE 2 trial. Int J Stroke 2014; 9:860-5. [PMID: 24684804 DOI: 10.1111/ijs.12271] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 12/16/2013] [Indexed: 01/19/2023]
Abstract
BACKGROUND DEFUSE 2 demonstrated that patients with magnetic resonance imaging mismatch had a favorable clinical response to tissue reperfusion assessed by magnetic resonance imaging. This study reports the endovascular results and correlates angiographic reperfusion with clinical and imaging outcomes. METHODS Prospectively enrolled ischemic stroke patients underwent baseline magnetic resonance imaging and started endovascular therapy within 12 h of onset. Patients were classified as either target mismatch or no target mismatch using magnetic resonance imaging. The pre- and postprocedure angiogram was evaluated to determine thrombolysis in cerebral infarction scores. Favorable clinical response was determined at day 30, and good functional outcome was defined as a modified Rankin Scale 0-2 at day 90. RESULTS One-hundred patients had attempted endovascular treatment. At procedure end, 23% were thrombolysis in cerebral infarction 0-1, 31% thrombolysis in cerebral infarction 2A, 28% thrombolysis in cerebral infarction 2B, and 18% thrombolysis in cerebral infarction 3. More favorable thrombolysis in cerebral infarction-reperfusion scores were associated with greater magnetic resonance imaging reperfusion (P<0·001). thrombolysis in cerebral infarction scores correlated with 30-day favorable clinical response (P=0·041) and 90-day modified Rankin Scale 0-2 (P=0·008). These correlations were significant for target mismatch patients at 30 days (P=0·034) and 90 days (P=0·003). Infarct growth was strongly associated with poorer thrombolysis in cerebral infarction scores in target mismatch patients (P<0·001). Patients with thrombolysis in cerebral infarctionnfarction 2A reperfusion had less magnetic resonance imaging reperfusion (P=0·004) and poorer clinical outcome at 90 days (P=0·01) compared with thrombolysis in cerebral infarction 2B-3 patients. CONCLUSION Thrombolysis in cerebral infarction reperfusion following endovascular therapy for ischemic stroke is highly correlated with magnetic resonance imaging reperfusion, infarct growth, and clinical outcome.
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Affiliation(s)
- Michael P Marks
- Stanford Stroke Center, Stanford University School of Medicine, Palo Alto, CA, USA
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Madai VI, Galinovic I, Grittner U, Zaro-Weber O, Schneider A, Martin SZ, Samson-Himmelstjerna FCV, Stengl KL, Mutke MA, Moeller-Hartmann W, Ebinger M, Fiebach JB, Sobesky J. DWI intensity values predict FLAIR lesions in acute ischemic stroke. PLoS One 2014; 9:e92295. [PMID: 24658092 PMCID: PMC3962388 DOI: 10.1371/journal.pone.0092295] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 02/21/2014] [Indexed: 12/03/2022] Open
Abstract
Background and Purpose In acute stroke, the DWI-FLAIR mismatch allows for the allocation of patients to the thrombolysis window (<4.5 hours). FLAIR-lesions, however, may be challenging to assess. In comparison, DWI may be a useful bio-marker owing to high lesion contrast. We investigated the performance of a relative DWI signal intensity (rSI) threshold to predict the presence of FLAIR-lesions in acute stroke and analyzed its association with time-from-stroke-onset. Methods In a retrospective, dual-center MR-imaging study we included patients with acute stroke and time-from-stroke-onset ≤12 hours (group A: n = 49, 1.5T; group B: n = 48, 3T). DW- and FLAIR-images were coregistered. The largest lesion extent in DWI defined the slice for further analysis. FLAIR-lesions were identified by 3 raters, delineated as regions-of-interest (ROIs) and copied on the DW-images. Circular ROIs were placed within the DWI-lesion and labeled according to the FLAIR-pattern (FLAIR+ or FLAIR−). ROI-values were normalized to the unaffected hemisphere. Adjusted and nonadjusted receiver-operating-characteristics (ROC) curve analysis on patient level was performed to analyze the ability of a DWI- and ADC-rSI threshold to predict the presence of FLAIR-lesions. Spearman correlation and adjusted linear regression analysis was performed to assess the relationship between DWI-intensity and time-from-stroke-onset. Results DWI-rSI performed well in predicting lesions in FLAIR-imaging (mean area under the curve (AUC): group A: 0.84; group B: 0.85). An optimal mean DWI-rSI threshold was identified (A: 162%; B: 161%). ADC-maps performed worse (mean AUC: A: 0.58; B: 0.77). Adjusted regression models confirmed the superior performance of DWI-rSI. Correlation coefficents and linear regression showed a good association with time-from-stroke-onset for DWI-rSI, but not for ADC-rSI. Conclusion An easily assessable DWI-rSI threshold identifies the presence of lesions in FLAIR-imaging with good accuracy and is associated with time-from-stroke-onset in acute stroke. This finding underlines the potential of a DWI-rSI threshold as a marker of lesion age.
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Affiliation(s)
- Vince I. Madai
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
- Department of Neurology, Charité-Universtitätsmedizin, Berlin, Germany
| | - Ivana Galinovic
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
| | - Ulrike Grittner
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
- Department for Biostatistics and Clinical Epidemiology, Charité-Universitätsmedizin, Berlin, Germany
| | - Olivier Zaro-Weber
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
- Max-Planck-Institute for Neurological Research, Cologne, Germany
| | - Alice Schneider
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
- Department for Biostatistics and Clinical Epidemiology, Charité-Universitätsmedizin, Berlin, Germany
| | - Steve Z. Martin
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
| | | | - Katharina L. Stengl
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
- Department of Neurology, Charité-Universtitätsmedizin, Berlin, Germany
| | - Matthias A. Mutke
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
- Department of Neurology, Charité-Universtitätsmedizin, Berlin, Germany
| | | | - Martin Ebinger
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
- Department of Neurology, Charité-Universtitätsmedizin, Berlin, Germany
| | - Jochen B. Fiebach
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
| | - Jan Sobesky
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
- Department of Neurology, Charité-Universtitätsmedizin, Berlin, Germany
- * E-mail:
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Abstract
Data drive the analyses of any ischemic stroke trial, culminating in the main results and potential next steps. The distinct purpose of a given trial, advancing a novel treatment or examining routine clinical practice, determines the nature of essential data elements. Information gathering for an effective trial depends on ample data, adequate infrastructure, and properly planned statistical analyses. This review highlights the fact that successful future trials will require appropriate expertise that extends far beyond these basic considerations in order to move from identification of basic risk factors that are associated with outcomes to knowledge of pathophysiology and causation of outcomes. Efficient and productive data collection by local and central sites must be complemented by expert core lab adjudications. Source data archiving, including complete DICOM imaging datasets or biological specimens, are needed to maximize the potential for study interpretation and financial investment. Standard terminology, such as common data elements and definitions, enhance study comparisons. Screening logs attest to generalizability of a study. Real-time data transmission and core lab evaluation will be critical to guide adaptive trial design. Despite the overwhelming focus on the intervention in a particular treatment trial, individual pathophysiology must be considered. Understanding individual subject characteristics is a tenet of the coming era of precision stroke care, where the course of a given patient and eventual outcome is paramount. This will require a new approach to data collection in clinical trials.
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137
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Palmer AM. The utility of biomarkers in CNS drug development. Drug Discov Today 2014; 19:201-3. [DOI: 10.1016/j.drudis.2013.11.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 11/20/2013] [Indexed: 12/14/2022]
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138
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Eilaghi A, d'Esterre CD, Lee TY, Jakubovic R, Brooks J, Liu RTK, Zhang L, Swartz RH, Aviv RI. Toward patient-tailored perfusion thresholds for prediction of stroke outcome. AJNR Am J Neuroradiol 2014; 35:472-7. [PMID: 24113471 DOI: 10.3174/ajnr.a3740] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Multiple patient-specific clinical and radiologic parameters impact traditional perfusion thresholds used to classify/determine tissue outcome. We sought to determine whether modified baseline perfusion thresholds calculated by integrating baseline perfusion and clinical factors better predict tissue fate and clinical outcome. MATERIALS AND METHODS CTP within 4.5 hours of acute anterior circulation stroke onset and 5- to 7-day MR imaging were performed for 203 patients with stroke, divided into derivation (n = 114) and validation (n = 89) data bases. Affected regions were operationally classified as infarct and noninfarct according to baseline CTP and follow-up FLAIR imaging. Perfusion thresholds were derived for each of the infarct and noninfarct regions, without and with transformation by baseline clinical and radiologic variables by using a general linear mixed model. Performance of transformed and nontransformed perfusion thresholds for tissue fate and 90-day clinical outcome prediction was then tested in the derivation data base. Reproducibility of models was verified by using bootstrapping and validated in an independent cohort. RESULTS Perfusion threshold transformation by clinical and radiologic baseline parameters significantly improved tissue fate prediction for both gray matter and white matter (P < .001). Transformed thresholds improved the 90-day outcome prediction for CBF and time-to-maximum (P < .001). Transformed relative CBF and absolute time-to-maximum values demonstrated maximal GM and WM accuracies in the derivation and validation cohorts (relative CBF GM: 91%, 86%; WM: 86%, 83%; absolute time-to-maximum 88%, 79%, and 80%, 76% respectively). CONCLUSIONS Transformation of baseline perfusion parameters by patient-specific clinical and radiologic parameters significantly improves the accuracy of tissue fate and clinical outcome prediction.
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Affiliation(s)
- A Eilaghi
- From the Robarts Research Institute (A.E., C.D.d., T.Y.L.), University of Western Ontario, London, Ontario, Canada
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139
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Marks MP, Lansberg MG, Mlynash M, Olivot JM, Straka M, Kemp S, McTaggart R, Inoue M, Zaharchuk G, Bammer R, Albers GW. Effect of collateral blood flow on patients undergoing endovascular therapy for acute ischemic stroke. Stroke 2014; 45:1035-9. [PMID: 24569816 DOI: 10.1161/strokeaha.113.004085] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Our aim was to determine the relationships between angiographic collaterals and diffusion/perfusion findings, subsequent infarct growth, and clinical outcome in patients undergoing endovascular therapy for ischemic stroke. METHODS Sixty patients with a thrombolysis in cerebral infarction (TICI) score of 0 or 1 and internal carotid artery/M1 occlusion at baseline were evaluated. A blinded reader assigned a collateral score using a previous 5-point scale, from 0 (no collateral flow) to 4 (complete/rapid collaterals to the entire ischemic territory). The analysis was dichotomized to poor flow (0-2) versus good flow (3-4). Collateral score was correlated with baseline National Institutes of Health Stroke Scale, diffusion-weighted imaging volume, perfusion-weighted imaging volume (Tmax ≥6 seconds), TICI reperfusion, infarct growth, and modified Rankin Scale score at day 90. RESULTS Collateral score correlated with baseline National Institutes of Health Stroke Scale (P=0.002) and median volume of tissue at Tmax ≥6 seconds (P=0.009). Twenty-nine percent of patients with poor collateral flow had TICI 2B-3 reperfusion versus 65.5% with good flow (P=0.009). Patients with poor collaterals who reperfused (TICI 2B-3) were more likely to have a good functional outcome (modified Rankin Scale score 0-2 at 90 days) compared with patients who did not reperfuse (odds ratio, 12; 95% confidence interval, 1.6-98). There was no difference in the rate of good functional outcome after reperfusion in patients with poor collaterals versus good collaterals (P=1.0). Patients with poor reperfusion (TICI 0-2a) showed a trend toward greater infarct growth if they had poor collaterals versus good collaterals (P=0.06). CONCLUSIONS Collaterals correlate with baseline National Institutes of Health Stroke Scale, perfusion-weighted imaging volume, and good reperfusion. However, target mismatch patients who reperfuse seem to have favorable outcomes at a similar rate, irrespective of the collateral score. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT01349946.
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Affiliation(s)
- Michael P Marks
- From Stanford Stroke Center, Stanford University School of Medicine, Palo Alto, CA
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140
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Dagonnier M, Howells DW, Donnan GA, Dewey HM. Recruitment to trials of late thrombolysis: lessons from the EXTEND study. J Clin Neurosci 2014; 21:1215-9. [PMID: 24583057 DOI: 10.1016/j.jocn.2013.10.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 10/25/2013] [Indexed: 10/25/2022]
Abstract
To increase the percentage of acute stroke patients benefiting from thrombolysis, the utility of expanding the time window of treatment beyond 4.5 hours after stroke onset needs to be investigated. We aimed to identify the target population and the challenges of recruitment of patients for the time window beyond 4.5 hours. Extending the time for Thrombolysis in Emergency Neurological Deficits (EXTEND), a multicentre randomised controlled trial testing the efficacy of thrombolytic therapy in patients with clinically significant ischaemic penumbra between 4.5 to 9 hours after stroke onset, was used as a model to evaluate inclusion and exclusion criteria for late thrombolysis trials. Data from all stroke patients admitted to Austin Health over a 1 year period were retrospectively analysed. Case notes were examined to determine potential trial eligibility. Of 556 patients assessed, 95 (17%) presented during the EXTEND time window. Sixty-seven of these (70.5%) were wake-up strokes (WUS) and 28 (29.5%) arrived between 4.5 and 9 hours after symptoms onset. At least one exclusion criterion was found for 78 (82%) of them. Hence, 17 (3%) patients arrived within an appropriate time frame for the study without any exclusion criteria. Most of these (13) arrived outside routine MRI hours. The number of patients recruited would have increased more than three-fold if imaging had been available 24 hours, 7 days a week. A significant proportion (17%) of ischaemic stroke patients presented between 4.5 and 9 hours after stroke onset. The majority of these were WUS. The major challenge identified for patient recruitment was imaging availability.
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Affiliation(s)
- Marie Dagonnier
- National Stroke Research Institute, The Florey Institute for Neurosciences and Mental Health, Melbourne Brain Centre, Austin Campus, 245 Burgundy Street, Heidelberg, VIC 3084, Australia; University of Melbourne, Melbourne, VIC, Australia.
| | - David W Howells
- National Stroke Research Institute, The Florey Institute for Neurosciences and Mental Health, Melbourne Brain Centre, Austin Campus, 245 Burgundy Street, Heidelberg, VIC 3084, Australia
| | - Geoffrey A Donnan
- National Stroke Research Institute, The Florey Institute for Neurosciences and Mental Health, Melbourne Brain Centre, Austin Campus, 245 Burgundy Street, Heidelberg, VIC 3084, Australia; University of Melbourne, Melbourne, VIC, Australia; Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Helen M Dewey
- National Stroke Research Institute, The Florey Institute for Neurosciences and Mental Health, Melbourne Brain Centre, Austin Campus, 245 Burgundy Street, Heidelberg, VIC 3084, Australia; University of Melbourne, Melbourne, VIC, Australia; Department of Neurology, Austin Health, Heidelberg, VIC, Australia
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141
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Stability of ischemic core volume during the initial hours of acute large vessel ischemic stroke in a subgroup of mechanically revascularized patients. Neuroradiology 2014; 56:325-32. [DOI: 10.1007/s00234-014-1329-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 01/15/2014] [Indexed: 10/25/2022]
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142
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Hoffmann A, Zhu G, Wintermark M. Advanced neuroimaging in stroke patients: prediction of tissue fate and hemorrhagic transformation. Expert Rev Cardiovasc Ther 2014; 10:515-24. [DOI: 10.1586/erc.12.30] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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143
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Manning NW, Campbell BCV, Oxley TJ, Chapot R. Acute ischemic stroke: time, penumbra, and reperfusion. Stroke 2014; 45:640-4. [PMID: 24399376 DOI: 10.1161/strokeaha.113.003798] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Nathan W Manning
- From the Florey Institute of Neuroscience and Mental Health (N.W.M., B.C.V.C., T.J.O.) and Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (B.C.V.C., T.J.O.), University of Melbourne, Parkville, Australia; and Department of Intracranial Endovascular Therapy, Alfried-Krupp Krankenhaus Hospital, Essen, Germany (R.C.)
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144
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Tsai YH, Yuan R, Huang YC, Yeh MY, Lin CP, Biswal BB. Disruption of brain connectivity in acute stroke patients with early impairment in consciousness. Front Psychol 2014; 4:956. [PMID: 24427147 PMCID: PMC3877750 DOI: 10.3389/fpsyg.2013.00956] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 12/04/2013] [Indexed: 11/13/2022] Open
Abstract
Impairment in consciousness is common in acute stroke patients and is correlated with the clinical outcome after stroke. The underlying mechanism is not completely understood, with little known about brain activity and connectivity changes in acute stroke patients having impaired consciousness. In this study, we investigated changes in regional brain activity and brain networks of consciousness impaired stroke patients, as well as the amplitude of spontaneous low frequency fluctuation (ALFF) of each time series. Regional homogeneity (ReHo) of each voxel was measured, and resting state network analysis was consequently conducted. Results from this study demonstrate that, compared to normal subjects, the intensities of ALFF and ReHo, as well as the strength of the default mode network (DMN) connectivity, were significantly decreased in the precuneus and posterior cingulate cortex regions among stroke patients with impaired consciousness. Furthermore, the strength of the DMN was highly correlated with differences in the Glasgow Coma Scale (GCS) scores between the onset time and the scanning time. Results from this study suggest that the resting state fMRI is a feasible tool for the evaluation of acute stroke patients with an early impairment of consciousness. The detailed mechanisms, implications of these brain activities and networks exhibiting changes will require further investigation.
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Affiliation(s)
- Yuan-Hsiung Tsai
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University Taipei, Taiwan ; Department of Diagnostic Radiology, Chang Gung Memorial Hospital at Chiayi, College of Medicine and School of Medical Technology, Chang-Gung University Taoyuan, Taiwan
| | - Rui Yuan
- Department of Biomedical Engineering, New Jersey Institute of Technology Newark, NJ, USA
| | - Yen-Chu Huang
- Department of Neurology, Chang Gung Memorial Hospital at Chiayi, College of Medicine and School of Medical Technology, Chang-Gung University Taoyuan, Taiwan
| | - Mei-Yu Yeh
- Department of Diagnostic Radiology, Chang Gung Memorial Hospital at Chiayi, College of Medicine and School of Medical Technology, Chang-Gung University Taoyuan, Taiwan
| | - Ching-Po Lin
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University Taipei, Taiwan ; Institute of Neuroscience, National Yang-Ming University Taipei, Taiwan
| | - Bharat B Biswal
- Department of Biomedical Engineering, New Jersey Institute of Technology Newark, NJ, USA
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145
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Davis S, Donnan GA. Time Is Penumbra: Imaging, Selection and Outcome. Cerebrovasc Dis 2014; 38:59-72. [DOI: 10.1159/000365503] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 06/25/2014] [Indexed: 11/19/2022] Open
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146
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Liggins JTP, Yoo AJ, Mishra NK, Wheeler HM, Straka M, Leslie-Mazwi TM, Chaudhry ZA, Kemp S, Mlynash M, Bammer R, Albers GW, Lansberg MG. A score based on age and DWI volume predicts poor outcome following endovascular treatment for acute ischemic stroke. Int J Stroke 2013; 10:705-9. [PMID: 24207136 DOI: 10.1111/ijs.12207] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 08/30/2013] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND AIMS The Houston Intra-Arterial Therapy score predicts poor functional outcome following endovascular treatment for acute ischemic stroke based on clinical variables. The present study sought to (a) create a predictive scoring system that included a neuroimaging variable and (b) determine if the scoring systems predict the clinical response to reperfusion. METHODS Separate datasets were used to derive (n = 110 from the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution 2 study) and validate (n = 125 from Massachusetts General Hospital) scoring systems that predict poor functional outcome, defined as a modified Rankin Scale score of 4-6 at 90 days. RESULTS Age (P < 0·001; β = 0·087) and diffusion-weighted imaging volume (P = 0·023; β = 0·025) were the independent predictors of poor functional outcome. The Stanford Age and Diffusion-Weighted Imaging score was created based on the patient's age (0-3 points) and diffusion-weighted imaging lesion volume (0-1 points). The percentage of patients with a poor functional outcome increased significantly with the number of points on the Stanford Age and Diffusion-Weighted Imaging score (P < 0·01 for trend). The area under the receiver operating characteristic curve for the Stanford Age and Diffusion-Weighted Imaging score was 0·82 in the derivation dataset. In the validation cohort, the area under the receiver operating characteristic curve was 0·69 for the Stanford Age and Diffusion-Weighted Imaging score and 0·66 for the Houston Intra-Arterial Therapy score (P = 0·45 for the difference). Reperfusion, but not the interactions between the prediction scores and reperfusion, were predictors of outcome (P > 0·5). CONCLUSIONS The Stanford Age and Diffusion-Weighted Imaging and Houston Intra-Arterial Therapy scores can be used to predict poor functional outcome following endovascular therapy with good accuracy. However, these scores do not predict the clinical response to reperfusion. This limits their utility as tools to select patients for acute stroke interventions.
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Affiliation(s)
- John T P Liggins
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University Medical Center, Stanford, CA, USA
| | - Albert J Yoo
- Department of Radiology, Division of Interventional Neuroradiology, Massachusetts General Hospital, Boston, MA, USA
| | - Nishant K Mishra
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University Medical Center, Stanford, CA, USA
| | - Hayley M Wheeler
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University Medical Center, Stanford, CA, USA
| | - Matus Straka
- Department of Radiology, Lucas Magnetic Resonance Spectroscopy and Imaging Center, Stanford University Medical Center, Stanford, CA, USA
| | - Thabele M Leslie-Mazwi
- Department of Radiology, Division of Interventional Neuroradiology, Massachusetts General Hospital, Boston, MA, USA
| | - Zeshan A Chaudhry
- Department of Radiology, Division of Interventional Neuroradiology, Massachusetts General Hospital, Boston, MA, USA
| | - Stephanie Kemp
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University Medical Center, Stanford, CA, USA
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University Medical Center, Stanford, CA, USA
| | - Roland Bammer
- Department of Radiology, Lucas Magnetic Resonance Spectroscopy and Imaging Center, Stanford University Medical Center, Stanford, CA, USA
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University Medical Center, Stanford, CA, USA
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University Medical Center, Stanford, CA, USA
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147
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Amemiya S, Kunimatsu A, Saito N, Ohtomo K. Cerebral hemodynamic impairment: assessment with resting-state functional MR imaging. Radiology 2013; 270:548-55. [PMID: 24072777 DOI: 10.1148/radiol.13130982] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To test the feasibility of noninvasive global assessment of cerebral hemodynamic impairment with use of resting-state blood oxygenation level-dependent functional magnetic resonance (MR) imaging. MATERIALS AND METHODS In this institutional review board-approved study, five patients with chronic hypoperfusion without neurologic impairment and six patients with acute stroke underwent 10-minute resting-state functional MR imaging and dynamic susceptibility-weighted contrast-enhanced perfusion MR imaging, which was considered the standard of reference. All patients gave informed consent. The temporal shift of low-frequency signal fluctuations in each voxel compared with the averaged whole brain or global mean signal at resting-state functional MR imaging and the delay in time to peak at dynamic susceptibility-weighted contrast-enhanced perfusion imaging were computed with voxel-wise analysis. The similarity of the temporal delay maps obtained with resting-state functional MR imaging and perfusion data, as well as the stability of the resting-state functional MR imaging measurement, were evaluated with the Dice similarity coefficient (DSC) and the two-tailed t test (random-effect analysis). RESULTS The brain tissue with normal perfusion at dynamic susceptibility-weighted contrast-enhanced imaging showed no delay to global mean signal at resting-state functional MR imaging, whereas areas of abnormal perfusion with delayed time to peak (3.4 seconds ± 2.1) showed a delay at resting-state functional MR imaging that was similar to the time to peak at dynamic susceptibility-weighted contrast-enhanced perfusion imaging, both in spatial coverage (mean DSC, 0.57 ± 0.16) and tendency (t = 5.1, P < .001). Resting-state functional MR imaging measurements were highly stable (mean DSC, 0.83 ± 0.12). CONCLUSION Resting-state functional MR imaging temporal-shift analysis can noninvasively demonstrate the extent and degree of perfusion delay in patients with hypoperfusion both with and without neurologic deficit.
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Affiliation(s)
- Shiori Amemiya
- From the Departments of Radiology (S.A., A.K., K.O.) and Neurosurgery (N.S.), Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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148
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Wardlaw JM, Muir KW, Macleod MJ, Weir C, McVerry F, Carpenter T, Shuler K, Thomas R, Acheampong P, Dani K, Murray A. Clinical relevance and practical implications of trials of perfusion and angiographic imaging in patients with acute ischaemic stroke: a multicentre cohort imaging study. J Neurol Neurosurg Psychiatry 2013; 84:1001-7. [PMID: 23644501 PMCID: PMC3756443 DOI: 10.1136/jnnp-2012-304807] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND In randomised trials testing treatments for acute ischaemic stroke, imaging markers of tissue reperfusion and arterial recanalisation may provide early response indicators. OBJECTIVE To determine the predictive value of structural, perfusion and angiographic imaging for early and late clinical outcomes and assess practicalities in three comprehensive stroke centres. METHODS We recruited patients with potentially disabling stroke in three stroke centres, performed magnetic resonance (MR) or CT, including perfusion and angiography imaging, within 6 h, at 72 h and 1 month after stroke. We assessed the National Institutes of Health Stroke Scale (NIHSS) score serially and functional outcome at 3 months, tested associations between clinical variables and structural imaging, several perfusion parameters and angiography. RESULTS Among 83 patients, median age 71 (maximum 89), median NIHSS 7 (range 1-30), 38 (46%) received alteplase, 41 (49%) had died or were dependent at 3 months. Most baseline imaging was CT (76%); follow-up was MR (79%) despite both being available acutely. At presentation, perfusion lesion size varied considerably between parameters (p<0.0001); 40 (48%) had arterial occlusion. Arterial occlusion and baseline perfusion lesion extent were both associated with baseline NIHSS (p<0.0001). Recanalisation by 72 h was associated with 1 month NIHSS (p=0.0007) and 3 month functional outcome (p=0.048), whereas tissue reperfusion, using even the best perfusion parameter, was not (p=0.11, p=0.08, respectively). CONCLUSION Early recanalisation on angiography appeared to predict clinical outcome more directly than did tissue reperfusion. Acute assessment with CT and follow-up with MR was practical and feasible, did not preclude image analysis, and would enhance trial recruitment and generalisability of results.
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Affiliation(s)
- Joanna M Wardlaw
- Division of Clinical Neurosciences, University of Edinburgh, Edinburgh, UK.
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149
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150
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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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