1
|
Zhang X, Liu Q, Guo L, Guo X, Zhou X, Lv S, Lin Y, Wang J. Insights into multilevel tissue-level collateral status using ColorViz maps from dual data sources in acute ischemic cerebrovascular diseases: A STARD-compliant retrospective study. Medicine (Baltimore) 2024; 103:e39787. [PMID: 39312348 PMCID: PMC11419551 DOI: 10.1097/md.0000000000039787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 08/30/2024] [Indexed: 09/25/2024] Open
Abstract
This study aims to explore the utility of ColorViz mapping from dual data sources for assessing arterial collateral circulation and predicting cerebral tissue-level collateral (TLC) in patients with acute ischemic cerebrovascular diseases. A retrospective study was conducted at a single center on a cohort of 79 patients diagnosed with acute ischemic cerebrovascular diseases between November 2021 and April 2022, who had undergone both multi-phase CT angiography (mCTA) and computed tomography perfusion (CTP). The quality of images and arterial collateral status depicted on ColorViz maps from dual data-sets (mCTA and CTP) were assessed using a "5-point scale" and a "10-point scale," respectively. The status of TLC was evaluated by analyzing multilevel hypoperfusion volume and the hypoperfusion intensity ratio (HIR). The Spearman correlation coefficient was employed to examine the association between arterial collateral status derived from dual data sources and TLC. Receiver operating characteristic curve analysis was used to determine the diagnostic efficacy in detecting large vessel occlusive acute ischemic stroke (LVO-AIS). The ColorViz maps derived from dual data sources facilitated comparable image quality, with over 95% of cases meeting diagnostic criteria, for the evaluation of arterial level collateral circulation. Patients with robust arterial collateral circulation, as determined by dual data sources, were more likely to exhibit favorable TLC status, as evidenced by reductions in hypoperfusion volume (Tmax > 4 seconds, Tmax > 6 seconds, Tmax > 8 seconds, and Tmax > 10 seconds, P < .05) and HIR (Tmax > 6 seconds/4 seconds, Tmax > 8 seconds/4 seconds, Tmax > 10 seconds/4 seconds, and Tmax > 8 seconds/6 seconds, P < .05). The sensitivity and specificity in detecting LVO-AIS was 60.00% and 97.73% for mCTA source maps, while 74.29% and 72.73% for CTP source maps (P > .05 based on De-Long test). In conclusion, this study indicates that ColorViz maps derived from both data sources are equally important in evaluating arterial collateral circulation and enhancing diagnostic efficiency in patients with LVO-AIS, as well as offering insights into the TLC status based on hypoperfusion volume and HIR.
Collapse
Affiliation(s)
- Xiaoxiao Zhang
- Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Xiamen Radiology Quality Control Center, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Qingyu Liu
- Department of Ultrasound, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Luxin Guo
- Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Xiaoxi Guo
- Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Xinhua Zhou
- Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Shaomao Lv
- Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Xiamen Radiology Quality Control Center, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Yu Lin
- Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Xiamen Radiology Quality Control Center, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Department of Radiology, The First Affiliated Hospital of Fujian Medical University, The First Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Jinan Wang
- Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Xiamen Radiology Quality Control Center, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| |
Collapse
|
2
|
Shourav MMI, Godasi RR, Anisetti B, English SW, Lyle MA, Huang JF, Meschia JF, Lin MP. Association between heart failure and cerebral collateral flow in large vessel occlusive ischemic stroke. J Stroke Cerebrovasc Dis 2024; 33:107999. [PMID: 39243832 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2024] [Revised: 08/21/2024] [Accepted: 09/04/2024] [Indexed: 09/09/2024] Open
Abstract
BACKGROUND Cerebral collateral circulation plays a crucial role in determining the extent of brain ischemia in large vessel occlusive (LVO) stroke. Heart failure (HF) is known to cause cerebral hypoperfusion, yet the relationship between HF and robustness of collateral flow has not been well described. METHODS Consecutive patients with middle cerebral and/or internal carotid LVO who underwent endovascular thrombectomy (EVT) between 2012 and 2020 were included. Single-phase head CTA prior to EVT was used to assess collateral status (poor <50 % filling; good ≥50 %). Classification of HF by left ventricular ejection fraction (LVEF) on echocardiogram was used where HF with reduced ejection fraction (HFrEF) had LVEF ≤40 %, HF with preserved EF (HFpEF) had LVEF ≥50 % with evidence of structural heart disease, and no HF had LVEF≥50 % without structural heart disease. Multivariable logistic regression analyses were performed to evaluate the association between HF and poor collaterals. RESULTS We identified 235 patients, mean age was 69 ± 15 years; initial NIHSS was 18 ± 7. Of these, 107 (45.5 %) had HF and 105 (44.7 %) had poor collaterals. Those with HF were likely to have poor collaterals compared to those without HF (56.1 % vs 35.2 %, P = 0.001). There was a dose-dependent relationship between EF and poor collaterals: adjusted odds of poor collaterals were 1.63 and 2.45 in HFpEF and HFrEF, compared to those without HF (trend P = .018). CONCLUSION Patients with HFrEF are more likely to have poor cerebral collaterals. Further study is needed to explore the pathomechanisms. Optimization of HF may improve cerebral collaterals and enhance EVT outcomes.
Collapse
Affiliation(s)
| | - Raja R Godasi
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, United States
| | - Bhrugun Anisetti
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, United States
| | - Stephen W English
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, United States
| | - Melissa A Lyle
- Department of Cardiology, Heart Failure and Transplant, Mayo Clinic, Jacksonville, FL, United States
| | - Josephine F Huang
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, United States
| | - James F Meschia
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, United States
| | - Michelle P Lin
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, United States.
| |
Collapse
|
3
|
Salim HA, Hamam O, Parilday G, Moustafa RA, Ghandour S, Rutgers M, Sharara M, Cho A, Mazumdar I, Radmard M, Shin C, Montes D, Malhotra A, Romero JM, Yedavalli V. Relative Cerebral Blood Flow as an Indirect Imaging Surrogate in Patients With Anterior Circulation Large Vessel Occlusion and Association of Baseline Characteristics With Poor Collateral Status. J Am Heart Assoc 2024; 13:e034581. [PMID: 39158542 DOI: 10.1161/jaha.124.034581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 07/15/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND In acute ischemic stroke (AIS), collateral status (CS) is an important predictor of favorable outcomes in patients with AIS. Among quantitative cerebral perfusion parameters, relative cerebral blood flow (rCBF) is considered an accurate perfusion-based indicator of CS. This study investigated the relationship between admission laboratory values, baseline characteristics, and CS as assessed by rCBF in patients with AIS-large vessel occlusion. METHODS AND RESULTS In this retrospective multicenter study, consecutive patients presenting with AIS secondary to anterior circulation large vessel occlusion who underwent pretreatment computed tomography perfusion were included. The computed tomography perfusion data processed by RAPID (IschemaView, Menlo Park, CA) generated the rCBF. Binary logistic regression models assessed the relationship between patients' baseline characteristics, admission laboratory values, and poor CS. The primary outcome measure was the presence of poor CS, which was defined as rCBF <38% at a lesion size ≥27 mL. Between January 2017 and September 2022, there were 221 consecutive patients with AIS-large vessel occlusion included in our study (mean age 67.0±15.8 years, 119 men [53.8%]). Logistic regression showed that male sex (odds ratio [OR], 2.98 [1.59-5.59]; P=0.001), chronic kidney disease (OR, 5.18 [2.44-11.0]; P<0.001), admission National Institutes of Health Stroke Scale score ≥12 (OR, 5.17 [2.36-11.36]; P<0.001), and systolic blood pressure <140 (OR, 2.00 [1.07-3.76]; P=0.030) were associated with poor CS. CONCLUSIONS Higher stroke severity on admission with National Institutes of Health Stroke Scale score ≥12, systolic blood pressure <140, chronic kidney disease, and male sex are statistically significantly associated with poor CS in patients with AIS due to anterior circulation large vessel occlusion as defined by rCBF <38%.
Collapse
Affiliation(s)
| | | | | | | | | | - Moustafa Rutgers
- Rutgers University School of Arts and Sciences New Brunswick NJ USA
| | | | - Andrew Cho
- Johns Hopkins University School of Medicine Baltimore MD USA
| | - Ishan Mazumdar
- Johns Hopkins University School of Medicine Baltimore MD USA
| | | | | | - Daniel Montes
- University of Colorado Anschutz Medical Campus Aurora CA USA
| | | | | | | |
Collapse
|
4
|
Chen Y, Wu J, Chen M, Zhu Y, Wang H, Cui T, Zhang S, Wang D. Association between metabolic syndrome and outcomes of large-artery atherosclerosis stroke treated with reperfusion therapy. J Stroke Cerebrovasc Dis 2024; 33:107927. [PMID: 39142610 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 08/06/2024] [Accepted: 08/09/2024] [Indexed: 08/16/2024] Open
Abstract
AIM We aimed to investigate the impact of metabolic syndrome (MetS) on the outcomes of stroke patients with large-artery atherosclerosis who underwent reperfusion therapy. METHODS A retrospective analysis was carried out on patients receiving reperfusion therapy for atherothrombotic stroke between January 2019 and May 2021. MetS was diagnosed according to the AHA/NHLBI criteria. The primary outcome was the composite outcome of disability (modified Rankin Scale [mRS] score 3-5), death or stroke recurrence within 3 months of stroke onset. Secondary outcomes included disability and death within 3 months as well as hemorrhagic transformation (HT) and symptomatic intracranial hemorrhage (sICH) within 24 hours after reperfusion treatment. The independent association of MetS with the above outcomes and the highly correlated components of MetS was examined using binary logistic regression analysis. RESULTS A total of 174 patients were enrolled. MetS patients had a higher proportion of the composite outcome (p = 0.012), disability (p = 0.029) and HT (p = 0.049) than those without MetS, except for death (p = 0.375) and sICH (p = 0.306). Following adjustments, MetS remained independently associated with the composite outcome (adjusted OR, 3.011 [95 %CI 1.372-6.604]; p = 0.006) and disability (adjusted OR, 2.727 [95 %CI 1.220-6.098]; p = 0.015), but not HT (adjusted OR, 1.872 [95 %CI 0.854-4.104]; p = 0.117). Hypertriglyceridemia was remarkedly associated with the composite outcome (adjusted OR, 9.746 [95 % CI 2.402-39.536]; p = 0.001) and disability (adjusted OR, 6.966 [95 % CI 1.889-25.692]; p = 0.004). CONCLUSION MetS is independently associated with an increased risk of composite outcome and disability in patients with large-artery atherosclerosis stroke receiving reperfusion therapy, and hypertriglyceridemia is the main component that drives the effect of MetS on outcomes.
Collapse
Affiliation(s)
- Yaqi Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China; Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, PR China.
| | - Jiongxing Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China; Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, PR China.
| | - Mingxi Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China; Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, PR China.
| | - Yuyi Zhu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China; Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, PR China.
| | - Huan Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China; Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, PR China.
| | - Ting Cui
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China; Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, PR China.
| | - Shihong Zhang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China; Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, PR China.
| | - Deren Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China; Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, PR China.
| |
Collapse
|
5
|
Sojak L, Toebak AM, Gallino C, Von Streng T, Rudin S, Kriemler LF, Zietz A, Wagner B, Gensicke H, Sutter R, Nickel CH, Katan M, Bonati LH, Psychogios M, Dittrich TD, De Marchis GM. Association between ischaemic stroke aetiology and leptomeningeal collateral status: a retrospective cohort study. Swiss Med Wkly 2024; 154:3584. [PMID: 39137358 DOI: 10.57187/s.3584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024] Open
Abstract
INTRODUCTION There is limited understanding of the pathomechanistic relationship between leptomeningeal collateral formation and ischaemic stroke aetiology. We aimed to assess the association of leptomeningeal collateral status and ischaemic stroke aetiology, using the widely recognised "Trial of Org 10172 in Acute Stroke Treatment" (TOAST) classification categorising strokes into five distinct aetiologies. METHODS Retrospective study of consecutively admitted adult ischaemic stroke patients at a Swiss stroke centre. Leptomeningeal collateral status was assessed on admission with single-phase CT-angiographies using a validated 4-point score. Patients were categorised into large-artery atherosclerosis (LAA), cardioembolic (CE), small-vessel disease (SVD) and cryptogenic (CG) according to the TOAST classification. We performed ordinal and binary (poor [collaterals filling ≤50% of the occluded territory] vs good [collaterals filling >50% of the occluded territory] collateralisation) logistic regression to evaluate the impact of TOAST aetiology on collateral status. RESULTS Among 191 patients, LAA patients had better collateral status compared to non-LAA aetiology (LAA: 2 vs CE: 2 vs SVD: 3 vs CG: 2, pLAA vs non-LAA = 0.04). In weighted multivariate logistic regression, LAA and SVD independently predicted better collateral status (binary models [adjusted odds ratio; aOR]: LAA: 3.72 [1.21-11.44] and SVD: 4.19 [1.21-14.52]; ordinal models [adjusted common odds ratio; acOR]: LAA: 2.26 [95% CI: 1.23-4.15] and SVD: 1.94 [1.03-3.66]), while CE predicted worse collateral status (binary models [aOR]: CE: 0.17 [0.07-0.41]; ordinal models [acOR]: CE: 0.24 [0.11-0.51]). CONCLUSION The aetiology of ischaemic stroke is associated with leptomeningeal collateral status on single-phase CT-angiography, with LAA and SVD predicting better and CE predicting worse collateral status.
Collapse
Affiliation(s)
- Lina Sojak
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Anna M Toebak
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Neurology and Stroke Center, Cantonal Hospital St Gallen, St Gallen, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Camilla Gallino
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Tennessee Von Streng
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Salome Rudin
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Lilian F Kriemler
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Clinic for Internal Medicine, Cantonal Hospital Schaffhausen, Schaffhausen, Switzerland
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Benjamin Wagner
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, Basel, Switzerland
| | - Raoul Sutter
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Department of Intensive Care Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Christian H Nickel
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Emergency Department, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Mira Katan
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Rheinfelden Rehabilitation Clinic, Rheinfelden, Switzerland
| | - Marios Psychogios
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Tolga D Dittrich
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Neurology and Stroke Center, Cantonal Hospital St Gallen, St Gallen, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Neurology and Stroke Center, Cantonal Hospital St Gallen, St Gallen, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| |
Collapse
|
6
|
Liebeskind DS, Luff MK, Bracard S, Guillemin F, Jahan R, Jovin TG, Majoie CBLM, Mitchell PJ, van der Lugt A, Menon BK, San Roman L, Campbell B, Muir KW, Hill MD, Dippel DWJ, Saver JL, Demchuk AM, Davalos A, White P, Brown SB, Goyal M. Collaterals at angiography guide clinical outcomes after endovascular stroke therapy in HERMES. J Neurointerv Surg 2024:jnis-2024-021808. [PMID: 38991735 DOI: 10.1136/jnis-2024-021808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 06/18/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Robust collateral circulation has been linked with better reperfusion and clinical outcomes. It remains unclear how individual assessments of collateral circulation may be translated into clinical practice. METHODS The pooled Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials (HERMES) angiography dataset was analyzed by a centralized, independent imaging core blinded to other clinical data. Conventional angiography was acquired immediately prior to endovascular therapy. Collaterals were graded with the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN) system and associated with baseline patient characteristics, reperfusion, and day 90 modified Rankin Score (mRS). Both 90-day all-cause mortality and day 90 mRS were modeled via multivariable logistic regression. RESULTS Angiography was available in 376/605 (62%) patients. Baseline ASPECTS (Alberta Stroke Program Early CT Score) (p=0.043), history of diabetes mellitus (p=0.048), site of occlusion (p<0.001), and degree of subsequent Thrombolysis in Cerebral Infarction (TICI) reperfusion (p<0.001) were associated with collateral grades. ASITN collateral grade was strongly associated with ordinal mRS from baseline to 90 days in an unadjusted analysis (p<0.001). Multivariable regression demonstrated that collateral status is a strong determinant of mRS outcome in the presence of other predictors (OR=1.37 per grade, 95% CI [1.05 to 1.74], p=0.018). By comparing ORs, 1 unit of ASITN was determined to be approximately equivalent to 4.5 points of NIHSS, 11 years of age, 1.5 points of ASPECTS, or 100 min less delay from onset to puncture, in terms of impact on mRS. CONCLUSIONS Individual collateral physiology may contribute significantly to reperfusion success and clinical outcomes after acute ischemic stroke. Building a consensus for the role of angiographic collateral assessment in the allocation of adjuvant reperfusion therapies may help galvanize a precision medicine approach in stroke.
Collapse
Affiliation(s)
- David S Liebeskind
- Neurology, University of California Los Angeles (UCLA), Los Angeles, California, USA
| | - Marie K Luff
- University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Serge Bracard
- Diagnostic and Interventional Neuroradiology, University of Lorraine, Nancy, France
| | | | - Reza Jahan
- Interventional Neuroradiology, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Tudor G Jovin
- Neurology, Cooper University Hospital, Camden, New Jersey, USA
| | - Charles B L M Majoie
- Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter J Mitchell
- Radiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Aad van der Lugt
- Radiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Bijoy K Menon
- Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada
| | - Luis San Roman
- Neurointerventional Department, Hospital Clinic, Barcelona, Spain
| | - Bruce Campbell
- Medicine and Neurology, Melbourne Brain Centre, The Royal Melbourne Hospital, Parkville, Missouri, Australia
| | - Keith W Muir
- School of Psychology and Neuroscience, University of Glasgow, Glasgow, UK
| | - Michael D Hill
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Clinical Neurosciences, Foothills Medical Centre, Calgary, Alberta, Canada
| | | | - Jeffrey L Saver
- Comprehensive Stroke Center and Neurology, David Geffen School of Medicine, Los Angeles, California, USA
| | - Andrew M Demchuk
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Clinical Neurosciences, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Antoni Davalos
- Neurology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Phil White
- Institute of Neuroscience, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Scott B Brown
- Altair Biostatistics, Mooresville, North Carolina, USA
| | - Mayank Goyal
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
7
|
Güney R, Potreck A, Neuberger U, Schmitt N, Purrucker J, Möhlenbruch MA, Bendszus M, Seker F. Association of Carotid Artery Disease with Collateralization and Infarct Growth in Patients with Acute Middle Cerebral Artery Occlusion. AJNR Am J Neuroradiol 2024; 45:574-580. [PMID: 38575322 PMCID: PMC11288550 DOI: 10.3174/ajnr.a8180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/11/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND AND PURPOSE Collaterals are important in large vessel occlusions (LVO), but the role of carotid artery disease (CAD) in this context remains unclear. This study aimed to investigate the impact of CAD on intracranial collateralization and infarct growth after thrombectomy in LVO. MATERIALS AND METHODS All patients who underwent thrombectomy due to M1 segment occlusion from 01/2015 to 12/2021 were retrospectively included. Internal carotid artery stenosis according to NASCET was assessed on the affected and nonaffected sides. Collaterals were assessed according to the Tan score. Infarct growth was quantified by comparing ASPECTS on follow-up imaging with baseline ASPECTS. RESULTS In total, 709 patients were included, 118 (16.6%) of whom presented with CAD (defined as severe stenosis ≥70% or occlusion ipsilaterally), with 42 cases (5.9%) being contralateral. Good collateralization (Tan 3) was present in 56.5% of the patients with ipsilateral CAD and 69.1% of the patients with contralateral CAD. The ipsilateral stenosis grade was an independent predictor of good collateral supply (adjusted OR: 1.01; NASCET point, 95% CI: 1.00-1.01; P = .009), whereas the contralateral stenosis grade was not (P = .34). Patients with ipsilateral stenosis of ≥70% showed less infarct growth (median ASPECTS decay: 1; IQR: 0-2) compared with patients with 0%-69% stenosis (median: 2; IQR: 1-3) (P = .005). However, baseline ASPECTS was significantly lower in patients with stenosis of 70%-100% (P < .001). The results of a multivariate analysis revealed that increasing ipsilateral stenosis grade (adjusted OR: 1.0; 95% CI: 0.99-1.00; P = .004) and good collateralization (adjusted OR: 0.5; 95% CI: 0.4-0.62; P < .001) were associated with less infarct growth. CONCLUSIONS CAD of the ipsilateral ICA is an independent predictor of good collateral supply. Patients with CAD tend to have larger baseline infarct size but less infarct growth.
Collapse
Affiliation(s)
- Resul Güney
- From the Departments of Neuroradiology (R.G., A.P., U.N., N.S., M.A.M., M.B., F.S.) Heidelberg University Hospital, Heidelberg, Germany
| | - Arne Potreck
- From the Departments of Neuroradiology (R.G., A.P., U.N., N.S., M.A.M., M.B., F.S.) Heidelberg University Hospital, Heidelberg, Germany
| | - Ulf Neuberger
- From the Departments of Neuroradiology (R.G., A.P., U.N., N.S., M.A.M., M.B., F.S.) Heidelberg University Hospital, Heidelberg, Germany
| | - Niclas Schmitt
- From the Departments of Neuroradiology (R.G., A.P., U.N., N.S., M.A.M., M.B., F.S.) Heidelberg University Hospital, Heidelberg, Germany
| | - Jan Purrucker
- Departments of Neurology (J.P.), Heidelberg University Hospital, Heidelberg, Germany
| | - Markus A Möhlenbruch
- From the Departments of Neuroradiology (R.G., A.P., U.N., N.S., M.A.M., M.B., F.S.) Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- From the Departments of Neuroradiology (R.G., A.P., U.N., N.S., M.A.M., M.B., F.S.) Heidelberg University Hospital, Heidelberg, Germany
| | - Fatih Seker
- From the Departments of Neuroradiology (R.G., A.P., U.N., N.S., M.A.M., M.B., F.S.) Heidelberg University Hospital, Heidelberg, Germany
| |
Collapse
|
8
|
Bandet MV, Winship IR. Aberrant cortical activity, functional connectivity, and neural assembly architecture after photothrombotic stroke in mice. eLife 2024; 12:RP90080. [PMID: 38687189 PMCID: PMC11060715 DOI: 10.7554/elife.90080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
Despite substantial progress in mapping the trajectory of network plasticity resulting from focal ischemic stroke, the extent and nature of changes in neuronal excitability and activity within the peri-infarct cortex of mice remains poorly defined. Most of the available data have been acquired from anesthetized animals, acute tissue slices, or infer changes in excitability from immunoassays on extracted tissue, and thus may not reflect cortical activity dynamics in the intact cortex of an awake animal. Here, in vivo two-photon calcium imaging in awake, behaving mice was used to longitudinally track cortical activity, network functional connectivity, and neural assembly architecture for 2 months following photothrombotic stroke targeting the forelimb somatosensory cortex. Sensorimotor recovery was tracked over the weeks following stroke, allowing us to relate network changes to behavior. Our data revealed spatially restricted but long-lasting alterations in somatosensory neural network function and connectivity. Specifically, we demonstrate significant and long-lasting disruptions in neural assembly architecture concurrent with a deficit in functional connectivity between individual neurons. Reductions in neuronal spiking in peri-infarct cortex were transient but predictive of impairment in skilled locomotion measured in the tapered beam task. Notably, altered neural networks were highly localized, with assembly architecture and neural connectivity relatively unaltered a short distance from the peri-infarct cortex, even in regions within 'remapped' forelimb functional representations identified using mesoscale imaging with anaesthetized preparations 8 weeks after stroke. Thus, using longitudinal two-photon microscopy in awake animals, these data show a complex spatiotemporal relationship between peri-infarct neuronal network function and behavioral recovery. Moreover, the data highlight an apparent disconnect between dramatic functional remapping identified using strong sensory stimulation in anaesthetized mice compared to more subtle and spatially restricted changes in individual neuron and local network function in awake mice during stroke recovery.
Collapse
Affiliation(s)
- Mischa Vance Bandet
- Neuroscience and Mental Health Institute, University of AlbertaEdmontonCanada
- Neurochemical Research Unit, University of AlbertaEdmontonCanada
- Department of Psychiatry, University of AlbertaEdmontonCanada
| | - Ian Robert Winship
- Neuroscience and Mental Health Institute, University of AlbertaEdmontonCanada
- Neurochemical Research Unit, University of AlbertaEdmontonCanada
- Department of Psychiatry, University of AlbertaEdmontonCanada
| |
Collapse
|
9
|
Lengyel B, Magyar-Stang R, Pál H, Debreczeni R, Sándor ÁD, Székely A, Gyürki D, Csippa B, István L, Kovács I, Sótonyi P, Mihály Z. Non-Invasive Tools in Perioperative Stroke Risk Assessment for Asymptomatic Carotid Artery Stenosis with a Focus on the Circle of Willis. J Clin Med 2024; 13:2487. [PMID: 38731014 PMCID: PMC11084304 DOI: 10.3390/jcm13092487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/17/2024] [Accepted: 04/20/2024] [Indexed: 05/13/2024] Open
Abstract
This review aims to explore advancements in perioperative ischemic stroke risk estimation for asymptomatic patients with significant carotid artery stenosis, focusing on Circle of Willis (CoW) morphology based on the CTA or MR diagnostic imaging in the current preoperative diagnostic algorithm. Functional transcranial Doppler (fTCD), near-infrared spectroscopy (NIRS), and optical coherence tomography angiography (OCTA) are discussed in the context of evaluating cerebrovascular reserve capacity and collateral vascular systems, particularly the CoW. These non-invasive diagnostic tools provide additional valuable insights into the cerebral perfusion status. They support biomedical modeling as the gold standard for the prediction of the potential impact of carotid artery stenosis on the hemodynamic changes of cerebral perfusion. Intraoperative risk assessment strategies, including selective shunting, are explored with a focus on CoW variations and their implications for perioperative ischemic stroke and cognitive function decline. By synthesizing these insights, this review underscores the potential of non-invasive diagnostic methods to support clinical decision making and improve asymptomatic patient outcomes by reducing the risk of perioperative ischemic neurological events and preventing further cognitive decline.
Collapse
Affiliation(s)
- Balázs Lengyel
- Department of Vascular and Endovascular Surgery, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (B.L.); (P.S.J.)
| | - Rita Magyar-Stang
- Department of Neurology, Semmelweis University, 1085 Budapest, Hungary; (R.M.-S.); (H.P.); (R.D.)
- Szentágothai Doctoral School of Neurosciences, Semmelweis University, 1085 Budapest, Hungary
| | - Hanga Pál
- Department of Neurology, Semmelweis University, 1085 Budapest, Hungary; (R.M.-S.); (H.P.); (R.D.)
- Szentágothai Doctoral School of Neurosciences, Semmelweis University, 1085 Budapest, Hungary
| | - Róbert Debreczeni
- Department of Neurology, Semmelweis University, 1085 Budapest, Hungary; (R.M.-S.); (H.P.); (R.D.)
- Szentágothai Doctoral School of Neurosciences, Semmelweis University, 1085 Budapest, Hungary
| | - Ágnes Dóra Sándor
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary; (Á.D.S.); (A.S.)
| | - Andrea Székely
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary; (Á.D.S.); (A.S.)
| | - Dániel Gyürki
- Department of Hydrodynamic Systems, Faculty of Mechanical Engineering, Budapest University of Technology and Economics, 1085 Budapest, Hungary; (D.G.); (B.C.)
| | - Benjamin Csippa
- Department of Hydrodynamic Systems, Faculty of Mechanical Engineering, Budapest University of Technology and Economics, 1085 Budapest, Hungary; (D.G.); (B.C.)
| | - Lilla István
- Department of Ophthalmology, Semmelweis University, 1085 Budapest, Hungary; (L.I.); (I.K.)
| | - Illés Kovács
- Department of Ophthalmology, Semmelweis University, 1085 Budapest, Hungary; (L.I.); (I.K.)
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY 10065, USA
- Department of Clinical Ophthalmology, Faculty of Health Sciences, Semmelweis University, 1085 Budapest, Hungary
| | - Péter Sótonyi
- Department of Vascular and Endovascular Surgery, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (B.L.); (P.S.J.)
| | - Zsuzsanna Mihály
- Department of Vascular and Endovascular Surgery, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (B.L.); (P.S.J.)
| |
Collapse
|
10
|
Ramos JN, Calvão-Pires P, Gil I, Baptista T, Branco C, Branco G, Marto JP. Hemoglobin in large vessel occlusion: Look further than collaterals. J Clin Neurosci 2024; 121:100-104. [PMID: 38382284 DOI: 10.1016/j.jocn.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/22/2024] [Accepted: 02/12/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Abnormal hemoglobin (Hb) levels lead to poorer outcomes in ischemic stroke, though the mechanisms remain elusive. We aimed to study the role of Hb on imaging and clinical outcomes, namely on collaterals as it is a known mediator of infarct growth. METHODS Retrospective cohort study of patients with large vessel occlusion ischemic stroke admitted to our center. Demographics, clinical and imaging variables were collected, particularly baseline hemoglobin, presence of anemia and collateral score. Collaterals were scored from 0 to 3 and defined as poor if 0-1. Multivariable analyses were performed for collateral score and clinical outcomes (3-month mortality and good prognosis). RESULTS We included 811 patients, 215 (26.5 %) with anemia. Patients with anemia were older, had more comorbidities and more severe strokes. Hemoglobin levels and anemia were not associated with collateral score (OR 0.97, 95 % CI 0.89-1.05, p = 0.414 and OR 0.89, 95 % CI 0.64-1.24, p = 0.487, respectively) nor with poor collaterals (OR 0.96, 95 % CI 0.88-1.05, p = 0.398 and OR 0.86, 95 % CI 0.60-1.23, p = 0.406, respectively). Hb levels were associated with 3-month mortality (OR 0.85, 95 % CI 0.76-0.96, p = 0.008). CONCLUSION Hemoglobin or anemia were not found to be associated with collateral status. Our results raise further questions regarding the pathophysiology of anemia and outcomes in ischemic stroke, highlighting the need for future research.
Collapse
Affiliation(s)
- João Nuno Ramos
- Department of Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal.
| | - Pedro Calvão-Pires
- Department of Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Inês Gil
- Department of Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Tiago Baptista
- Department of Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Cristina Branco
- Department of Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Gabriel Branco
- Department of Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - João Pedro Marto
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal; CEDOC, NOVA Medical School, Lisboa, Portugal
| |
Collapse
|
11
|
Liu Y, Li S, Tian X, Leung TW, Liu L, Liebeskind DS, Leng X. Cerebral haemodynamics in symptomatic intracranial atherosclerotic disease: a narrative review of the assessment methods and clinical implications. Stroke Vasc Neurol 2023; 8:521-530. [PMID: 37094991 PMCID: PMC10800270 DOI: 10.1136/svn-2023-002333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/07/2023] [Indexed: 04/26/2023] Open
Abstract
Intracranial atherosclerotic disease (ICAD) is a common cause of ischaemic stroke and transient ischaemic attack (TIA) with a high recurrence rate. It is often referred to as intracranial atherosclerotic stenosis (ICAS), when the plaque has caused significant narrowing of the vessel lumen. The lesion is usually considered 'symptomatic ICAD/ICAS' (sICAD/sICAS) when it has caused an ischaemic stroke or TIA. The severity of luminal stenosis has long been established as a prognostic factor for stroke relapse in sICAS. Yet, accumulating studies have also reported the important roles of plaque vulnerability, cerebral haemodynamics, collateral circulation, cerebral autoregulation and other factors in altering the stroke risks across patients with sICAS. In this review article, we focus on cerebral haemodynamics in sICAS. We reviewed imaging modalities/methods in assessing cerebral haemodynamics, the haemodynamic metrics provided by these methods and application of these methods in research and clinical practice. More importantly, we reviewed the significance of these haemodynamic features in governing the risk of stroke recurrence in sICAS. We also discussed other clinical implications of these haemodynamic features in sICAS, such as the associations with collateral recruitment and evolution of the lesion under medical treatment, and indications for more individualised blood pressure management for secondary stroke prevention. We then put forward some knowledge gaps and future directions on these topics.
Collapse
Affiliation(s)
- Yuying Liu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Shuang Li
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Xuan Tian
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Thomas W Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - David S Liebeskind
- Department of Neurology, Neurovascular Imaging Research Core, University of California Los Angeles, Los Angeles, California, USA
| | - Xinyi Leng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| |
Collapse
|
12
|
Sperti M, Arba F, Acerbi A, Busto G, Fainardi E, Sarti C. Determinants of cerebral collateral circulation in acute ischemic stroke due to large vessel occlusion. Front Neurol 2023; 14:1181001. [PMID: 37265461 PMCID: PMC10230086 DOI: 10.3389/fneur.2023.1181001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/11/2023] [Indexed: 06/03/2023] Open
Abstract
Introduction Cerebral collateral circulation has a central role in ischemic stroke pathophysiology, and it is considered to correlate with infarct size, the success of reperfusion therapies, and clinical outcomes. Our aim was to study the factors influencing the development of collaterals in patients with acute ischemic stroke eligible for endovascular treatment. Materials and methods We enrolled patients with acute ischemic stroke and large vessel occlusion of anterior circulation potentially eligible for endovascular treatment. Included patients performed multiphase CT angiography to assess collaterals that were graded by the Menon Grading Score. We investigated the associations between clinical factors and collaterals and tested independent associations with logistic (good vs. poor collaterals) and ordinal (collateral grade grouped, Menon 0-2, 3, 4-5) regression analysis adjusting for age, sex, stroke severity, and onset to CT time (OCTT). Results We included 520 patients, the mean age was 75 (±13.6) years, 215 (41%) were men, and the median (IQR) NIHSS was 17 (11-22). Good collaterals were present in 323 (62%) patients and were associated with lower NIHSS (median 16 vs. 18; p < 0.001) and left hemisphere involvement (60% vs. 45%; p < 0.001), whereas previous stroke/TIA was more frequent in patients with poor collaterals (17 vs. 26%; p = 0.014). These results were confirmed in both logistic and ordinal regression analyses where good collaterals were associated with lower NIHSS (OR = 0.94; 95% CI = 0.91-0.96; cOR = 0.95; 95% CI = 0.92-0.97, respectively) and left hemisphere stroke (OR = 2.24; 95% CI = 1.52-3.28; cOR = 2.11; 95% CI = 1.46-3.05, respectively), while previous stroke/TIA was associated with poor collaterals (OR = 0.57; 95% CI = 0.36-0.90; cOR = 0.61; 95% CI = 0.40-0.94, respectively). Vascular risk factors, demographics, and pre-stroke treatments did not influence the collateral score. Discussion The results of our study suggest that risk factors and demographics do not influence the development of collateral circles, except for a negative relation with previous ischemic events. We confirm an already reported observation of a possible protective effect of collaterals on tissue damage assuming NIHSS as its surrogate. The association between left hemispheric stroke and better collaterals deserves to be further explored. Further efforts are needed to identify the factors that favor the development of collaterals.
Collapse
Affiliation(s)
- Martina Sperti
- Department of Neurofarba, University of Florence, Florence, Italy
| | - Francesco Arba
- Stroke Unit, Careggi University Hospital, Florence, Italy
| | - Amedeo Acerbi
- Department of Neurofarba, University of Florence, Florence, Italy
| | - Giorgio Busto
- Neuroradiology, Careggi University Hospital, Florence, Italy
| | - Enrico Fainardi
- Neuroradiology, Careggi University Hospital, Florence, Italy
| | - Cristina Sarti
- Department of Neurofarba, University of Florence, Florence, Italy
- Stroke Unit, Careggi University Hospital, Florence, Italy
| |
Collapse
|
13
|
Jiang L, Miao Z, Chen H, Geng W, Yong W, Chen YC, Zhang H, Duan S, Yin X, Zhang Z. Radiomics Analysis of Diffusion-Weighted Imaging and Long-Term Unfavorable Outcomes Risk for Acute Stroke. Stroke 2023; 54:488-498. [PMID: 36472198 DOI: 10.1161/strokeaha.122.040418] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Diffusion-weighted imaging radiomics could be used as prognostic biomarkers in acute ischemic stroke. We aimed to identify a clinical and diffusion-weighted imaging radiomics model for individual unfavorable outcomes risk assessment in acute ischemic stroke. METHODS A total of 1716 patients with acute ischemic stroke from 2 centers were divided into a training cohort and a validation cohort. Patient outcomes were measured with the modified Rankin Scale score. An unfavorable outcome was defined as a modified Rankin Scale score greater than 2. The primary end point was all-cause mortality or outcomes 1 year after stroke. The MRI-DRAGON score was calculated based on previous publications. We extracted and selected the infarct features on diffusion-weighted imaging to construct a radiomic signature. The clinic-radiomics signature was built by measuring the Cox proportional risk regression score (CrrScore) and compared with the MRI-DRAGON score and the ClinicScore. CrrScore model performance was estimated by 1-year unfavorable outcomes prediction. RESULTS A high radiomic signature predicted a higher probability of unfavorable outcomes than a low radiomic signature in the training (hazard ratio, 3.19 [95% CI, 2.51-4.05]; P<0.0001) and validation (hazard ratio, 3.25 [95% CI, 2.20-4.80]; P<0.0001) cohorts. The diffusion-weighted imaging Alberta Stroke Program Early CT Score, age, glucose level before therapy, National Institutes of Health Stroke Scale score on admission, glycated hemoglobin' radiomic signature, hemorrhagic infarction, and malignant cerebral edema were associated with an unfavorable outcomes risk after multivariable adjustment. A CrrScore nomogram was developed to predict outcomes and had the best performance in the training (area under the curve, 0.862) and validation cohorts (area under the curve, 0.858). The CrrScore model time-dependent areas under the curve of the probability of unfavorable outcomes at 1 year in the training and validation cohorts were 0.811 and 0.801, respectively. CONCLUSIONS The CrrScore model allows the accurate prediction of patients with acute ischemic stroke outcomes and can potentially guide rehabilitation therapies for patients with different risks of unfavorable outcomes.
Collapse
Affiliation(s)
- Liang Jiang
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, China (L.J., Z.M., H.C., W.G., W.Y., Y.-C.C., X.Y.)
| | - Zhengfei Miao
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, China (L.J., Z.M., H.C., W.G., W.Y., Y.-C.C., X.Y.)
| | - Huiyou Chen
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, China (L.J., Z.M., H.C., W.G., W.Y., Y.-C.C., X.Y.)
| | - Wen Geng
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, China (L.J., Z.M., H.C., W.G., W.Y., Y.-C.C., X.Y.)
| | - Wei Yong
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, China (L.J., Z.M., H.C., W.G., W.Y., Y.-C.C., X.Y.)
| | - Yu-Chen Chen
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, China (L.J., Z.M., H.C., W.G., W.Y., Y.-C.C., X.Y.)
| | - Hong Zhang
- Department of Radiology, Affiliated Jiangning Hospital of Nanjing Medical University, China (H.Z.)
| | - Shaofeng Duan
- GE Healthcare' Precision Health Institution' China (S.D.)
| | - Xindao Yin
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, China (L.J., Z.M., H.C., W.G., W.Y., Y.-C.C., X.Y.)
| | - Zhiqiang Zhang
- Department of Radiology, Affiliated Jinling Hospital, Medical School of Nanjing University, China (Z.Z.)
| |
Collapse
|
14
|
Yuan H, Liu J, Gu Y, Ji X, Nan G. Intermittent hypoxia conditioning as a potential prevention and treatment strategy for ischemic stroke: Current evidence and future directions. Front Neurosci 2022; 16:1067411. [PMID: 36507357 PMCID: PMC9732261 DOI: 10.3389/fnins.2022.1067411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/11/2022] [Indexed: 11/26/2022] Open
Abstract
Ischemic stroke (IS) is the leading cause of disability and death worldwide. Owing to the aging population and unhealthy lifestyles, the incidence of cerebrovascular disease is high. Vascular risk factors include hypertension, diabetes, dyslipidemia, and obesity. Therefore, in addition to timely and effective reperfusion therapy for IS, it is crucial to actively control these risk factors to reduce the incidence and recurrence rates of IS. Evidence from human and animal studies suggests that moderate intermittent hypoxia (IH) exposure is a promising therapeutic strategy to ameliorate common vascular risk factors and comorbidities. Given the complex pathophysiological mechanisms underlying IS, effective treatment must focus on reducing injury in the acute phase and promoting repair in the recovery phase. Therefore, this review discusses the preclinical perspectives on IH conditioning as a potential treatment for neurovascular injury and highlights IH pre and postconditioning strategies for IS. Hypoxia conditioning reduces brain injury by increasing resistance to acute ischemic and hypoxic stress, exerting neuroprotective effects, and promoting post-injury repair and regeneration. However, whether IH produces beneficial effects depends not only on the hypoxic regimen but also on inter-subject differences. Therefore, we discuss the factors that may influence the effectiveness of IH treatment, including age, sex, comorbidities, and circadian rhythm, which can be used to help identify the optimal intervention population and treatment protocols for more accurate, individualized clinical translation. In conclusion, IH conditioning as a non-invasive, non-pharmacological, systemic, and multi-targeted intervention can not only reduce brain damage after stroke but can also be applied to the prevention and functional recovery of IS, providing brain protection at different stages of the disease. It represents a promising therapeutic strategy. For patients with IS and high-risk groups, IH conditioning is expected to develop as an adjunctive clinical treatment option to reduce the incidence, recurrence, disability, and mortality of IS and to reduce disease burden.
Collapse
Affiliation(s)
- Honghua Yuan
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Jia Liu
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Advanced Innovation Center for Big Data-based Precision Medicine, Capital Medical University, Beijing, China
| | - Yuhang Gu
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Xunming Ji
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Advanced Innovation Center for Big Data-based Precision Medicine, Capital Medical University, Beijing, China,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China,*Correspondence: Xunming Ji,
| | - Guangxian Nan
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China,Guangxian Nan,
| |
Collapse
|
15
|
Arteaga DF, Ulep R, Kumar KK, Southerland AM, Conaway MR, Faber J, Wintermark M, Joyner D, Sharashidze V, Hirsch K, Giurgiutiu DV, Hannawi Y, Aziz Y, Shutter L, Visweswaran A, Williams A, Williams K, Gunter S, Haughey HM, Bruno A, Johnston KC, Patel VN. Collateral status, hyperglycemia, and functional outcome after acute ischemic stroke. BMC Neurol 2022; 22:408. [PMID: 36333676 PMCID: PMC9635077 DOI: 10.1186/s12883-022-02943-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Mixed data exist regarding the association between hyperglycemia and functional outcome after acute ischemic stroke when accounting for the impact of leptomeningeal collateral flow. We sought to determine whether collateral status modifies the association between treatment group and functional outcome in a subset of patients with large vessel occlusion enrolled in the Stroke Hyperglycemia Insulin Network Effort (SHINE) trial. METHODS In this post-hoc analysis, we analyzed patients enrolled into the SHINE trial with anterior circulation large vessel occlusion who underwent imaging with CT angiography prior to glucose control treatment group assignment. The primary analysis assessed the degree to which collateral status modified the effect between treatment group and functional outcome as defined by the 90-day modified Rankin Scale score. Logistic regression was used to model the data, with adjustments made for thrombectomy status, age, post-perfusion thrombolysis in cerebral infarction (TICI) score, tissue plasminogen activator (tPA) use, and baseline National Institutes of Health Stroke Scale (NIHSS) score. Five SHINE trial centers contributed data for this analysis. Statistical significance was defined as a p-value < 0.05. RESULTS Among the 1151 patients in the SHINE trial, 57 with angiographic data were included in this sub-analysis, of whom 19 had poor collaterals and 38 had good collaterals. While collateral status had no effect (p = 0.855) on the association between glucose control treatment group and functional outcome, patients with good collaterals were more likely to have a favorable functional outcome (p = 0.001, OR 5.02; 95% CI 1.37-16.0). CONCLUSIONS In a post-hoc analysis using a subset of patients with angiographic data enrolled in the SHINE trial, collateral status did not modify the association between glucose control treatment group and functional outcome. However, consistent with prior studies, there was a significant association between good collateral status and favorable outcome in patients with large vessel occlusion stroke. TRIAL REGISTRATION ClinicalTrials.gov Identifier is NCT01369069. Registration date is June 8, 2011.
Collapse
Affiliation(s)
- Daniel F. Arteaga
- grid.461421.40000 0004 0435 9205Department Neurology, St Thomas Rutherford Hospital, Murfreesboro, 1700 Medical Center Pkwy, Murfreesboro, TN 37129 USA
| | - Robin Ulep
- grid.168010.e0000000419368956Department of Neurology, Stanford University, Stanford, CA USA
| | - Kevin K. Kumar
- grid.168010.e0000000419368956Department of Neurosurgery, Stanford University, Stanford, CA USA
| | - Andrew M. Southerland
- grid.27755.320000 0000 9136 933XDepartment of Neurology, University of Virginia, Charlottesville, VA USA
| | - Mark R. Conaway
- grid.27755.320000 0000 9136 933XDepartment of Statistics, University of Virginia, Charlottesville, VA USA
| | - James Faber
- grid.410711.20000 0001 1034 1720Department of Cell Biology and Physiology, University of North Carolina, Chapel Hill, NC USA
| | - Max Wintermark
- grid.168010.e0000000419368956Department of Radiology, Stanford University, Stanford, CA USA
| | - David Joyner
- grid.27755.320000 0000 9136 933XDepartment of Radiology, University of Virginia, Charlottesville, VA USA
| | - Vera Sharashidze
- grid.189967.80000 0001 0941 6502Department of Neurology, Emory University, Atlanta, GA USA
| | - Karen Hirsch
- grid.168010.e0000000419368956Department of Neurology, Stanford University, Stanford, CA USA
| | - Dan-Victor Giurgiutiu
- grid.410427.40000 0001 2284 9329Department of Neurology, Medical College of Georgia at Augusta University, Augusta, GA USA
| | - Yousef Hannawi
- grid.261331.40000 0001 2285 7943Department of Neurology, The Ohio State University, Columbus, OH USA
| | - Yasmin Aziz
- grid.21925.3d0000 0004 1936 9000Department of Neurology, University of Pittsburgh, Pittsburgh, PA USA
| | - Lori Shutter
- grid.21925.3d0000 0004 1936 9000Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Anita Visweswaran
- grid.168010.e0000000419368956Department of Neurology, Stanford University, Stanford, CA USA
| | - Alana Williams
- grid.189967.80000 0001 0941 6502Department of Neurology, Emory University, Atlanta, GA USA
| | - Kori Williams
- grid.410427.40000 0001 2284 9329Department of Neurology, Medical College of Georgia at Augusta University, Augusta, GA USA
| | - Sonya Gunter
- grid.27755.320000 0000 9136 933XDepartment of Neurology, University of Virginia, Charlottesville, VA USA
| | - Heather M. Haughey
- grid.27755.320000 0000 9136 933XDepartment of Neurology, University of Virginia, Charlottesville, VA USA
| | - Askiel Bruno
- grid.410427.40000 0001 2284 9329Department of Neurology, Medical College of Georgia at Augusta University, Augusta, GA USA
| | - Karen C. Johnston
- grid.27755.320000 0000 9136 933XDepartment of Neurology, University of Virginia, Charlottesville, VA USA
| | - Vishal N. Patel
- grid.189967.80000 0001 0941 6502Department of Neurology, Emory University, Atlanta, GA USA
| | | |
Collapse
|
16
|
Lin GH, Song JX, Huang TD, Fu NX, Zhong LL. Relationship between the stroke mechanism of symptomatic middle cerebral artery atherosclerotic diseases and culprit plaques based on high-resolution vessel wall imaging. Front Neurol 2022; 13:968417. [PMID: 36188409 PMCID: PMC9523534 DOI: 10.3389/fneur.2022.968417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/18/2022] [Indexed: 11/20/2022] Open
Abstract
Purpose For patients with symptomatic middle cerebral artery (MCA) atherosclerotic stenosis, identifying the potential stroke mechanisms may contribute to secondary prevention. The purpose of the study is to explore the relationship between stroke mechanisms and the characteristics of culprit plaques in patients with atherosclerotic ischemic stroke in the M1 segment of the middle cerebral artery (MCA) based on high-resolution vessel wall imaging (HR-VWI). Methods We recruited 61 patients with acute ischemic stroke due to MCA atherosclerotic stenosis from Shenzhen Bao'an District People's Hospital. According to prespecified criteria based on infarct topography and magnetic resonance angiography, possible stroke mechanisms were divided into parent artery atherosclerosis occluding penetrating artery (P), artery-to-artery embolism (A), hypoperfusion (H), and mixed mechanisms (M). The correlation between the characteristics of MCA M1 culprit plaque and different stroke mechanisms was analyzed using HR-VWI. The indicators included plaque surface irregularity, T1 hyperintensity, location, plaque burden (PB), remodeling index (RI), enhancement rate, and stenosis rate. Results Parental artery atherosclerosis occluding penetrating artery was the most common mechanism (37.7%). The proposed criteria showed substantial to excellent interrater reproducibility (κ, 0.728; 0.593–0.863). Compared with the P group, the surface irregularity, T1 hyperintensity, and obvious enhancement of the culprit plaque in the A group were more common (p < 0.0125). Compared with the other stroke mechanisms, positive remodeling of culprit plaques was more common (p < 0.0125), the RI was greater (p < 0.05), and the PB was the smallest (p < 0.05) in the P group. The enhancement ratio (ER) was smaller in the P group (p < 0.05). Compared with the A group, T1 hyperintensity of the culprit plaque was more common in the H group (p < 0.0125), and the stenosis rate was greater (p < 0.05). After adjustment for clinical demographic factors in the binary logistic regression analysis, the enhancement level (odds ratio [OR] 0.213, 95% CI (0.05–0.91), p = 0.037) and PB of culprit plaque (OR 0, 95% CI (0–0.477), p = 0.034) were negatively associated with P groups. Conclusion The culprit plaque characteristics of patients with symptomatic MCA atherosclerotic in different stroke mechanisms may be evaluated using HR-VWI. The plaque characteristics of different stroke mechanisms may have clinical value for the selection of treatment strategies and prevention of stroke recurrence. Clinical trial registration Identifier: ChiCTR1900028533.
Collapse
|
17
|
Sato Y, Falcone-Juengert J, Tominaga T, Su H, Liu J. Remodeling of the Neurovascular Unit Following Cerebral Ischemia and Hemorrhage. Cells 2022; 11:2823. [PMID: 36139398 PMCID: PMC9496956 DOI: 10.3390/cells11182823] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/18/2022] [Accepted: 08/30/2022] [Indexed: 11/23/2022] Open
Abstract
Formulated as a group effort of the stroke community, the transforming concept of the neurovascular unit (NVU) depicts the structural and functional relationship between brain cells and the vascular structure. Composed of both neural and vascular elements, the NVU forms the blood-brain barrier that regulates cerebral blood flow to meet the oxygen demand of the brain in normal physiology and maintain brain homeostasis. Conversely, the dysregulation and dysfunction of the NVU is an essential pathological feature that underlies neurological disorders spanning from chronic neurodegeneration to acute cerebrovascular events such as ischemic stroke and cerebral hemorrhage, which were the focus of this review. We also discussed how common vascular risk factors of stroke predispose the NVU to pathological changes. We synthesized existing literature and first provided an overview of the basic structure and function of NVU, followed by knowledge of how these components remodel in response to ischemic stroke and brain hemorrhage. A greater understanding of the NVU dysfunction and remodeling will enable the design of targeted therapies and provide a valuable foundation for relevant research in this area.
Collapse
Affiliation(s)
- Yoshimichi Sato
- Department of Neurological Surgery, UCSF, San Francisco, CA 94158, USA
- Department of Neurological Surgery, SFVAMC, San Francisco, CA 94158, USA
- Department of Neurosurgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Jaime Falcone-Juengert
- Department of Neurological Surgery, UCSF, San Francisco, CA 94158, USA
- Department of Neurological Surgery, SFVAMC, San Francisco, CA 94158, USA
| | - Teiji Tominaga
- Department of Neurosurgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Hua Su
- Department of Anesthesia, UCSF, San Francisco, CA 94143, USA
- Center for Cerebrovascular Research, UCSF, San Francisco, CA 94143, USA
| | - Jialing Liu
- Department of Neurological Surgery, UCSF, San Francisco, CA 94158, USA
- Department of Neurological Surgery, SFVAMC, San Francisco, CA 94158, USA
| |
Collapse
|
18
|
The Supratrochlear Artery Sign—A New Piece in the Puzzle of Cerebral Vasospasm. Diagnostics (Basel) 2022; 12:diagnostics12092185. [PMID: 36140586 PMCID: PMC9498286 DOI: 10.3390/diagnostics12092185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/02/2022] [Accepted: 09/07/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Cerebral vasospasm (CVS) after subarachnoid hemorrhage (SAH) has been extensively investigated, but the impact of collateralization remains unclear. We investigated the predictive value of collateral activation for delayed cerebral ischemia (DCI)-related infarctions and functional outcome. Methods: Data from 43 patients with CVS (January 2014 to August 2021) were evaluated for the angiographic presence of leptomeningeal and ophthalmic collaterals (anterior falcine artery (AFA), supratrochlear artery (STA), dorsal nasal artery (DNA)) on internal carotid artery angiograms. Vasospasm-related infarction and the modified Rankin Scale (mRS) score after six months were chosen as the endpoints. Results: 77% of the patients suffered from DCI-related infarctions. In 233 angiograms (at hospitalization, before spasmolysis, after six months), positive vessel signs were observed in 31 patients for STA, 35 for DNA, and 31 for AFA. The STA sign had the highest positive (84.6%) and negative (85.7%) predictive value for unfavorable outcome (mRS 4–6) in patients aged ≥50 years. DNA and AFA signs were not meaningful predictors for either endpoint. Leptomeningeal collaterals showed a positive Pearson’s correlation with the STA sign in 87.5% (p = 0.038) without providing any prediction for either endpoint. Conclusions: The STA sign is associated with clinical outcome in patients with CVS after SAH aged ≥50 years, and was correlated with the occurrence of leptomeningeal collaterals.
Collapse
|
19
|
Ger Akarsu F, Aykaç Ö, Özcan Özdemir A. Identifying 'fast progressors' likely to benefit from mechanical thrombectomy. J Clin Neurosci 2022; 103:4-8. [PMID: 35785615 DOI: 10.1016/j.jocn.2022.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/24/2022] [Accepted: 06/25/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Although the effect of mechanical thrombectomy in large vessel occlusions has been clearly demonstrated, there are different opinions about the treatment of patients with low ASPECT scores. We conducted this research to explore the utility of mechanical thrombectomy for the fast progressor patients. METHODS We evaluated 394 patients with large vessel occlusion (LVO) who applied to our center between 2012 and 2020 retrospectively. Patients with posterior system stroke and who admitted 6 h after the onset of symptoms, were not included in the study. The remaining 256 patients were divided into two groups as computed tomography angiography source image Alberta stroke program early computer tomography score (CTA-SI ASPECT) ≤ 6 and > 6. Modified rankin scale (mRS) 0-2 defined as good clinical outcome. Thrombolysis in cerebral infarction (TICI) score 2c-3 was accepted as successful recanalization. RESULTS The mean age of the patients in the fast-progressive group (23.4%; n = 60) was 66.3 ± 11.6 years, whereas the mean age of the CTA-SI ASPECTS > 6 group (76.6%; n = 196) was 62.4 ± 12.8 years (p = 0.034) A statistically significant difference was found between the groups regarding 90-day mRS (p < 0.001). Whereas 61.7% of the patients with a CTA-SI ASPECTS > 6 had a 90-day mRS 0-2, this rate was 28.3% for patients with a CTA-SI ASPECTS ≤ 6. CONCLUSION According to our study, approximately 1/3 of patients with ASPECTS ≤ 6 benefit from mechanical thrombectomy. In this patient group, age emerged as a determinant of good clinical outcome.
Collapse
Affiliation(s)
- Fatma Ger Akarsu
- Department of Neurology, Eskisehir Osmangazi University, Eskişehir, Turkey.
| | - Özlem Aykaç
- Department of Neurology, Eskisehir Osmangazi University, Eskişehir, Turkey
| | | |
Collapse
|
20
|
Sim JE, Chung JW, Seo WK, Bang OY, Kim GM. Association of Systolic Blood Pressure and Cerebral Collateral Flow in Acute Ischemic Stroke by Stroke Subtype. Front Neurol 2022; 13:863483. [PMID: 35645966 PMCID: PMC9136006 DOI: 10.3389/fneur.2022.863483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/14/2022] [Indexed: 11/30/2022] Open
Abstract
Background and Purpose Collateral flow in acute ischemic stroke is known as a predictor of treatment outcome and long-term prognosis. However, factors determining the initial collateral flow remain unclear. We investigated factors related to collateral flow in patients with acute ischemic stroke caused by large vessel occlusion (AIS-LVO) and further analyzed the results according to stroke etiology. Methods This was a retrospective study using prospective stroke registry data from a single university hospital from October 2014 to May 2021. AIS-LVO with middle cerebral artery M1 occlusion identified by pre-treatment multiphasic computed tomography angiography was included. Collateral flow score was graded on a 6-point ordinal scale according to pial arterial filling. Results A total of 74 patients [cardioembolism (CE): 57; large artery atherosclerosis (LAA): 17] was included. The mean age of all patients was 72.2 ± 11.7 years, and 37.8 % (n = 28) were men. Multivariate regression analysis showed that initial SBP [odds ratio (OR): 0.994; 95% confidence interval (CI): 0.990–0.998; p = 0.002] and stroke etiology (OR: 0.718; 95% CI: 0.548–0.940; p = 0.019) were independent factors of the collateral flow grade. Collateral flow grade was independently associated with initial SBP in the CE group (OR: 0.993; 95% CI: 0.989–0.998; p = 0.004) but not in the LAA group (OR: 0.992; 95% CI: 0.980–1.004; p = 0.218). Initial SBP was significantly correlated with NIHSS score in the CE group but not in the LAA group (r2= 0.091, p = 0.023; r2 = 0.043, p = 0.426, respectively). Conclusions Elevated initial SBP was associated with poor cerebral collateral flow and more severe symptoms in the CE group, but not in the LAA group in patients with AIS-LVO. These findings suggest differential effects of initial SBP elevation on collateral flow by stroke subtypes.
Collapse
|
21
|
Khan A, De Boever P, Gerrits N, Akhtar N, Saqqur M, Ponirakis G, Gad H, Petropoulos IN, Shuaib A, Faber JE, Kamran S, Malik RA. Retinal vessel multifractals predict pial collateral status in patients with acute ischemic stroke. PLoS One 2022; 17:e0267837. [PMID: 35511879 PMCID: PMC9070887 DOI: 10.1371/journal.pone.0267837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 04/16/2022] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES Pial collateral blood flow is a major determinant of the outcomes of acute ischemic stroke. This study was undertaken to determine whether retinal vessel metrics can predict the pial collateral status and stroke outcomes in patients. METHODS Thirty-five patients with acute stroke secondary to middle cerebral artery (MCA) occlusion underwent grading of their pial collateral status from computed tomography angiography and retinal vessel analysis from retinal fundus images. RESULTS The NIHSS (14.7 ± 5.5 vs 10.1 ± 5.8, p = 0.026) and mRS (2.9 ± 1.6 vs 1.9 ± 1.3, p = 0.048) scores were higher at admission in patients with poor compared to good pial collaterals. Retinal vessel multifractals: D0 (1.673±0.028vs1.652±0.025, p = 0.028), D1 (1.609±0.027vs1.590±0.025, p = 0.044) and f(α)max (1.674±0.027vs1.652±0.024, p = 0.019) were higher in patients with poor compared to good pial collaterals. Furthermore, support vector machine learning achieved a fair sensitivity (0.743) and specificity (0.707) for differentiating patients with poor from good pial collaterals. Age (p = 0.702), BMI (p = 0.422), total cholesterol (p = 0.842), triglycerides (p = 0.673), LDL (p = 0.952), HDL (p = 0.366), systolic blood pressure (p = 0.727), HbA1c (p = 0.261) and standard retinal metrics including CRAE (p = 0.084), CRVE (p = 0.946), AVR (p = 0.148), tortuosity index (p = 0.790), monofractal Df (p = 0.576), lacunarity (p = 0.531), curve asymmetry (p = 0.679) and singularity length (p = 0.937) did not differ between patients with poor compared to good pial collaterals. CONCLUSIONS This is the first translational study to show increased retinal vessel multifractal dimensions in patients with acute ischemic stroke and poor pial collaterals. A retinal vessel classifier was developed to differentiate between patients with poor and good pial collaterals and may allow rapid non-invasive identification of patients with poor pial collaterals.
Collapse
Affiliation(s)
- Adnan Khan
- Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Patrick De Boever
- Department of Biology, University of Antwerp, Antwerp, Wilrijk, Belgium
- Center of Environmental Sciences, Hasselt University, Diepenbeek, Belgium
- VITO (Flemish Institute for Technological Research), Health Unit, Mol, Belgium
| | - Nele Gerrits
- VITO (Flemish Institute for Technological Research), Health Unit, Mol, Belgium
| | - Naveed Akhtar
- Institute of Neuroscience, Hamad Medical Corporation, Doha, Qatar
| | - Maher Saqqur
- Trillium Hospital, University of Toronto at Mississauga, Mississauga, ON, Canada
- Department of Medicine, University of Alberta, Edmonton, Canada
| | | | - Hoda Gad
- Weill Cornell Medicine-Qatar, Doha, Qatar
| | | | - Ashfaq Shuaib
- Institute of Neuroscience, Hamad Medical Corporation, Doha, Qatar
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - James E. Faber
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Saadat Kamran
- Institute of Neuroscience, Hamad Medical Corporation, Doha, Qatar
| | | |
Collapse
|
22
|
Hung SH, Kramer S, Werden E, Campbell BCV, Brodtmann A. Pre-stroke Physical Activity and Cerebral Collateral Circulation in Ischemic Stroke: A Potential Therapeutic Relationship? Front Neurol 2022; 13:804187. [PMID: 35242097 PMCID: PMC8886237 DOI: 10.3389/fneur.2022.804187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/12/2022] [Indexed: 11/13/2022] Open
Abstract
Favorable cerebral collateral circulation contributes to hindering penumbral tissue from progressing to infarction and is associated with positive clinical outcomes after stroke. Given its clinical importance, improving cerebral collateral circulation is considered a therapeutic target to reduce burden after stroke. We provide a hypothesis-generating discussion on the potential association between pre-stroke physical activity and cerebral collateral circulation in ischemic stroke. The recruitment of cerebral collaterals in acute ischemic stroke may depend on anatomical variations, capacity of collateral vessels to vasodilate, and individual risk factors. Physical activity is associated with improved cerebral endothelial and vascular function related to vasodilation and angiogenic adaptations, and risk reduction in individual risk factors. More research is needed to understand association between cerebral collateral circulation and physical activity. A presentation of different methodological considerations for measuring cerebral collateral circulation and pre-stroke physical activity in the context of acute ischemic stroke is included. Opportunities for future research into cerebral collateral circulation, physical activity, and stroke recovery is presented.
Collapse
Affiliation(s)
- Stanley Hughwa Hung
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Sharon Kramer
- Centre for Quality and Patient Safety Research, Alfred Health Partnership, Melbourne, VIC, Australia.,Faculty of Health, School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia
| | - Emilio Werden
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia.,Melbourne Dementia Research Centre, The Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
| | - Bruce C V Campbell
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia.,Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Amy Brodtmann
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia.,Melbourne Dementia Research Centre, The Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
| |
Collapse
|
23
|
Li Z, Li Q, Ji Y, Chu Z, Zhao S, Ma L, Zhou Z, Yang Q, Huang X. Pre-Existing Non-Disabling Encephalomalacia Confers Risk to Stroke Outcomes After Endovascular Treatment. Front Neurol 2022; 13:833737. [PMID: 35222256 PMCID: PMC8873094 DOI: 10.3389/fneur.2022.833737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 01/11/2022] [Indexed: 11/19/2022] Open
Abstract
Background Patients with previous stroke episodes tend to have poor outcomes after an endovascular treatment (EVT). Encephalomalacia (EM) is an objective indicator of previous strokes but has not been systematically investigated. The fundamental aim of this exploration is to investigate the effects of a pre-existing non-disabling EM on clinical outcomes after EVT. Methods Consecutive patients undergoing an EVT due to the anterior circulation large vessel occlusion (LVO) strokes were enrolled in the study. The pre-existing EM was defined as the focal hypodense lesions (≥ 3 mm in maximum diameter) on a non-contrast cranial CT using axial images before EVT. The primary outcome was the 90-day functional assessment using the modified Rankin Scale (mRS) score. The safety outcome was the incidence of symptomatic intracranial hemorrhage (sICH) defined as any hemorrhage within 24 h after an EVT, which is responsible for an increase of ≥ 4 points in the score of National Institutes of Health Stroke Scale (NIHSS). Results Of the 433 patients analyzed in this investigation, a pre-existing non-disabling EM was observed in 106 (24.5%) patients. After adjusting for potential confounding factors, patients with contralateral EM (OR = 2.68, 95% CI = 1.13–6.31; P = 0.025) and with an EM+ > 20 mm in maximum diameter (OR = 2.21, 95% CI = 1.01–4.85; P =0.048) were substantially associated with unfavorable outcomes (mRS > 2). For the sICH, we did not observe any association with the pre-existing EM (P > 0.05). Conclusions A pre-existing non-disabling EM is common and safe in patients undergoing EVT. However, a contralateral EM and the large size of EM may predict an unfavorable outcome at 90 days, which should receive more attention before EVT.
Collapse
Affiliation(s)
- Zibao Li
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Qiang Li
- Department of Medical Record Management, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Yachen Ji
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Zhaohu Chu
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Shoucai Zhao
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Lingsong Ma
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Qian Yang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Xianjun Huang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| |
Collapse
|
24
|
Hong Y, Fang J, Ma M, Su W, Zhou M, Tang L, Tang H, He L. The Hyperdense middle cerebral artery sign is associated with poor leptomeningeal collaterals in acute ischemic stroke: a retrospective study. BMC Neurol 2022; 22:51. [PMID: 35148711 PMCID: PMC8832774 DOI: 10.1186/s12883-022-02566-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 01/19/2022] [Indexed: 02/08/2023] Open
Abstract
Background The hyperdense middle cerebral artery sign (HMCAS) is an early radiological marker to provide an early diagnosis and to identify ischemia. As reported, HMCAS is associated with heavy clot burden. Moreover, a heavy clot burden may cause obstruction of the orifices of arteries for leptomeningeal collateral flows and can lead to severe clinical conditions. However, the direct relationship between HMCAS and collateral flows remains unclear. Therefore, we explored the association between HMCAS and leptomeningeal collaterals in patients with acute ischemic stroke. Methods Consecutive ischemic stroke patients were enrolled from January 2015 to April 2021. HMCAS appearance and collateral status were detected by multimodal computed tomography at admission. Logistic regression analyses helped to identify the association between HMCAS, collateral flows and stroke severity. Results In 494 included patients, 180 (36.4%) presented with HMCAS. Ipsilateral collaterals were not seen or less prominent in patients with HMCAS (P < 0.001). The HMCAS appearance was significantly associated with less collaterals (odds ratio 5.17, 95% confidence interval 3.27-8.18, P < 0.001), internal carotid artery + M1/M1 occlusion, the initial stroke severity and follow-up outcomes. Subgroup analyses further confirmed HMCAS as an indicator of poor collaterals in ischemic stroke (all P values < 0.05). Conclusions HMCAS is associated with poor leptomeningeal collaterals, the stroke severity and a poor neurological outcome. Therefore, the HMCAS appearance can act as an early warning sign for healthcare professionals to be alert for poor collateral flows and poor neurological outcomes in ischemic stroke patients with middle cerebral artery occlusion.
Collapse
Affiliation(s)
- Ye Hong
- Department of Neurology, West China Hospital of Sichuan University, Wainan Guoxue Xiang #37, Chengdu, 610041, Sichuan, China.,Institute of Brain Science and Brain-Inspired Technology of West China Hospital, Sichuan University, Chengdu, China
| | - Jinghuan Fang
- Department of Neurology, West China Hospital of Sichuan University, Wainan Guoxue Xiang #37, Chengdu, 610041, Sichuan, China.,Institute of Brain Science and Brain-Inspired Technology of West China Hospital, Sichuan University, Chengdu, China
| | - Mengmeng Ma
- Department of Neurology, West China Hospital of Sichuan University, Wainan Guoxue Xiang #37, Chengdu, 610041, Sichuan, China.,Institute of Brain Science and Brain-Inspired Technology of West China Hospital, Sichuan University, Chengdu, China
| | - Wei Su
- Department of Neurology, West China Hospital of Sichuan University, Wainan Guoxue Xiang #37, Chengdu, 610041, Sichuan, China.,Institute of Brain Science and Brain-Inspired Technology of West China Hospital, Sichuan University, Chengdu, China
| | - Muke Zhou
- Department of Neurology, West China Hospital of Sichuan University, Wainan Guoxue Xiang #37, Chengdu, 610041, Sichuan, China.,Institute of Brain Science and Brain-Inspired Technology of West China Hospital, Sichuan University, Chengdu, China
| | - Li Tang
- Department of Neurology, West China Hospital of Sichuan University, Wainan Guoxue Xiang #37, Chengdu, 610041, Sichuan, China.,Institute of Brain Science and Brain-Inspired Technology of West China Hospital, Sichuan University, Chengdu, China
| | - Huairong Tang
- Department of Health Management Center, West China Hospital of Sichuan University, Wainan Guoxue Xiang #37, Chengdu, 610041, Sichuan, China.
| | - Li He
- Department of Neurology, West China Hospital of Sichuan University, Wainan Guoxue Xiang #37, Chengdu, 610041, Sichuan, China. .,Institute of Brain Science and Brain-Inspired Technology of West China Hospital, Sichuan University, Chengdu, China.
| |
Collapse
|
25
|
Huang Q, Cai G, Liu T, Liu Z. Relationships Among Gut Microbiota, Ischemic Stroke and Its Risk Factors: Based on Research Evidence. Int J Gen Med 2022; 15:2003-2023. [PMID: 35795301 PMCID: PMC9252587 DOI: 10.2147/ijgm.s353276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/08/2022] [Indexed: 11/27/2022] Open
Abstract
Stroke is a highly lethal disease and disabling illness while ischemic stroke accounts for the majority of stroke. It has been found that inflammation plays a key role in the initiation and progression of stroke, and atherosclerotic plaque rupture is considered to be the leading cause of ischemic stroke. Furthermore, chronic inflammatory diseases, such as obesity, type 2 diabetes mellitus (T2DM) and hypertension, are also considered as the high-risk factors for stroke. Recently, the topic on how gut microbiota affects human health has aroused great concern. The initiation and progression of ischemic stroke has been found to have close relation with gut microbiota dysbiosis. Hence, this manuscript briefly summarizes the roles of gut microbiota in ischemic stroke and its related risk factors, and the practicability of preventing and alleviating ischemic stroke by reconstructing gut microbiota.
Collapse
Affiliation(s)
- Qinhong Huang
- First Clinical School, Guangzhou Medical University, Guangzhou, 511436, People’s Republic of China
| | - Guannan Cai
- First Clinical School, Guangzhou Medical University, Guangzhou, 511436, People’s Republic of China
| | - Ting Liu
- Guangzhou Key Laboratory of Enhanced Recovery after Abdominal Surgery, Innovation Center for Advanced Interdisciplinary Medicine, the Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510700, People’s Republic of China
- Correspondence: Ting Liu; Zhihua Liu, Email ;
| | - Zhihua Liu
- Department of Anorectal Surgery, the Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510700, People’s Republic of China
| |
Collapse
|
26
|
Lee S, Jiang B, Wintermark M, Mlynash M, Christensen S, Sträter R, Broocks G, Grams A, Dorn F, Nikoubashman O, Kaiser D, Morotti A, Jensen-Kondering U, Trenkler J, Möhlenbruch M, Fiehler J, Wildgruber M, Kemmling A, Psychogios M, Sporns PB. Cerebrovascular Collateral Integrity in Pediatric Large Vessel Occlusion: Analysis of the Save ChildS Study. Neurology 2022; 98:e352-e363. [PMID: 34795051 DOI: 10.1212/wnl.0000000000013081] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/22/2021] [Accepted: 11/04/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Robust cerebrovascular collaterals in adult patients with large vessel occlusion stroke have been associated with longer treatment windows, better recanalization rates, and improved outcomes, but the role of collaterals in pediatric stroke is not known. The primary aim was to determine whether favorable collaterals correlated with better radiographic and clinical outcomes in children with ischemic stroke who underwent thrombectomy. METHODS This study analyzed a subset of children enrolled in SaveChildS, a retrospective, multicenter, observational cohort study of 73 pediatric patients with stroke who underwent thrombectomy between 2000 and 2018 at 27 US and European centers. Included patients had baseline angiographic imaging and follow-up modified Rankin Scale scores available for review. Posterior circulation occlusions were excluded. Cerebrovascular collaterals were graded on acute neuroimaging by 2 blinded neuroradiologists according to the Tan collateral score, in which favorable collaterals are defined as >50% filling and unfavorable collaterals as <50% filling distal to the occluded vessel. Collateral status was correlated with clinical and neuroimaging characteristics and outcomes. Between-group comparisons were performed with the Wilcoxon rank-sum test for continuous variables or Fisher exact test for binary variables. RESULTS Thirty-three children (mean age 10.9 [SD ±4.9]) years were included; 14 (42.4%) had favorable collaterals. Median final stroke volume as a percent of total brain volume (TBV) was significantly lower in patients with favorable collaterals (1.35% [interquartile range (IQR) 1.14%-3.76%] vs 7.86% [IQR 1.54%-11.07%], p = 0.049). Collateral status did not correlate with clinical outcome, infarct growth, or final Alberta Stroke Program Early CT Score (ASPECTS) in our cohort. Patients with favorable collaterals had higher baseline ASPECTS (7 [IQR 6-8] vs 5.5 [4-6], p = 0.006), smaller baseline ischemic volume (1.57% TBV [IQR 1.09%-2.29%] vs 3.42% TBV [IQR 1.26%-5.33%], p = 0.035), and slower early infarct growth rate (2.4 mL/h [IQR 1.5-5.1 mL/h] vs 10.4 mL/h [IQR 3.0-30.7 mL/h], p = 0.028). DISCUSSION Favorable collaterals were associated with smaller final stroke burden and slower early infarct growth rate but not with better clinical outcome in our study. Prospective studies are needed to determine the impact of collaterals in childhood stroke. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that in children with ischemic stroke undergoing thrombectomy, favorable collaterals were associated with improved radiographic outcomes but not with better clinical outcomes.
Collapse
Affiliation(s)
- Sarah Lee
- From the Department of Neurology & Neurological Sciences, Stanford Stroke Center (S.L., M. Mlynash, S.C.), Department of Neurology & Neurological Sciences (S.L.), Division of Child Neurology, and Department of Radiology (B.J., M. Wintermark), Division of Neuroradiology, Stanford University School of Medicine, CA; Department of Pediatrics (R.S.), University Hospital of Muenster; Department of Diagnostic and Interventional Neuroradiology (G.B., J.F., P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department of Neuroradiology (F.D.), University Hospital Bonn; Department of Neuroradiology (O.N.), RWTH Aachen University; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden, Germany; ASST Valcamonica (A.M.), UOSD Neurology, Esine (BS), Brescia, Italy; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Campus Kiel; Institute of Neuroradiology (U.J.-K.), UKSH Campus Lübeck, Germany; Department of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Department of Neuroradiology (M. Möhlenbruch), Heidelberg University Hospital; Department of Radiology (M. Wildgruber), University Hospital, LMU Munich; Department of Neuroradiology (A.K.), Marburg University Hospital, Germany; and Department of Neuroradiology (M.P., P.B.S.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland.
| | - Bin Jiang
- From the Department of Neurology & Neurological Sciences, Stanford Stroke Center (S.L., M. Mlynash, S.C.), Department of Neurology & Neurological Sciences (S.L.), Division of Child Neurology, and Department of Radiology (B.J., M. Wintermark), Division of Neuroradiology, Stanford University School of Medicine, CA; Department of Pediatrics (R.S.), University Hospital of Muenster; Department of Diagnostic and Interventional Neuroradiology (G.B., J.F., P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department of Neuroradiology (F.D.), University Hospital Bonn; Department of Neuroradiology (O.N.), RWTH Aachen University; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden, Germany; ASST Valcamonica (A.M.), UOSD Neurology, Esine (BS), Brescia, Italy; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Campus Kiel; Institute of Neuroradiology (U.J.-K.), UKSH Campus Lübeck, Germany; Department of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Department of Neuroradiology (M. Möhlenbruch), Heidelberg University Hospital; Department of Radiology (M. Wildgruber), University Hospital, LMU Munich; Department of Neuroradiology (A.K.), Marburg University Hospital, Germany; and Department of Neuroradiology (M.P., P.B.S.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland
| | - Max Wintermark
- From the Department of Neurology & Neurological Sciences, Stanford Stroke Center (S.L., M. Mlynash, S.C.), Department of Neurology & Neurological Sciences (S.L.), Division of Child Neurology, and Department of Radiology (B.J., M. Wintermark), Division of Neuroradiology, Stanford University School of Medicine, CA; Department of Pediatrics (R.S.), University Hospital of Muenster; Department of Diagnostic and Interventional Neuroradiology (G.B., J.F., P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department of Neuroradiology (F.D.), University Hospital Bonn; Department of Neuroradiology (O.N.), RWTH Aachen University; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden, Germany; ASST Valcamonica (A.M.), UOSD Neurology, Esine (BS), Brescia, Italy; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Campus Kiel; Institute of Neuroradiology (U.J.-K.), UKSH Campus Lübeck, Germany; Department of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Department of Neuroradiology (M. Möhlenbruch), Heidelberg University Hospital; Department of Radiology (M. Wildgruber), University Hospital, LMU Munich; Department of Neuroradiology (A.K.), Marburg University Hospital, Germany; and Department of Neuroradiology (M.P., P.B.S.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland
| | - Michael Mlynash
- From the Department of Neurology & Neurological Sciences, Stanford Stroke Center (S.L., M. Mlynash, S.C.), Department of Neurology & Neurological Sciences (S.L.), Division of Child Neurology, and Department of Radiology (B.J., M. Wintermark), Division of Neuroradiology, Stanford University School of Medicine, CA; Department of Pediatrics (R.S.), University Hospital of Muenster; Department of Diagnostic and Interventional Neuroradiology (G.B., J.F., P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department of Neuroradiology (F.D.), University Hospital Bonn; Department of Neuroradiology (O.N.), RWTH Aachen University; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden, Germany; ASST Valcamonica (A.M.), UOSD Neurology, Esine (BS), Brescia, Italy; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Campus Kiel; Institute of Neuroradiology (U.J.-K.), UKSH Campus Lübeck, Germany; Department of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Department of Neuroradiology (M. Möhlenbruch), Heidelberg University Hospital; Department of Radiology (M. Wildgruber), University Hospital, LMU Munich; Department of Neuroradiology (A.K.), Marburg University Hospital, Germany; and Department of Neuroradiology (M.P., P.B.S.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland
| | - Soren Christensen
- From the Department of Neurology & Neurological Sciences, Stanford Stroke Center (S.L., M. Mlynash, S.C.), Department of Neurology & Neurological Sciences (S.L.), Division of Child Neurology, and Department of Radiology (B.J., M. Wintermark), Division of Neuroradiology, Stanford University School of Medicine, CA; Department of Pediatrics (R.S.), University Hospital of Muenster; Department of Diagnostic and Interventional Neuroradiology (G.B., J.F., P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department of Neuroradiology (F.D.), University Hospital Bonn; Department of Neuroradiology (O.N.), RWTH Aachen University; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden, Germany; ASST Valcamonica (A.M.), UOSD Neurology, Esine (BS), Brescia, Italy; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Campus Kiel; Institute of Neuroradiology (U.J.-K.), UKSH Campus Lübeck, Germany; Department of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Department of Neuroradiology (M. Möhlenbruch), Heidelberg University Hospital; Department of Radiology (M. Wildgruber), University Hospital, LMU Munich; Department of Neuroradiology (A.K.), Marburg University Hospital, Germany; and Department of Neuroradiology (M.P., P.B.S.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland
| | - Ronald Sträter
- From the Department of Neurology & Neurological Sciences, Stanford Stroke Center (S.L., M. Mlynash, S.C.), Department of Neurology & Neurological Sciences (S.L.), Division of Child Neurology, and Department of Radiology (B.J., M. Wintermark), Division of Neuroradiology, Stanford University School of Medicine, CA; Department of Pediatrics (R.S.), University Hospital of Muenster; Department of Diagnostic and Interventional Neuroradiology (G.B., J.F., P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department of Neuroradiology (F.D.), University Hospital Bonn; Department of Neuroradiology (O.N.), RWTH Aachen University; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden, Germany; ASST Valcamonica (A.M.), UOSD Neurology, Esine (BS), Brescia, Italy; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Campus Kiel; Institute of Neuroradiology (U.J.-K.), UKSH Campus Lübeck, Germany; Department of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Department of Neuroradiology (M. Möhlenbruch), Heidelberg University Hospital; Department of Radiology (M. Wildgruber), University Hospital, LMU Munich; Department of Neuroradiology (A.K.), Marburg University Hospital, Germany; and Department of Neuroradiology (M.P., P.B.S.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland
| | - Gabriel Broocks
- From the Department of Neurology & Neurological Sciences, Stanford Stroke Center (S.L., M. Mlynash, S.C.), Department of Neurology & Neurological Sciences (S.L.), Division of Child Neurology, and Department of Radiology (B.J., M. Wintermark), Division of Neuroradiology, Stanford University School of Medicine, CA; Department of Pediatrics (R.S.), University Hospital of Muenster; Department of Diagnostic and Interventional Neuroradiology (G.B., J.F., P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department of Neuroradiology (F.D.), University Hospital Bonn; Department of Neuroradiology (O.N.), RWTH Aachen University; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden, Germany; ASST Valcamonica (A.M.), UOSD Neurology, Esine (BS), Brescia, Italy; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Campus Kiel; Institute of Neuroradiology (U.J.-K.), UKSH Campus Lübeck, Germany; Department of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Department of Neuroradiology (M. Möhlenbruch), Heidelberg University Hospital; Department of Radiology (M. Wildgruber), University Hospital, LMU Munich; Department of Neuroradiology (A.K.), Marburg University Hospital, Germany; and Department of Neuroradiology (M.P., P.B.S.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland
| | - Astrid Grams
- From the Department of Neurology & Neurological Sciences, Stanford Stroke Center (S.L., M. Mlynash, S.C.), Department of Neurology & Neurological Sciences (S.L.), Division of Child Neurology, and Department of Radiology (B.J., M. Wintermark), Division of Neuroradiology, Stanford University School of Medicine, CA; Department of Pediatrics (R.S.), University Hospital of Muenster; Department of Diagnostic and Interventional Neuroradiology (G.B., J.F., P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department of Neuroradiology (F.D.), University Hospital Bonn; Department of Neuroradiology (O.N.), RWTH Aachen University; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden, Germany; ASST Valcamonica (A.M.), UOSD Neurology, Esine (BS), Brescia, Italy; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Campus Kiel; Institute of Neuroradiology (U.J.-K.), UKSH Campus Lübeck, Germany; Department of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Department of Neuroradiology (M. Möhlenbruch), Heidelberg University Hospital; Department of Radiology (M. Wildgruber), University Hospital, LMU Munich; Department of Neuroradiology (A.K.), Marburg University Hospital, Germany; and Department of Neuroradiology (M.P., P.B.S.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland
| | - Franziska Dorn
- From the Department of Neurology & Neurological Sciences, Stanford Stroke Center (S.L., M. Mlynash, S.C.), Department of Neurology & Neurological Sciences (S.L.), Division of Child Neurology, and Department of Radiology (B.J., M. Wintermark), Division of Neuroradiology, Stanford University School of Medicine, CA; Department of Pediatrics (R.S.), University Hospital of Muenster; Department of Diagnostic and Interventional Neuroradiology (G.B., J.F., P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department of Neuroradiology (F.D.), University Hospital Bonn; Department of Neuroradiology (O.N.), RWTH Aachen University; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden, Germany; ASST Valcamonica (A.M.), UOSD Neurology, Esine (BS), Brescia, Italy; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Campus Kiel; Institute of Neuroradiology (U.J.-K.), UKSH Campus Lübeck, Germany; Department of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Department of Neuroradiology (M. Möhlenbruch), Heidelberg University Hospital; Department of Radiology (M. Wildgruber), University Hospital, LMU Munich; Department of Neuroradiology (A.K.), Marburg University Hospital, Germany; and Department of Neuroradiology (M.P., P.B.S.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland
| | - Omid Nikoubashman
- From the Department of Neurology & Neurological Sciences, Stanford Stroke Center (S.L., M. Mlynash, S.C.), Department of Neurology & Neurological Sciences (S.L.), Division of Child Neurology, and Department of Radiology (B.J., M. Wintermark), Division of Neuroradiology, Stanford University School of Medicine, CA; Department of Pediatrics (R.S.), University Hospital of Muenster; Department of Diagnostic and Interventional Neuroradiology (G.B., J.F., P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department of Neuroradiology (F.D.), University Hospital Bonn; Department of Neuroradiology (O.N.), RWTH Aachen University; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden, Germany; ASST Valcamonica (A.M.), UOSD Neurology, Esine (BS), Brescia, Italy; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Campus Kiel; Institute of Neuroradiology (U.J.-K.), UKSH Campus Lübeck, Germany; Department of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Department of Neuroradiology (M. Möhlenbruch), Heidelberg University Hospital; Department of Radiology (M. Wildgruber), University Hospital, LMU Munich; Department of Neuroradiology (A.K.), Marburg University Hospital, Germany; and Department of Neuroradiology (M.P., P.B.S.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland
| | - Daniel Kaiser
- From the Department of Neurology & Neurological Sciences, Stanford Stroke Center (S.L., M. Mlynash, S.C.), Department of Neurology & Neurological Sciences (S.L.), Division of Child Neurology, and Department of Radiology (B.J., M. Wintermark), Division of Neuroradiology, Stanford University School of Medicine, CA; Department of Pediatrics (R.S.), University Hospital of Muenster; Department of Diagnostic and Interventional Neuroradiology (G.B., J.F., P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department of Neuroradiology (F.D.), University Hospital Bonn; Department of Neuroradiology (O.N.), RWTH Aachen University; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden, Germany; ASST Valcamonica (A.M.), UOSD Neurology, Esine (BS), Brescia, Italy; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Campus Kiel; Institute of Neuroradiology (U.J.-K.), UKSH Campus Lübeck, Germany; Department of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Department of Neuroradiology (M. Möhlenbruch), Heidelberg University Hospital; Department of Radiology (M. Wildgruber), University Hospital, LMU Munich; Department of Neuroradiology (A.K.), Marburg University Hospital, Germany; and Department of Neuroradiology (M.P., P.B.S.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland
| | - Andrea Morotti
- From the Department of Neurology & Neurological Sciences, Stanford Stroke Center (S.L., M. Mlynash, S.C.), Department of Neurology & Neurological Sciences (S.L.), Division of Child Neurology, and Department of Radiology (B.J., M. Wintermark), Division of Neuroradiology, Stanford University School of Medicine, CA; Department of Pediatrics (R.S.), University Hospital of Muenster; Department of Diagnostic and Interventional Neuroradiology (G.B., J.F., P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department of Neuroradiology (F.D.), University Hospital Bonn; Department of Neuroradiology (O.N.), RWTH Aachen University; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden, Germany; ASST Valcamonica (A.M.), UOSD Neurology, Esine (BS), Brescia, Italy; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Campus Kiel; Institute of Neuroradiology (U.J.-K.), UKSH Campus Lübeck, Germany; Department of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Department of Neuroradiology (M. Möhlenbruch), Heidelberg University Hospital; Department of Radiology (M. Wildgruber), University Hospital, LMU Munich; Department of Neuroradiology (A.K.), Marburg University Hospital, Germany; and Department of Neuroradiology (M.P., P.B.S.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland
| | - Ulf Jensen-Kondering
- From the Department of Neurology & Neurological Sciences, Stanford Stroke Center (S.L., M. Mlynash, S.C.), Department of Neurology & Neurological Sciences (S.L.), Division of Child Neurology, and Department of Radiology (B.J., M. Wintermark), Division of Neuroradiology, Stanford University School of Medicine, CA; Department of Pediatrics (R.S.), University Hospital of Muenster; Department of Diagnostic and Interventional Neuroradiology (G.B., J.F., P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department of Neuroradiology (F.D.), University Hospital Bonn; Department of Neuroradiology (O.N.), RWTH Aachen University; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden, Germany; ASST Valcamonica (A.M.), UOSD Neurology, Esine (BS), Brescia, Italy; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Campus Kiel; Institute of Neuroradiology (U.J.-K.), UKSH Campus Lübeck, Germany; Department of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Department of Neuroradiology (M. Möhlenbruch), Heidelberg University Hospital; Department of Radiology (M. Wildgruber), University Hospital, LMU Munich; Department of Neuroradiology (A.K.), Marburg University Hospital, Germany; and Department of Neuroradiology (M.P., P.B.S.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland
| | - Johannes Trenkler
- From the Department of Neurology & Neurological Sciences, Stanford Stroke Center (S.L., M. Mlynash, S.C.), Department of Neurology & Neurological Sciences (S.L.), Division of Child Neurology, and Department of Radiology (B.J., M. Wintermark), Division of Neuroradiology, Stanford University School of Medicine, CA; Department of Pediatrics (R.S.), University Hospital of Muenster; Department of Diagnostic and Interventional Neuroradiology (G.B., J.F., P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department of Neuroradiology (F.D.), University Hospital Bonn; Department of Neuroradiology (O.N.), RWTH Aachen University; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden, Germany; ASST Valcamonica (A.M.), UOSD Neurology, Esine (BS), Brescia, Italy; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Campus Kiel; Institute of Neuroradiology (U.J.-K.), UKSH Campus Lübeck, Germany; Department of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Department of Neuroradiology (M. Möhlenbruch), Heidelberg University Hospital; Department of Radiology (M. Wildgruber), University Hospital, LMU Munich; Department of Neuroradiology (A.K.), Marburg University Hospital, Germany; and Department of Neuroradiology (M.P., P.B.S.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland
| | - Markus Möhlenbruch
- From the Department of Neurology & Neurological Sciences, Stanford Stroke Center (S.L., M. Mlynash, S.C.), Department of Neurology & Neurological Sciences (S.L.), Division of Child Neurology, and Department of Radiology (B.J., M. Wintermark), Division of Neuroradiology, Stanford University School of Medicine, CA; Department of Pediatrics (R.S.), University Hospital of Muenster; Department of Diagnostic and Interventional Neuroradiology (G.B., J.F., P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department of Neuroradiology (F.D.), University Hospital Bonn; Department of Neuroradiology (O.N.), RWTH Aachen University; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden, Germany; ASST Valcamonica (A.M.), UOSD Neurology, Esine (BS), Brescia, Italy; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Campus Kiel; Institute of Neuroradiology (U.J.-K.), UKSH Campus Lübeck, Germany; Department of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Department of Neuroradiology (M. Möhlenbruch), Heidelberg University Hospital; Department of Radiology (M. Wildgruber), University Hospital, LMU Munich; Department of Neuroradiology (A.K.), Marburg University Hospital, Germany; and Department of Neuroradiology (M.P., P.B.S.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland
| | - Jens Fiehler
- From the Department of Neurology & Neurological Sciences, Stanford Stroke Center (S.L., M. Mlynash, S.C.), Department of Neurology & Neurological Sciences (S.L.), Division of Child Neurology, and Department of Radiology (B.J., M. Wintermark), Division of Neuroradiology, Stanford University School of Medicine, CA; Department of Pediatrics (R.S.), University Hospital of Muenster; Department of Diagnostic and Interventional Neuroradiology (G.B., J.F., P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department of Neuroradiology (F.D.), University Hospital Bonn; Department of Neuroradiology (O.N.), RWTH Aachen University; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden, Germany; ASST Valcamonica (A.M.), UOSD Neurology, Esine (BS), Brescia, Italy; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Campus Kiel; Institute of Neuroradiology (U.J.-K.), UKSH Campus Lübeck, Germany; Department of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Department of Neuroradiology (M. Möhlenbruch), Heidelberg University Hospital; Department of Radiology (M. Wildgruber), University Hospital, LMU Munich; Department of Neuroradiology (A.K.), Marburg University Hospital, Germany; and Department of Neuroradiology (M.P., P.B.S.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland
| | - Moritz Wildgruber
- From the Department of Neurology & Neurological Sciences, Stanford Stroke Center (S.L., M. Mlynash, S.C.), Department of Neurology & Neurological Sciences (S.L.), Division of Child Neurology, and Department of Radiology (B.J., M. Wintermark), Division of Neuroradiology, Stanford University School of Medicine, CA; Department of Pediatrics (R.S.), University Hospital of Muenster; Department of Diagnostic and Interventional Neuroradiology (G.B., J.F., P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department of Neuroradiology (F.D.), University Hospital Bonn; Department of Neuroradiology (O.N.), RWTH Aachen University; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden, Germany; ASST Valcamonica (A.M.), UOSD Neurology, Esine (BS), Brescia, Italy; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Campus Kiel; Institute of Neuroradiology (U.J.-K.), UKSH Campus Lübeck, Germany; Department of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Department of Neuroradiology (M. Möhlenbruch), Heidelberg University Hospital; Department of Radiology (M. Wildgruber), University Hospital, LMU Munich; Department of Neuroradiology (A.K.), Marburg University Hospital, Germany; and Department of Neuroradiology (M.P., P.B.S.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland
| | - André Kemmling
- From the Department of Neurology & Neurological Sciences, Stanford Stroke Center (S.L., M. Mlynash, S.C.), Department of Neurology & Neurological Sciences (S.L.), Division of Child Neurology, and Department of Radiology (B.J., M. Wintermark), Division of Neuroradiology, Stanford University School of Medicine, CA; Department of Pediatrics (R.S.), University Hospital of Muenster; Department of Diagnostic and Interventional Neuroradiology (G.B., J.F., P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department of Neuroradiology (F.D.), University Hospital Bonn; Department of Neuroradiology (O.N.), RWTH Aachen University; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden, Germany; ASST Valcamonica (A.M.), UOSD Neurology, Esine (BS), Brescia, Italy; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Campus Kiel; Institute of Neuroradiology (U.J.-K.), UKSH Campus Lübeck, Germany; Department of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Department of Neuroradiology (M. Möhlenbruch), Heidelberg University Hospital; Department of Radiology (M. Wildgruber), University Hospital, LMU Munich; Department of Neuroradiology (A.K.), Marburg University Hospital, Germany; and Department of Neuroradiology (M.P., P.B.S.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland
| | - Marios Psychogios
- From the Department of Neurology & Neurological Sciences, Stanford Stroke Center (S.L., M. Mlynash, S.C.), Department of Neurology & Neurological Sciences (S.L.), Division of Child Neurology, and Department of Radiology (B.J., M. Wintermark), Division of Neuroradiology, Stanford University School of Medicine, CA; Department of Pediatrics (R.S.), University Hospital of Muenster; Department of Diagnostic and Interventional Neuroradiology (G.B., J.F., P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department of Neuroradiology (F.D.), University Hospital Bonn; Department of Neuroradiology (O.N.), RWTH Aachen University; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden, Germany; ASST Valcamonica (A.M.), UOSD Neurology, Esine (BS), Brescia, Italy; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Campus Kiel; Institute of Neuroradiology (U.J.-K.), UKSH Campus Lübeck, Germany; Department of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Department of Neuroradiology (M. Möhlenbruch), Heidelberg University Hospital; Department of Radiology (M. Wildgruber), University Hospital, LMU Munich; Department of Neuroradiology (A.K.), Marburg University Hospital, Germany; and Department of Neuroradiology (M.P., P.B.S.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland
| | - Peter B Sporns
- From the Department of Neurology & Neurological Sciences, Stanford Stroke Center (S.L., M. Mlynash, S.C.), Department of Neurology & Neurological Sciences (S.L.), Division of Child Neurology, and Department of Radiology (B.J., M. Wintermark), Division of Neuroradiology, Stanford University School of Medicine, CA; Department of Pediatrics (R.S.), University Hospital of Muenster; Department of Diagnostic and Interventional Neuroradiology (G.B., J.F., P.B.S.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department of Neuroradiology (F.D.), University Hospital Bonn; Department of Neuroradiology (O.N.), RWTH Aachen University; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden, Germany; ASST Valcamonica (A.M.), UOSD Neurology, Esine (BS), Brescia, Italy; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Campus Kiel; Institute of Neuroradiology (U.J.-K.), UKSH Campus Lübeck, Germany; Department of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Department of Neuroradiology (M. Möhlenbruch), Heidelberg University Hospital; Department of Radiology (M. Wildgruber), University Hospital, LMU Munich; Department of Neuroradiology (A.K.), Marburg University Hospital, Germany; and Department of Neuroradiology (M.P., P.B.S.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland
| |
Collapse
|
27
|
Hashimoto T, Kunieda T, Honda T, Scalzo F, Ali L, Hinman J, Rao N, Nour M, Bahr-Hosseini M, Saver J, Raychev R, Liebeskind D. Reduced Leukoaraiosis, Noncardiac Embolic Stroke Etiology, and Shorter Thrombus Length Indicate Good Leptomeningeal Collateral Flow in Embolic Large-Vessel Occlusion. AJNR Am J Neuroradiol 2022; 43:63-69. [PMID: 34794948 PMCID: PMC8757540 DOI: 10.3174/ajnr.a7360] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 09/20/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND PURPOSE Acute leptomeningeal collateral flow is vital for maintaining perfusion to penumbral tissue in acute ischemic stroke caused by large-vessel occlusion. In this study, we aimed to investigate the clinically available indicators of leptomeningeal collateral variability in embolic large-vessel occlusion. MATERIALS AND METHODS Among prospectively registered consecutive patients with acute embolic anterior circulation large-vessel occlusion treated with thrombectomy, we analyzed 108 patients admitted from January 2015 to December 2019 who underwent evaluation of leptomeningeal collateral status on pretreatment CTA. Clinical characteristics, extent of leukoaraiosis on MR imaging, embolic stroke subtype, time of imaging, occlusive thrombus characteristics, presenting stroke severity, and clinical outcome were collected. The clinical indicators of good collateral status (>50% collateral filling of the occluded territory) were analyzed using multivariate logistic regression analysis. RESULTS Good collateral status was present in 67 patients (62%) and associated with independent functional outcomes at 3 months. Reduced leukoaraiosis (total Fazekas score, 0-2) was positively related to good collateral status (OR, 9.57; 95% CI, 2.49-47.75), while the cardioembolic stroke mechanism was inversely related to good collateral status (OR, 0.17; 95% CI, 0.02-0.87). In 82 patients with cardioembolic stroke, shorter thrombus length (OR, 0.91 per millimeter increase; 95% CI, 0.82-0.99) and reduced leukoaraiosis (OR, 5.79; 95% CI, 1.40-29.61) were independently related to good collateral status. CONCLUSIONS Among patients with embolic large-vessel occlusion, reduced leukoaraiosis, noncardiac embolism mechanisms including embolisms of arterial or undetermined origin, and shorter thrombus length in cardioembolism are indicators of good collateral flow.
Collapse
Affiliation(s)
- T. Hashimoto
- From the Department of Neurology and Comprehensive Stroke Center, University of California, Los Angeles, Los Angeles, California
| | - T. Kunieda
- From the Department of Neurology and Comprehensive Stroke Center, University of California, Los Angeles, Los Angeles, California
| | - T. Honda
- From the Department of Neurology and Comprehensive Stroke Center, University of California, Los Angeles, Los Angeles, California
| | - F. Scalzo
- From the Department of Neurology and Comprehensive Stroke Center, University of California, Los Angeles, Los Angeles, California
| | - L. Ali
- From the Department of Neurology and Comprehensive Stroke Center, University of California, Los Angeles, Los Angeles, California
| | - J.D. Hinman
- From the Department of Neurology and Comprehensive Stroke Center, University of California, Los Angeles, Los Angeles, California
| | - N.M. Rao
- From the Department of Neurology and Comprehensive Stroke Center, University of California, Los Angeles, Los Angeles, California
| | - M. Nour
- From the Department of Neurology and Comprehensive Stroke Center, University of California, Los Angeles, Los Angeles, California
| | - M. Bahr-Hosseini
- From the Department of Neurology and Comprehensive Stroke Center, University of California, Los Angeles, Los Angeles, California
| | - J.L. Saver
- From the Department of Neurology and Comprehensive Stroke Center, University of California, Los Angeles, Los Angeles, California
| | - R. Raychev
- From the Department of Neurology and Comprehensive Stroke Center, University of California, Los Angeles, Los Angeles, California
| | - D. Liebeskind
- From the Department of Neurology and Comprehensive Stroke Center, University of California, Los Angeles, Los Angeles, California
| |
Collapse
|
28
|
de Bortoli T, Boehm-Sturm P, Koch SP, Nieminen-Kelhä M, Wessels L, Mueller S, Ielacqua GD, Klohs J, Vajkoczy P, Hecht N. Three-Dimensional Iron Oxide Nanoparticle-Based Contrast-Enhanced Magnetic Resonance Imaging for Characterization of Cerebral Arteriogenesis in the Mouse Neocortex. Front Neurosci 2021; 15:756577. [PMID: 34899163 PMCID: PMC8662986 DOI: 10.3389/fnins.2021.756577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/02/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: Subsurface blood vessels in the cerebral cortex have been identified as a bottleneck in cerebral perfusion with the potential for collateral remodeling. However, valid techniques for non-invasive, longitudinal characterization of neocortical microvessels are still lacking. In this study, we validated contrast-enhanced magnetic resonance imaging (CE-MRI) for in vivo characterization of vascular changes in a model of spontaneous collateral outgrowth following chronic cerebral hypoperfusion. Methods: C57BL/6J mice were randomly assigned to unilateral internal carotid artery occlusion or sham surgery and after 21 days, CE-MRI based on T2*-weighted imaging was performed using ultra-small superparamagnetic iron oxide nanoparticles to obtain subtraction angiographies and steady-state cerebral blood volume (ss-CBV) maps. First pass dynamic susceptibility contrast MRI (DSC-MRI) was performed for internal validation of ss-CBV. Further validation at the histological level was provided by ex vivo serial two-photon tomography (STP). Results: Qualitatively, an increase in vessel density was observed on CE-MRI subtraction angiographies following occlusion; however, a quantitative vessel tracing analysis was prone to errors in our model. Measurements of ss-CBV reliably identified an increase in cortical vasculature, validated by DSC-MRI and STP. Conclusion: Iron oxide nanoparticle-based ss-CBV serves as a robust, non-invasive imaging surrogate marker for neocortical vessels, with the potential to reduce and refine preclinical models targeting the development and outgrowth of cerebral collateralization.
Collapse
Affiliation(s)
- Till de Bortoli
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Berlin, Germany
| | - Philipp Boehm-Sturm
- Center for Stroke Research Berlin (CSB), Berlin, Germany.,Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Cluster of Excellence and Charité Core Facility 7T Experimental MRIs, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Stefan P Koch
- Center for Stroke Research Berlin (CSB), Berlin, Germany.,Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Cluster of Excellence and Charité Core Facility 7T Experimental MRIs, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Melina Nieminen-Kelhä
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Berlin, Germany
| | - Lars Wessels
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Berlin, Germany
| | - Susanne Mueller
- Center for Stroke Research Berlin (CSB), Berlin, Germany.,Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Cluster of Excellence and Charité Core Facility 7T Experimental MRIs, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Giovanna D Ielacqua
- Institute for Biomedical Engineering, University of Zurich and ETH Zürich, Zurich, Switzerland
| | - Jan Klohs
- Institute for Biomedical Engineering, University of Zurich and ETH Zürich, Zurich, Switzerland
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Berlin, Germany
| |
Collapse
|
29
|
Saber H, Liebeskind DS. Infarct Progression in the Early and Late Phases of Acute Ischemic Stroke. Neurology 2021; 97:S60-S67. [PMID: 34785605 DOI: 10.1212/wnl.0000000000012795] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF REVIEW To explore factors associated with infarct progression in the early and late phase of acute ischemic stroke in patients undergoing endovascular therapy. RECENT FINDINGS Following ischemic stroke, brain injury can progress at a variable rate, at the expense of "penumbral tissue," which is the ischemic tissue at risk of infarction. Despite dramatic advances in endovascular stroke therapies with early revascularization in more than 80% of cases, nearly half of patients do not achieve functional independence despite successful recanalization. This is largely attributed to the irreversible damage that is already extensive at the time of revascularization. SUMMARY The underlying pathophysiology and determinants of the core infarct progression are complex and multifactorial, depending on a balance between brain energy consumption and collateral perfusion supply. It is crucial to develop creative and individualized theranostics to predict infarct progression and to "freeze" the tissue at risk prior to recanalization.
Collapse
Affiliation(s)
- Hamidreza Saber
- From the Department of Neurology, UCLA David Geffen School of Medicine, Los Angeles, CA
| | - David S Liebeskind
- From the Department of Neurology, UCLA David Geffen School of Medicine, Los Angeles, CA.
| |
Collapse
|
30
|
Scheldeman L, Wouters A, Lemmens R. Imaging selection for reperfusion therapy in acute ischemic stroke beyond the conventional time window. J Neurol 2021; 269:1715-1723. [PMID: 34718883 DOI: 10.1007/s00415-021-10872-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/18/2021] [Accepted: 10/20/2021] [Indexed: 01/15/2023]
Abstract
Originally, the efficacy of acute ischemic stroke treatment with thrombolysis or thrombectomy was only proven in narrow time windows of, respectively, 4.5 and 6 h after onset. Introducing imaging-based selection beyond non-contrast enhanced computed tomography has expanded the treatment window, focusing on presumed tissue status rather than solely on time after stroke onset. Different mismatch concepts have been adopted in clinical practice to select patients in the extended and unknown time window based on findings from randomized controlled trials. Since various concepts exist that can identify patients likely to benefit from reperfusion strategies, clinicians may wonder which imaging modality may be preferred in the emergency setting. In this review, we will discuss the different mismatch concepts and their practical implementation for patient selection for thrombolysis or thrombectomy, beyond the conventional time window.
Collapse
Affiliation(s)
- Lauranne Scheldeman
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium. .,Department of Neurosciences, Experimental Neurology, KU Leuven, University of Leuven, Leuven, Belgium. .,Center for Brain and Disease Research, Laboratory of Neurobiology, VIB, Leuven, Belgium.
| | - Anke Wouters
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium.,Department of Neurosciences, Experimental Neurology, KU Leuven, University of Leuven, Leuven, Belgium.,Center for Brain and Disease Research, Laboratory of Neurobiology, VIB, Leuven, Belgium.,Neurology, Amsterdam University Medical Centers, AMC, Amsterdam, The Netherlands
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium.,Department of Neurosciences, Experimental Neurology, KU Leuven, University of Leuven, Leuven, Belgium.,Center for Brain and Disease Research, Laboratory of Neurobiology, VIB, Leuven, Belgium
| |
Collapse
|
31
|
Corneal nerve loss as a surrogate marker for poor pial collaterals in patients with acute ischemic stroke. Sci Rep 2021; 11:19718. [PMID: 34611233 PMCID: PMC8492683 DOI: 10.1038/s41598-021-99131-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 09/17/2021] [Indexed: 01/01/2023] Open
Abstract
In patients with acute ischemic stroke, pial collaterals play a key role in limiting neurological disability by maintaining blood flow to ischemic penumbra. We hypothesized that patient with poor pial collaterals will have greater corneal nerve and endothelial cell abnormalities. In a cross-sectional study, 35 patients with acute ischemic stroke secondary to middle cerebral artery (MCA) occlusion with poor (n = 12) and moderate-good (n = 23) pial collaterals and 35 healthy controls underwent corneal confocal microscopy and quantification of corneal nerve and endothelial cell morphology. In patients with MCA stroke, corneal nerve fibre length (CNFL) (P < 0.001), corneal nerve fibre density (CNFD) (P = 0.025) and corneal nerve branch density (CNBD) (P = 0.002) were lower compared to controls. Age, BMI, cholesterol, triglycerides, HDL, LDL, systolic blood pressure, NIHSS and endothelial cell parameters did not differ but mRS was higher (p = 0.023) and CNFL (p = 0.026) and CNBD (p = 0.044) were lower in patients with poor compared to moderate-good collaterals. CNFL and CNBD distinguished subjects with poor from moderate-good pial collaterals with an AUC of 72% (95% CI 53–92%) and 71% (95% CI 53–90%), respectively. Corneal nerve loss is greater in patients with poor compared to moderate-good pial collaterals and may act as a surrogate marker for pial collateral status in patients with ischemic stroke.
Collapse
|
32
|
Yu F, Feng X, Li X, Liu Z, Liao D, Luo Y, Wei M, Huang Q, Zhang L, Xia J. Association of Plasma Metabolic Biomarker Sphingosine-1-Phosphate With Cerebral Collateral Circulation in Acute Ischemic Stroke. Front Physiol 2021; 12:720672. [PMID: 34489737 PMCID: PMC8416917 DOI: 10.3389/fphys.2021.720672] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 07/13/2021] [Indexed: 12/27/2022] Open
Abstract
Background: The contribution of metabolic profile to the cerebral collateral circulation in acute ischemic stroke (AIS) has not been fully outlined. In this study, we conducted a metabolomic study to assess the relationship between the metabolic biomarkers and the collateral status of AIS. Methods: A two-stage study was conducted from September 2019 to June 2021 in our hospital. There were 96 subjects including 66 patients with AIS and 30 healthy controls in the discovery stage and 80 subjects including 53 patients with AIS and 27 healthy controls in the validation stage. Collateral circulation was assessed by the Tan score based on computed tomographic angiography (CTA). Liquid chromatography-tandem mass spectrometry was used to identify differential metabolic markers. Then, an ELISA was employed to detect the plasma levels of sphingosine-1-phosphate (S1P). Results:There were 114 differential metabolites between patients with AIS and control groups and 37 differential metabolites between good collateral circulation (GCC) and poor collateral circulation (PCC) groups. The pathway enrichment analysis revealed that arginine biosynthesis was the only statistically significant pathway between AIS and control groups and sphingolipid metabolism was the only statistically significant pathway between GCC and PCC groups. The differential metabolites sphinganine-1-phosphate (SA1P) and S1P belong to the sphingolipid metabolism. In the discovery stage, when the GCC group was compared with the PCC group, the receiver operating characteristic (ROC) analysis showed that plasma SA1P relative levels demonstrated an area under the curve (AUC) of 0.719 (95% CI: 0.582–0.834), and S1P levels demonstrated an AUC of 0.701 (95% CI: 0.567–0.819). In addition, both plasma SA1P and S1P relative levels showed significant negative correlations with the 90-day modified Rankin Scale (mRS) score. In the validation sample, higher plasma S1P levels were independent predictors of GCC (p = 0.014), and plasma S1P levels demonstrated an AUC of 0.738 (95% CI: 0.599–0.849) to differentiate patients with GCC from patients with PCC. In addition, plasma S1P levels also showed significant negative correlations with the 90-day mRS score. Conclusion: We first illustrated the association between plasma metabolic profiles and cerebral collateral circulation in patients with AIS. Plasma S1P levels might be a potential diagnostic biomarker for predicting collateral circulation status in patients with AIS.
Collapse
Affiliation(s)
- Fang Yu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Xianjing Feng
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Xi Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Zeyu Liu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Di Liao
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Yunfang Luo
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Minping Wei
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Qin Huang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Lin Zhang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Jian Xia
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.,Clinical Research Center for Cerebrovascular Disease of Hunan Province, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| |
Collapse
|
33
|
Lee M, Kim CH, Kim Y, Jang MU, Mo HJ, Lee SH, Lim JS, Yu KH, Lee BC, Oh MS. High Triglyceride Glucose Index Is Associated with Poor Outcomes in Ischemic Stroke Patients after Reperfusion Therapy. Cerebrovasc Dis 2021; 50:691-699. [PMID: 34229319 DOI: 10.1159/000516950] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 04/28/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The triglyceride glucose index (TyG index) is a simple and reliable surrogate marker of insulin resistance (IR) that can predict functional outcomes and mortality after acute ischemic stroke (AIS). However, it is unclear whether the TyG index is associated with functional outcomes in patients with stroke who receive reperfusion therapy. Thus, we aimed to explore the prognostic value of the TyG index for the clinical outcomes of patients with AIS who underwent reperfusion therapy. METHODS We retrospectively assessed patients with AIS, with occlusion of either the middle cerebral artery or internal carotid artery, who were evaluated using multiphase computed tomography angiography (mCTA) and received reperfusion therapy. The TyG index was calculated as "ln [fasting glucose level (mg/dL) × triglyceride level (mg/dL)]/2." Collateral status was evaluated using mCTA based on the University of Calgary Scale. Clinical outcomes included 3-month functional outcomes, early neurological deterioration, recanalization status, and hemorrhagic transformation. RESULTS In all, 183 subjects (age 69.5 ± 12.4 years; men, 59.0%) were enrolled. The median initial National Institutes of Health Stroke Scale score was 15.0 (interquartile range [IQR] 11-18). The median TyG index was 4.8 (IQR, 4.6-5.1), and 158 patients had TyG levels >4.49, which represents the presence of IR. On univariate analysis, a higher TyG index was associated with both early neurological deterioration (18.4 vs. 0.0%, p = 0.041) and a 3-month poor functional outcome (mRS3-6) (61.4 vs. 32.0%, p = 0.011). After adjusting for multiple variables, including age, sex, type of reperfusion therapy, recanalization status, initial stroke severity, type of stroke, and history of hypertension and diabetes, high TyG index remained an independent predictor of a poor 3-month functional outcome (adjusted OR, 5.22; p = 0.014). However, TyG levels were not significantly associated with collateral status (p = 0.756). CONCLUSIONS IR, represented by a high TyG index, may predict poor 3-month functional outcomes in patients with AIS who undergo reperfusion therapy.
Collapse
Affiliation(s)
- Minwoo Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym Neurological Institute, Hallym University College of Medicine, Anyang, Republic of Korea,
| | - Chul-Ho Kim
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Yerim Kim
- Department of Neurology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Min Uk Jang
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
| | - Hee Jung Mo
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
| | - Sang-Hwa Lee
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Jae-Sung Lim
- Department of Neurology, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym Neurological Institute, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym Neurological Institute, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Mi Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym Neurological Institute, Hallym University College of Medicine, Anyang, Republic of Korea
| |
Collapse
|
34
|
Li Z, Zhang H, Han J, Chu Z, Zhao S, Yang Q, Huang X, Zhou Z. Time Course and Clinical Relevance of Neurological Deterioration After Endovascular Recanalization Therapy for Anterior Circulation Large Vessel Occlusion Stroke. Front Aging Neurosci 2021; 13:651614. [PMID: 34267642 PMCID: PMC8277420 DOI: 10.3389/fnagi.2021.651614] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 06/04/2021] [Indexed: 11/23/2022] Open
Abstract
Neurological deterioration (ND) is a devastating complication for patients with ischemic stroke after endovascular recanalization therapy (EVT). We aimed to investigate the time course and clinical relevance of ND after EVT. Consecutive patients with acute ischemic stroke who underwent EVT for large arterial occlusions of the anterior cerebral circulation were enrolled. The National Institutes of Health Stroke Scale (NIHSS) scores were assessed before EVT, at the end of EVT, at 24 h (d1), on day 3 (d3), on day 15 (d15), at discharge and anytime when ND was indicated. ND was defined as an increase of ≥ 4 points in the NIHSS score and was divided into acute ND (AD, within 24 h), subacute ND (SD, d1–d3), and delayed ND (DD, d3–d15 or discharge). Using multivariable logistic regression analysis, we explored predictors and outcomes of ND at different time periods. As a result, of 343 patients, 129 (37.6%) experienced ND, including 90 (26.2%) with AD, 27 (7.9%) with SD and 12 (3.5%) with DD. Multivariable logistic regression analysis revealed that history of hypertension, cardioembolic stroke, lower Alberta Stroke Program Early Computed Tomography Score (ASPECTS), and poor collaterals were significantly associated with an increased risk of AD; history of hypertension, lower ASPECTS, poor collaterals, and unsuccessful recanalization, with SD; and high admission NIHSS score, with DD. In addition, patients who experienced AD (OR = 10.22, P < 0.001), SD (OR = 15.89, P = 0.004), or DD (OR = 8.31, P = 0.015) were more likely to have poor outcomes. ND was a strong predictor of poor stroke outcomes. Management of related risk factors at different ND time periods might improve the prognosis of EVT.
Collapse
Affiliation(s)
- Zibao Li
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Hongchuan Zhang
- Department of Radiology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Jian Han
- Department of Neurology, Huangshan City People's Hospital, Huangshan, China
| | - Zhaohu Chu
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Shoucai Zhao
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Qian Yang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Xianjun Huang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| |
Collapse
|
35
|
Guebel DV, Torres NV, Acebes Á. Mapping the transcriptomic changes of endothelial compartment in human hippocampus across aging and mild cognitive impairment. Biol Open 2021; 10:bio057950. [PMID: 34184731 PMCID: PMC8181899 DOI: 10.1242/bio.057950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 04/07/2021] [Indexed: 12/17/2022] Open
Abstract
Compromise of the vascular system has important consequences on cognitive abilities and neurodegeneration. The identification of the main molecular signatures present in the blood vessels of human hippocampus could provide the basis to understand and tackle these pathologies. As direct vascular experimentation in hippocampus is problematic, we achieved this information by computationally disaggregating publicly available whole microarrays data of human hippocampal homogenates. Three conditions were analyzed: 'Young Adults', 'Aged', and 'aged with Mild Cognitive Impairment' (MCI). The genes identified were contrasted against two independent data-sets. Here we show that the endothelial cells from the Younger Group appeared in an 'activated stage'. In turn, in the Aged Group, the endothelial cells showed a significant loss of response to shear stress, changes in cell adhesion molecules, increased inflammation, brain-insulin resistance, lipidic alterations, and changes in the extracellular matrix. Some specific changes in the MCI group were also detected. Noticeably, in this study the features arisen from the Aged Group (high tortuosity, increased bifurcations, and smooth muscle proliferation), pose the need for further experimental verification to discern between the occurrence of arteriogenesis and/or vascular remodeling by capillary arterialization. This article has an associated First Person interview with the first author of the paper.
Collapse
Affiliation(s)
- Daniel V. Guebel
- Program Agustín de Betancourt, Universidad de La Laguna, Tenerife 38200, Spain
- Department of Biochemistry, Cellular Biology and Genetics, Institute of Biomedical Technologies, Universidad de La Laguna, Tenerife 38200, Spain
| | - Néstor V. Torres
- Department of Biochemistry, Cellular Biology and Genetics, Institute of Biomedical Technologies, Universidad de La Laguna, Tenerife 38200, Spain
| | - Ángel Acebes
- Department of Basic Medical Sciences, Institute of Biomedical Technologies, University of La Laguna, Tenerife 38200, Spain
| |
Collapse
|
36
|
Karamchandani RR, Rhoten JB, Strong D, Chang B, Asimos AW. Mortality after large artery occlusion acute ischemic stroke. Sci Rep 2021; 11:10033. [PMID: 33976365 PMCID: PMC8113323 DOI: 10.1038/s41598-021-89638-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 04/29/2021] [Indexed: 12/23/2022] Open
Abstract
Despite randomized trials showing a functional outcome benefit in favor of endovascular therapy (EVT), large artery occlusion acute ischemic stroke is associated with high mortality. We performed a retrospective analysis from a prospectively collected code stroke registry and included patients presenting between November 2016 and April 2019 with internal carotid artery and/or proximal middle cerebral artery occlusions. Ninety-day mortality status from registry follow-up was corroborated with the Social Security Death Index. A multivariable logistic regression model was fitted to determine demographic and clinical characteristics associated with 90-day mortality. Among 764 patients, mortality rate was 26%. Increasing age (per 10 years, OR 1.48, 95% CI 1.25-1.76; p < 0.0001), higher presenting NIHSS (per 1 point, OR 1.05, 95% CI 1.01-1.09, p = 0.01), and higher discharge modified Rankin Score (per 1 point, OR 4.27, 95% CI 3.25-5.59, p < 0.0001) were independently associated with higher odds of mortality. Good revascularization therapy, compared to no EVT, was independently associated with a survival benefit (OR 0.61, 95% CI 0.35-1.00, p = 0.048). We identified factors independently associated with mortality in a highly lethal form of stroke which can be used in clinical decision-making, prognostication, and in planning future studies.
Collapse
Affiliation(s)
- Rahul R Karamchandani
- Department of Neurology, Neurosciences Institute, Atrium Health, 1000 Blythe Blvd, Charlotte, NC, 28203, USA.
| | - Jeremy B Rhoten
- Department of Neurology, Neurosciences Institute, Atrium Health, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Dale Strong
- Information and Analytics Services, Atrium Health, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Brenda Chang
- Information and Analytics Services, Atrium Health, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Andrew W Asimos
- Department of Emergency Medicine, Neurosciences Institute, Atrium Health, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| |
Collapse
|
37
|
Derraz I, Ahmed R, Benali A, Corti L, Cagnazzo F, Dargazanli C, Gascou G, Riquelme C, Lefevre PH, Bonafe A, Arquizan C, Costalat V. FLAIR vascular hyperintensities and functional outcome in nonagenarians with anterior circulation large-vessel ischemic stroke treated with endovascular thrombectomy. Eur Radiol 2021; 31:7406-7416. [PMID: 33851277 DOI: 10.1007/s00330-021-07866-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 03/04/2021] [Accepted: 03/11/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To establish whether imaging assessments of irreversibly injured ischemic core and potentially salvageable penumbral volumes and collateral circulation were associated with functional outcome in nonagenarians (90 years or older) undergoing endovascular thrombectomy (EVT). METHODS Data from a prospectively maintained institutional registry of consecutive stroke patients treated with EVT from January 2012 to December 2018 were retrospectively analyzed. Functional outcome was evaluated with the modified Rankin scale (mRS) at 3 months. mRS score of 0-3 was defined as a good clinical outcome. Ischemic core and penumbral volumes were calculated using the RAPID software. Quantification of collateral circulation was performed using a fluid-attenuated inversion recovery vascular hyperintensity (FVH)-Alberta Stroke Program Early CT Score (ASPECTS) rating system. RESULTS Among 85 patients (age, 92.4 ± 2.6 years; men, 30.6%) treated with EVT, good outcome (mRS 0-3) was achieved in 29 (34.1%) patients and 31 (36.5%) patients died at 90 days. The median estimated ischemic core volume was 15 mL (IQR, 7-27 mL). The median mismatch volume was 83 mL (IQR, 43-120 mL). The median FVH score was 4 (IQR, 3-4). FVH score was independently associated with good functional outcome (adjusted OR = 1.96 [95% CI, 1.16-3.32]; p = 0.01 per 1-point increase) and mortality (adjusted OR = 0.54 [95% CI, 0.34-0.85]; p = 0.007 per 1-point increase). Ischemic core and mismatch volumes were associated with neither good outcome nor mortality. CONCLUSIONS In nonagenarians with anterior circulation large-vessel ischemic stroke, good collaterals as measured by the FVH-ASPECTS rating system are independently associated with improved outcomes and may help select patients for reperfusion therapy in this frail population. KEY POINTS • Endovascular thrombectomy can allow at least 1 in 3 patients older than 90 years of age to achieve good functional outcome (modified Rankin scale of 0-3) at 3 months. • Functional outcome at 3 months is associated with pre-stroke status (number and severity of patients' comorbidities). • A higher FVH score (as reflected by higher FLAIR vascular hyperintensity [FVH]-Alberta Stroke Program Early CT Score [ASPECTS] values) is independently associated with better 3-month functional outcome and mortality in nonagenarians with anterior circulation ischemic stroke.
Collapse
Affiliation(s)
- Imad Derraz
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France.
| | - Raed Ahmed
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Amel Benali
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Lucas Corti
- Department of Neurology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Federico Cagnazzo
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Cyril Dargazanli
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Gregory Gascou
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Carlos Riquelme
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Pierre-Henri Lefevre
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Alain Bonafe
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Caroline Arquizan
- Department of Neurology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Vincent Costalat
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| |
Collapse
|
38
|
He G, Wei L, Lu H, Li Y, Zhao Y, Zhu Y. Advances in imaging acute ischemic stroke: evaluation before thrombectomy. Rev Neurosci 2021; 32:495-512. [PMID: 33600678 DOI: 10.1515/revneuro-2020-0061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/05/2020] [Indexed: 11/15/2022]
Abstract
Recent advances in neuroimaging have demonstrated significant assessment benefits and appropriate triage of patients based on specific clinical and radiological features in the acute stroke setting. Endovascular thrombectomy is arguably the most important aspect of acute stroke management with an extended time window. Imaging-based physiological information may potentially shift the treatment paradigm from a rigid time-based model to a more flexible and individualized, tissue-based approach, increasing the proportion of patients amenable to treatment. Various imaging modalities are routinely used in the diagnosis and management of acute ischemic stroke, including multimodal computed tomography (CT) and magnetic resonance imaging (MRI). Therefore, these imaging methods should provide information beyond the presence or absence of intracranial hemorrhage as well as the presence and extent of the ischemic core, collateral circulation and penumbra in patients with neurological symptoms. Target mismatch may optimize selection of patients with late or unknown symptom onset who would potentially be eligible for revascularization therapy. The purpose of this study was to provide a comprehensive review of the current evidence about efficacy and theoretical basis of present imaging modalities, and explores future directions for imaging in the management of acute ischemic stroke.
Collapse
Affiliation(s)
- Guangchen He
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai200233, China
| | - Liming Wei
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai200233, China
| | - Haitao Lu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai200233, China
| | - Yuehua Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai200233, China
| | - Yuwu Zhao
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai200233, China
| | - Yueqi Zhu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai200233, China
| |
Collapse
|
39
|
Kanoke A, Akamatsu Y, Nishijima Y, To E, Lee CC, Li Y, Wang RK, Tominaga T, Liu J. The impact of native leptomeningeal collateralization on rapid blood flow recruitment following ischemic stroke. J Cereb Blood Flow Metab 2020; 40:2165-2178. [PMID: 32669022 PMCID: PMC7585920 DOI: 10.1177/0271678x20941265] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The leptomeningeal collateral status is an independent predictor of stroke outcome. By means of optical coherent tomography angiography to compare two mouse strains with different extent of native leptomeningeal collateralization, we determined the spatiotemporal dynamics of collateral flow and downstream hemodynamics following ischemic stroke. A robust recruitment of leptomeningeal collateral flow was detected immediately after middle cerebral artery (MCA) occlusion in C57BL/6 mice, with continued expansion over the course of seven days. In contrast, little collateral recruitment was seen in Balb/C mice during- and one day after MCAO, which coincided with a greater infarct size and worse functional outcome compared to C57BL/6, despite a slight improvement of cortical perfusion seven days after MCAO. Both strains of mice experienced a reduction of blood flow in the penetrating arterioles (PA) by more than 90% 30-min after dMCAO, although the decrease of PA flow was greater and the recovery was less in the Balb/C mice. Further, Balb/C mice also displayed a prolonged greater heterogeneity of capillary transit time after dMCAO in the MCA territory compared to C57BL/6 mice. Our data suggest that the extent of native leptomeningeal collaterals affects downstream hemodynamics with a long lasting impact in the microvascular bed after cortical stroke.
Collapse
Affiliation(s)
- Atsushi Kanoke
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.,SFVAMC, San Francisco, CA, USA.,Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yosuke Akamatsu
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.,SFVAMC, San Francisco, CA, USA.,Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuo Nishijima
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.,SFVAMC, San Francisco, CA, USA.,Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Eric To
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.,SFVAMC, San Francisco, CA, USA
| | - Chih C Lee
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.,SFVAMC, San Francisco, CA, USA
| | - Yuandong Li
- Department of Bioengineering, College of Engineering and School of Medicine, University of Washington, Seattle, WA, USA
| | - Ruikang K Wang
- Department of Bioengineering, College of Engineering and School of Medicine, University of Washington, Seattle, WA, USA
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jialing Liu
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.,SFVAMC, San Francisco, CA, USA
| |
Collapse
|
40
|
Kim BJ, Menon BK, Kim JY, Shin DW, Baik SH, Jung C, Han MK, Demchuk A, Bae HJ. Endovascular Treatment After Stroke Due to Large Vessel Occlusion for Patients Presenting Very Late From Time Last Known Well. JAMA Neurol 2020; 78:2769023. [PMID: 32777014 PMCID: PMC7418043 DOI: 10.1001/jamaneurol.2020.2804] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/19/2020] [Indexed: 12/22/2022]
Abstract
IMPORTANCE Endovascular treatment (EVT) after ischemic stroke due to emergent large vessel occlusion is usually constrained by a specific window of less than 16 to 24 hours from the time the patient was last known well (LKW). Patients with slow progression and tenacious collateral circulation may persist beyond 16 hours. OBJECTIVES To estimate the prevalence of salvageable tissues 16 hours or more from LKW after ischemic stroke due to emergent large vessel occlusion and investigate the effectiveness of EVT in delayed large vessel occlusion. DESIGN, SETTING AND PARTICIPANTS In this case-control study, from a total of 8032 patients with stroke or transient ischemic attack who were admitted between January 1, 2012, and December 31, 2018, to a single referral university hospital, 150 patients were retrospectively identified who had an acute ischemic stroke with internal carotid artery or middle cerebral artery occlusion, had a baseline National Institutes of Health Stroke Scale score of 6 or more, and arrived 16 hours or more from time LKW. The decision for EVT was made by a treating physician according to the institutional protocol. MAIN OUTCOMES AND MEASURES Baseline ischemic core, collateral circulation status, and computed tomographic or magnetic resonance perfusion parameters were retrospectively quantified. Follow-up images, evaluated a median of 93 hours (interquartile range, 66-120 hours) after arrival, were used to assess the final infarct and hemorrhagic transformation. The main outcome was the modified Rankin Scale score at 90 days. RESULTS For 150 patients (81 men [54%]; mean [SD] age at onset, 70.1 [13.0] years; median National Institutes of Health Stroke Scale score, 12 [interquartile range, 8-18]), the median ischemic core volume was 11.5 mL (interquartile range, 0-39.1 mL), the median penumbra volume (>6 seconds) was 55.0 mL (interquartile range, 15-128 mL), and the median mismatch ratio was 4.0 (interquartile range, 0.9-18.3). By the imaging inclusion criteria for EVT trials, there were 50 DAWN (DWI or CTP Assessment With Clinical Mismatch in the Triage of Wake-up and Late Presenting Strokes Undergoing Neurointervention With Trevo)-eligible patients (33%), 58 DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke)-eligible patients (39%), and 57 ESCAPE (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times)-eligible patients (38%). Endovascular treatment was performed for 24 patients (16%). In propensity score-matched analyses, EVT was associated with better odds of a 90-day modified Rankin Scale score of 0 to 2 (adjusted odds ratio, 11.08 [95% CI, 1.88-108.60]) and a 90-day modified Rankin Scale score shift (common adjusted odds ratio, 5.17 [95% CI, 1.80-15.62]). Type 2 parenchymal hemorrhage was seen in 3 of 24 patients (13%) who received EVT and in 4 of 126 patients (3%) who received medical management (adjusted odds ratio, 4.06 [95% CI, 0.63-26.30]). In a subgroup of 109 patients who were 24 hours from time LKW, EVT was associated with a favorable mRS shift (common adjusted odds ratio, 10.54 [95% CI, 2.18-59.34]). CONCLUSIONS AND RELEVANCE This study suggests that patients with anterior circulation large vessel occlusion presenting very late (>16 hours to 10 days) from the time they were LKW may benefit from EVT.
Collapse
Affiliation(s)
- Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Bijoy K. Menon
- Department of Clinical Neurosciences and Radiology, Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jun Yup Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Dong-Woo Shin
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Sung Hyun Baik
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Moon-Ku Han
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Andrew Demchuk
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Hee-Joon Bae
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| |
Collapse
|
41
|
Beard DJ, Li Z, Schneider AM, Couch Y, Cipolla MJ, Buchan AM. Rapamycin Induces an eNOS (Endothelial Nitric Oxide Synthase) Dependent Increase in Brain Collateral Perfusion in Wistar and Spontaneously Hypertensive Rats. Stroke 2020; 51:2834-2843. [PMID: 32772681 DOI: 10.1161/strokeaha.120.029781] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND PURPOSE Rapamycin is a clinically approved mammalian target of rapamycin inhibitor that has been shown to be neuroprotective in animal models of stroke. However, the mechanism of rapamycin-induced neuroprotection is still being explored. Our aims were to determine if rapamycin improved leptomeningeal collateral perfusion, to determine if this is through eNOS (endothelial nitric oxide synthase)-mediated vessel dilation and to determine if rapamycin increases immediate postreperfusion blood flow. METHODS Wistar and spontaneously hypertensive rats (≈14 weeks old, n=22 and n=15, respectively) were subjected to ischemia by middle cerebral artery occlusion (90 and 120 minutes, respectively) with or without treatment with rapamycin at 30-minute poststroke. Changes in middle cerebral artery and collateral perfusion territories were measured by dual-site laser Doppler. Reactivity to rapamycin was studied using isolated and pressurized leptomeningeal anastomoses. Brain injury was measured histologically or with triphenyltetrazolium chloride staining. RESULTS In Wistar rats, rapamycin increased collateral perfusion (43±17%), increased reperfusion cerebral blood flow (16±8%) and significantly reduced infarct volume (35±6 versus 63±8 mm3, P<0.05). Rapamycin dilated leptomeningeal anastomoses by 80±9%, which was abolished by nitric oxide synthase inhibition. In spontaneously hypertensive rats, rapamycin increased collateral perfusion by 32±25%, reperfusion cerebral blood flow by 44±16%, without reducing acute infarct volume 2 hours postreperfusion. Reperfusion cerebral blood flow was a stronger predictor of brain damage than collateral perfusion in both Wistar and spontaneously hypertensive rats. CONCLUSIONS Rapamycin increased collateral perfusion and reperfusion cerebral blood flow in both Wistar and comorbid spontaneously hypertensive rats that appeared to be mediated by enhancing eNOS activation. These findings suggest that rapamycin may be an effective acute therapy for increasing collateral flow and as an adjunct therapy to thrombolysis or thrombectomy to improve reperfusion blood flow.
Collapse
Affiliation(s)
- Daniel J Beard
- Acute Stroke Programme, Radcliffe Department of Medicine, University of Oxford, United Kingdom (D.J.B., A.M.S., Y.C., A.M.B.)
- School of Biomedical Science and Pharmacy, The University of Newcastle, Australia (D.J.B.)
| | - Zhaojin Li
- Department of Neurological Sciences, The University of Vermont, Burlington (Z.L., M.J.C.)
| | - Anna M Schneider
- Acute Stroke Programme, Radcliffe Department of Medicine, University of Oxford, United Kingdom (D.J.B., A.M.S., Y.C., A.M.B.)
| | - Yvonne Couch
- Acute Stroke Programme, Radcliffe Department of Medicine, University of Oxford, United Kingdom (D.J.B., A.M.S., Y.C., A.M.B.)
| | - Marilyn J Cipolla
- Department of Neurological Sciences, The University of Vermont, Burlington (Z.L., M.J.C.)
| | - Alastair M Buchan
- Acute Stroke Programme, Radcliffe Department of Medicine, University of Oxford, United Kingdom (D.J.B., A.M.S., Y.C., A.M.B.)
| |
Collapse
|
42
|
Ma J, Ma Y, Shuaib A, Winship IR. Improved collateral flow and reduced damage after remote ischemic perconditioning during distal middle cerebral artery occlusion in aged rats. Sci Rep 2020; 10:12392. [PMID: 32709950 PMCID: PMC7381676 DOI: 10.1038/s41598-020-69122-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/07/2020] [Indexed: 02/05/2023] Open
Abstract
Circulation through cerebral collaterals can maintain tissue viability until reperfusion is achieved. However, collateral circulation is time limited, and failure of collaterals is accelerated in the aged. Remote ischemic perconditioning (RIPerC), which involves inducing a series of repetitive, transient peripheral cycles of ischemia and reperfusion at a site remote to the brain during cerebral ischemia, may be neuroprotective and can prevent collateral failure in young adult rats. Here, we demonstrate the efficacy of RIPerC to improve blood flow through collaterals in aged (16-18 months of age) Sprague Dawley rats during a distal middle cerebral artery occlusion. Laser speckle contrast imaging and two-photon laser scanning microscopy were used to directly measure flow through collateral connections to ischemic tissue. Consistent with studies in young adult rats, RIPerC enhanced collateral flow by preventing the stroke-induced narrowing of pial arterioles during ischemia. This improved flow was associated with reduced early ischemic damage in RIPerC treated aged rats relative to controls. Thus, RIPerC is an easily administered, non-invasive neuroprotective strategy that can improve penumbral blood flow via collaterals. Enhanced collateral flow supports further investigation as an adjuvant therapy to recanalization therapy and a protective treatment to maintain tissue viability prior to reperfusion.
Collapse
Affiliation(s)
- Junqiang Ma
- Neurochemical Research Unit, Department of Psychiatry, 12-127 Clinical Sciences Building, University of Alberta, Edmonton, AB, T6G 2R3, Canada
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
- First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
| | - Yonglie Ma
- Neurochemical Research Unit, Department of Psychiatry, 12-127 Clinical Sciences Building, University of Alberta, Edmonton, AB, T6G 2R3, Canada
| | - Ashfaq Shuaib
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Ian R Winship
- Neurochemical Research Unit, Department of Psychiatry, 12-127 Clinical Sciences Building, University of Alberta, Edmonton, AB, T6G 2R3, Canada.
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada.
| |
Collapse
|
43
|
Biose IJ, Dewar D, Macrae IM, McCabe C. Impact of stroke co-morbidities on cortical collateral flow following ischaemic stroke. J Cereb Blood Flow Metab 2020; 40:978-990. [PMID: 31234703 PMCID: PMC7181095 DOI: 10.1177/0271678x19858532] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Acute hyperglycaemia and chronic hypertension worsen stroke outcome but their impact on collateral perfusion, a determinant of penumbral life span, is poorly understood. Laser-speckle contrast imaging (LSCI) was used to determine the influence of these stroke comorbidities on cortical perfusion after permanent middle cerebral artery occlusion (pMCAO) in spontaneously hypertensive stroke prone rats (SHRSP) and normotensive Wistar rats. Four independent studies were conducted. In animals without pMCAO, cortical perfusion remained stable over 180 min. Following pMCAO, cortical perfusion was markedly reduced at 30 min then gradually increased, via cortical collaterals, over the subsequent 3.5 h. In the contralateral non-ischaemic hemisphere, perfusion did not change over time. Acute hyperglycaemia (in normotensive Wistar) and chronic hypertension (SHRSP) attenuated the restoration of cortical perfusion after pMCAO. Inhaled nitric oxide did not influence cortical perfusion in SHRSP following pMCAO. Thus, hyperglycaemia at the time of arterial occlusion or pre-existing hypertension impaired the dynamic recruitment of cortical collaterals after pMCAO. The impairment of collateral recruitment may contribute to the detrimental effects these comorbidities have on stroke outcome.
Collapse
Affiliation(s)
- Ifechukwude J Biose
- Stroke and Brain Imaging, Institute of Neuroscience and Psychology, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.,Department of Anatomy and Forensic Anthropology, Cross River University of Technology, Calabar, Nigeria
| | - Deborah Dewar
- Stroke and Brain Imaging, Institute of Neuroscience and Psychology, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - I Mhairi Macrae
- Stroke and Brain Imaging, Institute of Neuroscience and Psychology, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Christopher McCabe
- Stroke and Brain Imaging, Institute of Neuroscience and Psychology, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| |
Collapse
|
44
|
Ma J, Ma Y, Shuaib A, Winship IR. Impaired Collateral Flow in Pial Arterioles of Aged Rats During Ischemic Stroke. Transl Stroke Res 2020; 11:243-253. [PMID: 31203565 PMCID: PMC7067739 DOI: 10.1007/s12975-019-00710-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 05/02/2019] [Accepted: 06/05/2019] [Indexed: 02/05/2023]
Abstract
Cerebral collateral circulation and age are critical factors in determining outcome from acute ischemic stroke. Aging may lead to rarefaction of cerebral collaterals, and thereby accelerate ischemic injury by reducing penumbral blood flow. Dynamic changes in pial collaterals after onset of cerebral ischemia may vary with age but have not been extensively studied. Here, laser speckle contrast imaging (LSCI) and two-photon laser scanning microscopy (TPLSM) were combined to monitor cerebral pial collaterals between the anterior cerebral artery (ACA) and the middle cerebral artery (MCA) in young adult and aged male Sprague Dawley rats during distal middle cerebral artery occlusion (dMCAo). Histological analysis showed that aged rats had significantly greater volumes of ischemic damage than young rats. LSCI showed that cerebral collateral perfusion declined over time after stroke in aged and young rats, and that this decline was significantly greater in aged rats. TPLSM demonstrated that pial arterioles narrowed faster after dMCAo in aged rats compared to young adult rats. Notably, while arteriole vessel narrowing was comparable 4.5 h after ischemic onset in aged and young adult rats, red blood cell velocity was stable in young adults but declined over time in aged rats. Overall, red blood cell flux through pial arterioles was significantly reduced at all time-points after 90 min post-dMCAo in aged rats relative to young adult rats. Thus, collateral failure is more severe in aged rats with significantly impaired pial collateral dynamics (reduced diameter, red blood cell velocity, and red blood cell flux) relative to young adult rats.
Collapse
Affiliation(s)
- Junqiang Ma
- Neurochemical Research Unit, Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, 12-127 Clinical Sciences Building, Edmonton, AB, T6G 2R3, Canada
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
- First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
| | - Yonglie Ma
- Neurochemical Research Unit, Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, 12-127 Clinical Sciences Building, Edmonton, AB, T6G 2R3, Canada
| | - Ashfaq Shuaib
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Ian R Winship
- Neurochemical Research Unit, Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, 12-127 Clinical Sciences Building, Edmonton, AB, T6G 2R3, Canada.
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada.
| |
Collapse
|
45
|
Conrad J, Ertl M, Oltmanns MH, Zu Eulenburg P. Prediction contribution of the cranial collateral circulation to the clinical and radiological outcome of ischemic stroke. J Neurol 2020; 267:2013-2021. [PMID: 32206898 PMCID: PMC7320948 DOI: 10.1007/s00415-020-09798-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 03/13/2020] [Accepted: 03/16/2020] [Indexed: 10/31/2022]
Abstract
BACKGROUND AND AIM The extent of penumbra tissue and outcome in stroke patients depend on the collateral cranial vasculature. To provide optimal individualized care for stroke patients in the emergency room setting we investigated the predictive capability of a stringent evaluation of the collateral vessels in ischemic stroke on clinical outcome and infarct size. METHODS We retrospectively studied uniform clinical and radiological data of 686 consecutive patients admitted to the emergency department with suspected acute ischemic stroke. Cranial collateral vasculature status was graded using the initial CT-angiography. Outcome was measured by mRS, NIHSS and final infarct size at hospital discharge. All data were used to build a linear regression model to predict the patients´ outcome. RESULTS Univariate and multivariate analyses showed significant effects of the whole brain collateral vessel score on all outcome variables. Atherosclerosis and piale collateral status were associated with the final infarct volume (FIV). Atherosclerosis and age were associated with the NIHSS at discharge. The presence of atherosclerosis, glucose level on admission and age were associated with the mRS at discharge. The multivariate models were able to predict 29% of the variance of the mRS at discharge, 24% of the variance in FIV and 17% of the variance of the NIHSS at discharge. The whole brain collateral status and the presence of atherosclerosis were the most relevant predictors for the clinical and radiological outcome. CONCLUSION The whole brain collateral vasculature status is clearly associated with clinical and radiological outcome but in a multivariate model seems not sufficiently predictive for FIV, mRS and NIHSS outcome at discharge in non-preselected patients admitted to the emergency department with ischemic stroke.
Collapse
Affiliation(s)
- Julian Conrad
- Department of Neurology, LMU Munich, Marchioninistr.15, 81377, Munich, Germany. .,German Center for Vertigo and Balance Disorders (DSGZ), LMU Munich, Munich, Germany.
| | - Matthias Ertl
- German Center for Vertigo and Balance Disorders (DSGZ), LMU Munich, Munich, Germany.,Department of Psychology, University of Bern, Bern, Switzerland
| | - Meret H Oltmanns
- Department of Neuroradiology, Johannes Gutenberg-University, Mainz, Germany
| | - Peter Zu Eulenburg
- German Center for Vertigo and Balance Disorders (DSGZ), LMU Munich, Munich, Germany.,Institute for Neuroradiology, LMU Munich, Munich, Germany
| |
Collapse
|
46
|
Liu Z, Han C, Wang H, Zhang Q, Li S, Bao X, Zhang Z, Duan L. Clinical characteristics and leptomeningeal collateral status in pediatric and adult patients with ischemic moyamoya disease. CNS Neurosci Ther 2020; 26:14-20. [PMID: 31875482 PMCID: PMC6930821 DOI: 10.1111/cns.13130] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/13/2019] [Accepted: 03/14/2019] [Indexed: 11/28/2022] Open
Abstract
AIM Previous studies have found significant differences in clinical characteristics between pediatric and adult moyamoya disease (MMD) patients, but few studies have focused on the factors underlying these differences. We aimed to investigate the differences in leptomeningeal collateral (LMC) status between pediatric and adult MMD patients and to analyze the effects of LMCs on clinical characteristics and therapeutic prognosis. METHODS We retrospectively analyzed 214 MMD patients from January 2014 to January 2016. Clinical characteristics and LMC status were compared between the pediatric and adult patients. LMC status was graded as good or poor depending on the retrograde flow from the posterior cerebral artery (PCA) on digital subtraction angiography (DSA). RESULTS A total of 83 pediatric and 131 adult (1:1.6) MMD patients were analyzed. Pediatric patients were more likely to experience a transient ischemic attack (81%), whereas adult patients were more likely to experience infarction (51%). Regarding the different MMD stages (the early, medium, and advanced stages corresponded to Suzuki stages 1-2, 3-4, and 5-6, respectively), the prevalence of good LMC status was higher for pediatric patients than for adult patients in the early stage (P = 0.047) and the medium stage (P = 0.001), but there were no differences between these patient groups in the advanced stage (P = 0.547). Worse postoperative angiographic outcomes (P = 0.017) were found in adult patients than in pediatric patients in the medium stage. Poor LMC status had strong correlations with infarction (P < 0.001 and P = 0.017) and poor postoperative outcomes (P = 0.003 and P = 0.043) in both pediatric and adult patients. CONCLUSIONS Pediatric MMD patients have greater patency and a greater ability to establish good LMC status than adult patients, and poor LMC status has a strong correlation with severe clinical symptoms and poor postoperative outcomes. LMC status may be an important factor in the differences in clinical characteristics and prognosis between pediatric and adult MMD patients.
Collapse
Affiliation(s)
- Zhi‐Wen Liu
- Department of Neurosurgery, The Fifth Medical Center of Chinese PLA General HospitalThe 307th Hospital of the Chinese People's Liberation ArmyAcademy of Military Medical ScienceBeijingChina
| | - Cong Han
- Department of Neurosurgery, The Fifth Medical Center of Chinese PLA General HospitalThe 307th Hospital of the Chinese People's Liberation ArmyAcademy of Military Medical ScienceBeijingChina
| | - Hui Wang
- Department of Neurosurgery, The Fifth Medical Center of Chinese PLA General HospitalThe 307th Hospital of the Chinese People's Liberation ArmyAcademy of Military Medical ScienceBeijingChina
| | - Qian Zhang
- Department of Neurosurgery, The Fifth Medical Center of Chinese PLA General HospitalThe 307th Hospital of the Chinese People's Liberation ArmyAcademy of Military Medical ScienceBeijingChina
| | - Si‐Jie Li
- Departments of Neurology and Neurosurgery, Xuanwu Hospital, Center of Stroke, Beijing Institute for Brain DisordersCapital Medical UniversityBeijingChina
| | - Xiang‐yang Bao
- Department of Neurosurgery, The Fifth Medical Center of Chinese PLA General HospitalThe 307th Hospital of the Chinese People's Liberation ArmyAcademy of Military Medical ScienceBeijingChina
| | - Zheng‐Shan Zhang
- Department of Neurosurgery, The Fifth Medical Center of Chinese PLA General HospitalThe 307th Hospital of the Chinese People's Liberation ArmyAcademy of Military Medical ScienceBeijingChina
| | - Lian Duan
- Department of Neurosurgery, The Fifth Medical Center of Chinese PLA General HospitalThe 307th Hospital of the Chinese People's Liberation ArmyAcademy of Military Medical ScienceBeijingChina
| |
Collapse
|
47
|
de Havenon A, Mlynash M, Kim-Tenser MA, Lansberg MG, Leslie-Mazwi T, Christensen S, McTaggart RA, Alexander M, Albers G, Broderick J, Marks MP, Heit JJ. Results From DEFUSE 3: Good Collaterals Are Associated With Reduced Ischemic
Core Growth but Not Neurologic Outcome. Stroke 2019; 50:632-638. [PMID: 30726184 DOI: 10.1161/strokeaha.118.023407] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background and Purpose- The effect of leptomeningeal collaterals for acute ischemic stroke patients with large vessel occlusion in the late window (>6 hours from last known normal) remains unknown. We sought to determine if collateral status on baseline computed tomography angiography impacted neurological outcome, ischemic core growth, and moderated the effect of endovascular thrombectomy in the late window. Methods- This is a prespecified analysis of DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke). We included patients with computed tomography angiography as their baseline imaging and rated collateral status using the validated scales described by Tan and Maas. The primary outcome is functional independence (modified Rankin Scale score of ≤2). Additional outcomes include the full range of the modified Rankin Scale, baseline ischemic core volume, change from baseline in the ischemic core volume at 24 hours, and death at 90 days. Results- Of the 130 patients in our cohort, 33 (25%) had poor collaterals and 97 (75%) had good collaterals. There was no difference in the rate of functional independence with good versus poor collaterals in unadjusted analysis (30% versus 39%; P=0.3) or after adjustment for treatment arm (odds ratio [95% CI], 0.61 [0.26-1.45]). Good collaterals were associated with significantly smaller ischemic core volume and less ischemic core growth. The difference in the treatment effect of endovascular thrombectomy was not significant ( P=0.8). Collateral status also did not affect the rate of stroke-related death (n [%], good versus poor collaterals, 18/97 [19%] versus 8/33 [24%], P=0.5]. Conclusions- In DEFUSE 3 patients, good leptomeningeal collaterals on single phase computed tomography angiography were not predictive of functional independence or death and did not impact the treatment effect of endovascular thrombectomy. These unexpected findings require further study to confirm their validity and to better understand the role of collaterals for stroke patients with anterior circulation large vessel occlusion in the late therapeutic window. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT02586415.
Collapse
Affiliation(s)
- Adam de Havenon
- From the Department of Neurology (A.d.H.), University of Utah, Salt Lake City
| | - Michael Mlynash
- Department of Neurology (M.M., M.G.L., S.C., G.A.), Stanford University, CA
| | - May A Kim-Tenser
- Department of Neurology, University of Southern California, Los Angeles (M.A.K.-T.)
| | - Maarten G Lansberg
- Department of Neurology (M.M., M.G.L., S.C., G.A.), Stanford University, CA
| | | | - Soren Christensen
- Department of Neurology (M.M., M.G.L., S.C., G.A.), Stanford University, CA
| | | | | | - Gregory Albers
- Department of Neurology (M.M., M.G.L., S.C., G.A.), Stanford University, CA
| | | | - Michael P Marks
- Department of Radiology (M.P.M., J.J.H.), Stanford University, CA
| | - Jeremy J Heit
- Department of Radiology (M.P.M., J.J.H.), Stanford University, CA
| | | |
Collapse
|
48
|
Broocks G, Kemmling A, Aberle J, Kniep H, Bechstein M, Flottmann F, Leischner H, Faizy TD, Nawabi J, Schön G, Sporns P, Thomalla G, Fiehler J, Hanning U. Elevated blood glucose is associated with aggravated brain edema in acute stroke. J Neurol 2019; 267:440-448. [PMID: 31667625 DOI: 10.1007/s00415-019-09601-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 10/20/2019] [Accepted: 10/21/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND PURPOSE Clinical outcome after endovascular thrombectomy in patients with acute ischemic stroke still varies significantly. Higher blood glucose levels (BGL) have been associated with worse clinical outcome, but the pathophysiological causes are not yet understood. We hypothesized that higher levels of BGL are associated with more pronounced ischemic brain edema and worse clinical outcome mediated by cerebral collateral circulation. METHODS 178 acute ischemic stroke patients who underwent mechanical thrombectomy were included. Early ischemic brain edema was determined using quantitative lesion water uptake on initial computed tomography (CT) and collateral status was assessed with an established 5-point scoring system in CT-angiography. Good clinical outcome was defined as functional independence (modified Rankin Scale [mRS] score 0-2). Multivariable logistic regression analysis was performed to predict functional independence and linear regression analyses to investigate the impact of BGL and collateral status on water uptake. RESULTS The mean BGL at admission was significantly lower in patients with good outcome at 90 days (116.5 versus 138.5 mg/dl; p < 0.001) and early water uptake was lower (6.3% versus 9.6%; p < 0.001). The likelihood for good outcome declined with increasing BGL (odds ratio [OR] per 100 mg/dl BGL increase: 0.15; 95% CI 0.02-0.86; p = 0.039). Worse collaterals (1% water uptake per point, 95% CI 0.4-1.7%) and higher BGL (0.6% per 10 mg/dl BGL, 95% CI 0.3-0.8%) were significantly associated with increased water uptake. CONCLUSION Elevated admission BGL were associated with increased early brain edema and poor clinical outcome mediated by collateral status. Patients with higher BGL might be targeted by adjuvant anti-edematous treatment.
Collapse
Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Andre Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany.,Faculty of Medicine Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Jens Aberle
- Department of Endocrinology and Diabetology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Jawed Nawabi
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.,Department of Radiology, Charité University Medical Center, Berlin, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| |
Collapse
|
49
|
Abstract
Cerebral small vessel disease (SVD) is characterized by changes in the pial and parenchymal microcirculations. SVD produces reductions in cerebral blood flow and impaired blood-brain barrier function, which are leading contributors to age-related reductions in brain health. End-organ effects are diverse, resulting in both cognitive and noncognitive deficits. Underlying phenotypes and mechanisms are multifactorial, with no specific treatments at this time. Despite consequences that are already considerable, the impact of SVD is predicted to increase substantially with the growing aging population. In the face of this health challenge, the basic biology, pathogenesis, and determinants of SVD are poorly defined. This review summarizes recent progress and concepts in this area, highlighting key findings and some major unanswered questions. We focus on phenotypes and mechanisms that underlie microvascular aging, the greatest risk factor for cerebrovascular disease and its subsequent effects.
Collapse
Affiliation(s)
- T Michael De Silva
- Department of Physiology, Anatomy and Microbiology, School of Life Sciences, La Trobe University, Melbourne Campus, Bundoora, Victoria 3086, Australia;
| | - Frank M Faraci
- Departments of Internal Medicine, Neuroscience, and Pharmacology, Francois M. Abboud Cardiovascular Center, Carver College of Medicine, University of Iowa, Iowa City, Iowa 52242, USA;
| |
Collapse
|
50
|
Wu Q, Li T, Zhu D, Lv F, Qin X. Altered expression of long noncoding RNAs in peripheral blood mononuclear cells in patients with impaired leptomeningeal collaterals after acute anterior large vessel occlusions. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:523. [PMID: 31807505 DOI: 10.21037/atm.2019.10.02] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background In the event of acute ischemic stroke (AIS) due to anterior large vessel occlusion (aLVO), leptomeningeal collaterals (LMCs) status is a key factor to define the severity and functional prognosis of this disease. However, the extent of LMCs exhibits substantial variability among the patients, which is genetic determined. Long non-coding RNAs (lncRNAs) expression profiles in human peripheral blood have been found to be altered after AIS. But whether there are specific lncRNAs correlated with LMC status in aLVO has not yet been investigated. Methods Differential lncRNA expression panels in peripheral blood mononuclear cells (PBMCs) were assessed by microarray analysis and individual quantitative real-time polymerase chain reaction (RT-PCR) in three independent sets consist of 134 patients with aLVO and 73 healthy controls (HCs). LMCs Status in those patients was assessed based on baseline computed tomographic angiography (CTA). Results Microarray analysis showed 23 differentially expressed lncRNAs in patients with poor LMCs status. After independent validations by RT-PCR, lncRNA ENST00000422956 was found to be significantly downregulated in patients with poor LMCs status. Receiver-operating characteristic (ROC) analysis revealed the area under the ROC curve (AUC) for ENST00000422956 to predict poor LMCs status was 0.749. Moreover, ENST00000422956 expression level and baseline National Institutes of Health Stroke Scale (NIHSS) score were identified as independent predictors for impaired LMCs, and a significantly positive correlation was observed between ENST00000422956 expression level and LMCs status. Via cis-regulatory analysis, paired box 8 (Pax8) was identified as the target gene for ENST00000422956. Conclusions The dysregulated lncRNA ENST00000422956 in PBMCs was associated with impairment of LMCs in patients with aLVO, suggesting that measurement of circulatory lncRNAs might be included as possible biomarkers for evaluation of LMCs status in AIS. More importantly, this might be the foundation for understand the potential roles of lncRNAs in LMCs formation after ischemic stroke.
Collapse
Affiliation(s)
- Qisi Wu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Ting Li
- Key Laboratory of Laboratory Medical Diagnostics, Ministry of Education, Department of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, China
| | - Dan Zhu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Fajin Lv
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Xinyue Qin
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| |
Collapse
|