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Lin Y, Xing Z, Lv S, Yang X, Kang J, Kang N, Wang J, Cao D. Colour-coded collateral and venous outflow patterns in estimating infarct progression and predicting functional independence for stroke patients in late time window. Br J Radiol 2024; 97:1335-1342. [PMID: 38754104 PMCID: PMC11186557 DOI: 10.1093/bjr/tqae104] [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: 04/18/2023] [Revised: 06/29/2023] [Accepted: 05/14/2024] [Indexed: 05/18/2024] Open
Abstract
OBJECTIVES To investigate whether cerebral collateral and venous outflow (VO) patterns on colour-coded multi-phase computed tomography angiography (mCTA) can estimate ischaemic core growth rate (IGR) and predict 90-day functional independence for patients with late-presenting acute ischaemic stroke (AIS). METHODS The retrospective analysis included 127 AIS patients with a late time window. All patients underwent baseline mCTA with colour-coded reconstruction and computed tomography perfusion. Both collateral score and VO score on colour-coded mCTA maps were analysed and recorded. The IGR was calculated as ischaemic core volume divided by the time from onset to imaging. A 90-day modified Rankin Scale score of 0-2 was defined as functional independence. Kendall's Tau-b analysis was used for nonparametric correlation analysis. Propensity scores, logistic regressions, and receiver operator characteristic (ROC) curves were applied to construct the prediction model. RESULTS Moderate correlations were found between collateral delay and IGR (Tau-b = -0.554) and between VO and IGR (Tau-b = -0.501). High collateral score (odds ratio = 3.01) and adequate VO (odds ratio = 4.89) remained independent predictors for 90-day functional independence after adjustment. The joint predictive model, which integrated the VO score and clinical features, demonstrated an area under the ROC curve (AUC) of 0.878. The AUCs of collateral score and VO score were 0.836 and 0.883 for outcome prediction after adjustment. CONCLUSIONS Cerebral collateral and VO patterns based on colour-coded mCTA can effectively predict infarct progression and 90-day clinical outcomes, even for AIS patients beyond the routine time window. ADVANCES IN KNOWLEDGE Colour-coded mCTA is a readily understandable post-processing technique for the rapid assessment of collateral circulation and VO status in stroke imaging. A moderate correlation was observed between the characteristics of collateral delay/VO on colour-coded mCTA and IGR in patients with AIS. Both high-quality collateral circulation and "red superficial middle cerebral vein sign" can predict 90-day functional independence even for patients beyond the routine time window.
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Affiliation(s)
- Yu Lin
- Department of Radiology, the First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China
- Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
- Xiamen Radiology Quality Control Center, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
| | - Zhen Xing
- Department of Radiology, the First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China
- Department of Radiology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
| | - Shaomao Lv
- Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
- Xiamen Radiology Quality Control Center, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
- School of Clinical Medicine, Fujian Medical University, Fuzhou 350005, China
- The Third Clinical Medical College, Fujian Medical University, Fuzhou 350005, China
| | - Xiefeng Yang
- Department of Radiology, the First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China
- Department of Radiology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
| | - Jianghe Kang
- Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
- Xiamen Radiology Quality Control Center, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
| | - Nannan Kang
- Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
| | - Jinan Wang
- Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
- Xiamen Radiology Quality Control Center, Zhongshan Hospital Affiliated to Xiamen University, School of Medicine, Xiamen University, Xiamen 361004, China
| | - Dairong Cao
- Department of Radiology, the First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China
- Department of Radiology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
- Fujian Provincial Key Laboratory of Precision Medicine for Cancer, the First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Key Laboratory of Radiation Biology of Fujian Higher Education Institutions, the First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
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Aboul-Nour H, Dolia J, Tarek MA, Grossberg JA, Pabaney A, Damiani M, Al-Bayati AR, Nogueira RG, Haussen DC. Competitive leptomeningeal flow impact on thrombectomy reperfusion grade rating. J Neurointerv Surg 2024:jnis-2023-021268. [PMID: 38302419 DOI: 10.1136/jnis-2023-021268] [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: 11/19/2023] [Accepted: 01/22/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Competitive leptomeningeal flow (CLF) can be observed immediately after mechanical thrombectomy (MT) reperfusion with retrograde contrast clearing of the distal leptomeningeal branches from non-contrast opacified flow through different vascular territories. We aim to evaluate the frequency of the CLF phenomenon, to determine if it has an association with the degree of leptomeningeal collateral status, and to understand the potentia impact it may have on the final expanded Treatment in Cerebral Ischemia (eTICI) score rating. METHODS Retrospective analysis of a prospective MT database spanning November 2020 to December 2021. Consecutive cases of intracranial internal carotid (i-ICA) or middle cerebral artery (MCA) M1 occlusions were included. CLF was defined by the observation of retrograde clearing of distal MCA branches that were previously opacified by antegrade reperfusion. The clearance of the distal branches is presumed to occur due to CLF via non-contrast opacified posterior cerebral artery or anterior cerebral artery flow. The washout was considered CLF if it cleared abruptly with or without forward reconstitution of antegrade opacification. RESULTS A total of 125 patients met the inclusion criteria. The median age was 64 years (IQR 52.5-75) and 64 (51%) were men. The baseline median National Institutes of Health Stroke Scale score was 17 (IQR 12-22) and the Alberta Stroke Program Early CT Score was 9 (IQR 8-10). Median last known well time to puncture was 7 hours (IQR 4-13.1) and 30.4% received tissue plasminogen activator. Final eTICI 2c-3 was achieved in 80%. CLF was present in 32 (25.6%) patients, who had comparable baseline characteristics to patients without CLF. Twelve (37.5%) patients had regional CLF and 20 (62.5%) had focal CLF. The CLF arm had better leptomeningeal single-phase CTA collaterals than the non-CLF arm (P=0.01). The inter-rater agreement for the eTICI score was moderate when CLF was present and strong in its absence (Krippendorf's alpha=0.65 and 0.81, respectively). There was minimal agreement (Kappa=0.3) for the presence versus absence of CLF between the two operators, possibly related to reader experience. CONCLUSION CLF was observed in 32% of patients, was associated with better collateral flow, and impacted the reported procedural eTICI rating.
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Affiliation(s)
- Hassan Aboul-Nour
- Departments of Neurology and Neurosurgery, University of Kentucky College of Medicine, Lexington, KY, USA
- Department of Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Jaydevsinh Dolia
- Department of Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Mohamed A Tarek
- Department of Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Jonathan A Grossberg
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Aqueel Pabaney
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Mateus Damiani
- Department of Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | | | - Raul G Nogueira
- Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
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Zhan Z, Gu F, Ji Y, Zhang Y, Ge Y, Wang Z. Thrombectomy with and without computed tomography perfusion imaging for large-vessel occlusion stroke in the extended time window: a meta-analysis of randomized clinical trials. Front Neurol 2023; 14:1185554. [PMID: 37669248 PMCID: PMC10470654 DOI: 10.3389/fneur.2023.1185554] [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: 03/13/2023] [Accepted: 07/27/2023] [Indexed: 09/07/2023] Open
Abstract
Objective In recent years, several studies have used computed tomography perfusion (CTP) to assess whether mechanical thrombectomy can be performed in patients with large-vessel occlusion (LVO) stroke in an extended time window. However, it has the disadvantage of being time-consuming and expensive. This study aimed to compare the impact of the CTP group with the non-CTP group [non-contrast CT (NCCT) ± CT angiography (CTA)] on the prognosis of this patient population. Methods A search of PubMed, EMBASE, and the Cochrane Library databases was conducted to collect randomized controlled trials (RCTs) comparing the two strategies. Outcome indicators and factors influencing prognosis were summarized by standardized mean differences, ratios, and relative risks with 95% confidence intervals using a random-effects model. Results A total of two RCTs were included in the combined analysis. There were no significant differences in the main outcome indicators (modified Rankin Scale score at 90 days, successful postoperative reperfusion rate) or the incidence of adverse events (90-day mortality and symptomatic intracranial hemorrhage) between the NCCT ± CTA and CTP groups. The time from the last puncture appeared to be significantly shorter in the NCCT ± CTA group than in the CTP group (SMD: -0.14; 95% CI: -0.24, -0.04). Among them, age (OR: 0.96; 95% CI: 0.94, 0.98), ASPECTS (OR: 1.18; 95% CI: 1.12, 1.24), NIHSS score (OR: 0.90; 95% CI: 0.89, 0.91), and diabetes (OR: 0.69; 95% CI: 0.54, 0.88) were associated with a 90-day independent functional outcome. Conclusion These findings suggest that the choice of NCCT ± CTA (without CTP) for the assessment of mechanical thrombectomy within 6-24 h after LVO in the anterior circulation is not significantly different from CTP; instead, the choice of NCCT ± CTA significantly reduces the time from onset to arterial puncture.
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Affiliation(s)
- Zheng Zhan
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Feng Gu
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yi Ji
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yu Zhang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yi Ge
- Department of Neurology, The Affiliated Changzhou Second People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, China
| | - Zhong Wang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
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Chung KJ, Khaw AV, Pandey SK, Lee DH, Mandzia JL, Lee TY. Feasibility of deconvolution-based multiphase CT angiography perfusion maps in acute ischemic stroke: Simulation and concordance with CT perfusion. J Stroke Cerebrovasc Dis 2022; 31:106844. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/20/2022] [Accepted: 10/06/2022] [Indexed: 11/07/2022] Open
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Tan Z, Parsons M, Bivard A, Sharma G, Mitchell P, Dowling R, Bush S, Churilov L, Xu A, Yan B. Comparison of Computed Tomography Perfusion and Multiphase Computed Tomography Angiogram in Predicting Clinical Outcomes in Endovascular Thrombectomy. Stroke 2022; 53:2926-2934. [PMID: 35748291 DOI: 10.1161/strokeaha.122.038576] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND In patients with acute stroke who undergo endovascular thrombectomy, the relative prognostic power of computed tomography perfusion (CTP) parameters compared with multiphase CT angiogram (mCTA) is unknown. We aimed to compare the predictive accuracy of mCTA and CTP parameters on clinical outcomes. METHODS We included patients with acute ischemic stroke who had anterior circulation large vessel occlusion within 24 hours of onset in Melbourne Brain Centre at the Royal Melbourne Hospital. All patients underwent CTP for endovascular thrombectomy, and the mCTA collateral score was determined using CTP-reconstructed mCTA images. The primary outcome was 90-day functional outcomes defined by modified Rankin Scale. Multivariable logistic regression models analyzed associations between mCTA and CTP parameters and 90-day functional outcomes. The ability to discriminate 90 days-functional outcomes was compared between mCTA collateral score and CTP parameters using receiver operating curve analysis and C statistics. RESULTS One hundred and twenty patients were included. The median age was 69 years (interquartile range, 60-79), the median baseline National Institutes of Health Stroke Scale score was 14 (interquartile range, 9-19). The baseline ischemic core volume, defined by CTP-based relative cerebral blood flow <30%, was associated with excellent functional outcome (modified Rankin Scale score 0-1; odds ratio, 0.942 [-0.897 to -0.989]; P=0.015) and poor functional outcome (modified Rankin Scale score 5-6; odds ratio, 1.032 [1.007-1.056]; P=0.010) at 90 days in the analysis of multivariable regression. There was no significant association between the mCTA score and excellent functional outcome (P=0.58) or poor functional outcome (P=0.155). The relative cerebral blood flow <30%-based regression model best fit the data for the 90-day poor functional outcome (C statistic, 0.834). CONCLUSIONS The CTP-based ischemic core volume may provide better discrimination for 90-day functional outcomes for patients with acute stroke undergoing endovascular thrombectomy than the mCTA collateral score.
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Affiliation(s)
- Zefeng Tan
- Department of Neurology, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China (Z.T., A.X.).,Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.).,Department of Neurology, the First People's Hospital of Foshan, China (Z.T.)
| | - Mark Parsons
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.).,Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Australia (P.M., R.D., S.B., B.Y.)
| | - Andrew Bivard
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.)
| | - Gagan Sharma
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.)
| | - Peter Mitchell
- Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Australia (P.M., R.D., S.B., B.Y.)
| | - Richard Dowling
- Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Australia (P.M., R.D., S.B., B.Y.)
| | - Steven Bush
- Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Australia (P.M., R.D., S.B., B.Y.)
| | - Leonid Churilov
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.)
| | - Anding Xu
- Department of Neurology, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China (Z.T., A.X.)
| | - Bernard Yan
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.).,Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Australia (P.M., R.D., S.B., B.Y.)
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Chu Y, Ma G, Xu XQ, Lu SS, Shi HB, Liu S, Liu QH, Wu FY. Comparison of time consumption and success rate between CT angiography- and CT perfusion- based imaging assessment strategy for the patients with acute ischemic stroke. BMC Med Imaging 2022; 22:152. [PMID: 36042400 PMCID: PMC9426246 DOI: 10.1186/s12880-022-00880-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 08/18/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Our study aimed to compare the time consumption and success rate between CTA- and CTP- based assessment strategy, and to clarify the risk factors associated with the CTP scan failure. METHODS Clinical and radiological data of 437 consecutive AIS patients who underwent multiphase CTA or CTP for pre-treatment evaluation were retrospectively enrolled (CTA group, n = 302; CTP group, n = 135). Time consumption and success rate of CTA- and CTP- based assessment strategy were compared using Mann-Whitney U test and Chi-Squared Test. Univariate analysis and receiver operating curve analysis were used to clarify the risk factors, and their performance in predicting the CTP scan failure. RESULTS Time consumption of CTP scan and reconstruction was significantly longer than that of CTA [775 s vs 263.5 s, P < 0.001]. CTP scan showed significantly higher failure rate than CTA (11% vs 1%, P < 0.001). Severe motion was the most common cause of CTP failure (n = 12, 80%). Baseline National Institute of Health Stroke Scale (NIHSS) score in CTP failure group was significantly higher than that in CTP success group [17 vs 13, P = 0.007]. Baseline NIHSS score of 11 was the optimal threshold value to predict CTP failure with an area under the curve of 0.715, a sensitivity of 86.7%, and a specificity of 45.0%. CONCLUSIONS CTP- based strategy showed longer time consumption and higher failure rate than CTA- based strategy. High baseline NIHSS score was significantly associated with CTP scan failure in AIS patients.
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Affiliation(s)
- Yue Chu
- grid.412676.00000 0004 1799 0784Department of Radiology, First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd., Nanjing, China
| | - Gao Ma
- grid.412676.00000 0004 1799 0784Department of Radiology, First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd., Nanjing, China
| | - Xiao-Quan Xu
- grid.412676.00000 0004 1799 0784Department of Radiology, First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd., Nanjing, China
| | - Shan-Shan Lu
- grid.412676.00000 0004 1799 0784Department of Radiology, First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd., Nanjing, China
| | - Hai-Bin Shi
- grid.412676.00000 0004 1799 0784Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Sheng Liu
- grid.412676.00000 0004 1799 0784Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Qiang-Hui Liu
- grid.412676.00000 0004 1799 0784Department of Emergency, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Fei-Yun Wu
- grid.412676.00000 0004 1799 0784Department of Radiology, First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd., Nanjing, China
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Fladt J, d'Esterre CD, Joundi R, McDougall C, Gensicke H, Barber P. Acute stroke imaging selection for mechanical thrombectomy in the extended time window: is it time to go back to basics? A review of current evidence. J Neurol Neurosurg Psychiatry 2022; 93:238-245. [PMID: 35115388 DOI: 10.1136/jnnp-2021-328000] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 01/05/2022] [Indexed: 12/15/2022]
Abstract
Treatment with endovascular therapy in the extended time window for acute ischaemic stroke with large vessel occlusion involves stringent selection criteria based on the two landmark studies DAWN and DEFUSE3. Current protocols typically include the requirement of advanced perfusion imaging which may exclude a substantial proportion of patients from receiving a potentially effective therapy. Efforts to offer endovascular reperfusion therapies to all appropriate candidates may be facilitated by the use of simplified imaging selection paradigms with widely available basic imaging techniques, such as non-contrast CT and CT angiography. Currently available evidence from our literature review suggests that patients meeting simplified imaging selection criteria may benefit as much as those patients selected using advanced imaging techniques (CT perfusion or MRI) from endovascular therapy in the extended time window. A comprehensive understanding of the role of imaging in patient selection is critical to optimising access to endovascular therapy in the extended time window and improving outcomes in acute stroke. This article provides an overview on current developments and future directions in this emerging area.
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Affiliation(s)
- Joachim Fladt
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Christopher D d'Esterre
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Raed Joundi
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Connor McDougall
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Henrik Gensicke
- Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Philip Barber
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Shlobin NA, Baig AA, Waqas M, Patel TR, Dossani RH, Wilson No Degree M, Cappuzzo JM, Siddiqui AH, Tutino VM, Levy EI. Artificial Intelligence for Large Vessel Occlusion Stroke: A Systematic Review. World Neurosurg 2021; 159:207-220.e1. [PMID: 34896351 DOI: 10.1016/j.wneu.2021.12.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 12/17/2022]
Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ammad A Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Tatsat R Patel
- Department of Mechanical and Aerospace Engineering, University at Buffalo, Buffalo NY USA
| | - Rimal H Dossani
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | | | - Justin M Cappuzzo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Vincent M Tutino
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Mechanical and Aerospace Engineering, University at Buffalo, Buffalo NY USA; Department of Pathology and Anatomical Sciences, University at Buffalo, Buffalo NY USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.
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9
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Wang C, Shi Z, Yang M, Huang L, Fang W, Jiang L, Ding J, Wang H. Deep learning-based identification of acute ischemic core and deficit from non-contrast CT and CTA. J Cereb Blood Flow Metab 2021; 41:3028-3038. [PMID: 34102912 PMCID: PMC8756471 DOI: 10.1177/0271678x211023660] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The accurate identification of irreversible infarction and salvageable tissue is important in planning the treatments for acute ischemic stroke (AIS) patients. Computed tomographic perfusion (CTP) can be used to evaluate the ischemic core and deficit, covering most of the territories of anterior circulation, but many community hospitals and primary stroke centers do not have the capability to perform CTP scan in emergency situation. This study aimed to identify AIS lesions from widely available non-contrast computed tomography (NCCT) and CT angiography (CTA) using deep learning. A total of 345AIS patients from our emergency department were included. A multi-scale 3D convolutional neural network (CNN) was used as the predictive model with inputs of NCCT, CTA, and CTA+ (8 s delay after CTA) images. An external cohort with 108 patients was included to further validate the generalization performance of the proposed model. Strong correlations with CTP-RAPID segmentations (r = 0.84 for core, r = 0.83 for deficit) were observed when NCCT, CTA, and CTA+ images were all used in the model. The diagnostic decisions according to DEFUSE3 showed high accuracy when using NCCT, CTA, and CTA+ (0.90±0.04), followed by the combination of NCCT and CTA (0.87±0.04), CTA-alone (0.76±0.06), and NCCT-alone (0.53±0.09).
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Affiliation(s)
- Chengyan Wang
- Human Phenome Institute, Fudan University, Shanghai, China.,Zhangjiang Fudan International Innovation Center, Shanghai, China
| | - Zhang Shi
- Department of Radiology, Changhai Hospital, Shanghai, China
| | - Ming Yang
- NeuroBlem Ltd. Co., Shanghai, China.,Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China
| | - Lixiang Huang
- Department of Radiology, Tianjin First Central Hospital, Tianjin, China
| | | | - Li Jiang
- NeuroBlem Ltd. Co., Shanghai, China
| | - Jing Ding
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - He Wang
- Human Phenome Institute, Fudan University, Shanghai, China.,Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China.,Key Laboratory of Computational Neuroscience and Brain-Inspired Intelligence (Fudan University), Ministry of Education, Shanghai, China
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Detection of Perfusion Deficits in Multiphase Computed Tomography Angiography-A Stroke Imaging Technique Based on Iodine Mapping on Spectral Computed Tomography: Initial Findings. J Comput Assist Tomogr 2021; 45:618-624. [PMID: 34176878 DOI: 10.1097/rct.0000000000001173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this study was to explore a novel method for brain tissue differentiation using quantitative analysis of multiphase computed tomography (CT) angiography (MP-CTA) on spectral CT, to assess whether it can distinguish underperfused from normal tissue, using CT perfusion (CTP) as reference. METHODS Noncontrast CT and MP-CTA images from 10 patients were analyzed in vascular regions through measurements of Hounsfield unit (HU) at 120 kV, HU at 40 keV, and iodine density. Regions were categorized as normal or ischemic according to CTP. Hounsfield unit and iodine density were compared regarding ability to separate normal and ischemic tissue, the difference in maximum time derivative of the right over left hemisphere ratio. RESULTS Iodine density had the highest maximum time derivatives and generated the largest mean separation between normal and ischemic tissue. CONCLUSIONS The method can be used to categorize tissue as normal or underperfused. Using iodine quantification seems to give a more distinct differentiation of perfusion defects compared with conventional HU.
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Zeleňák K, Krajina A, Meyer L, Fiehler J, Behme D, Bulja D, Caroff J, Chotai AA, Da Ros V, Gentric JC, Hofmeister J, Kass-Hout O, Kocatürk Ö, Lynch J, Pearson E, Vukasinovic I. How to Improve the Management of Acute Ischemic Stroke by Modern Technologies, Artificial Intelligence, and New Treatment Methods. Life (Basel) 2021; 11:life11060488. [PMID: 34072071 PMCID: PMC8229281 DOI: 10.3390/life11060488] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/22/2022] Open
Abstract
Stroke remains one of the leading causes of death and disability in Europe. The European Stroke Action Plan (ESAP) defines four main targets for the years 2018 to 2030. The COVID-19 pandemic forced the use of innovative technologies and created pressure to improve internet networks. Moreover, 5G internet network will be helpful for the transfer and collecting of extremely big databases. Nowadays, the speed of internet connection is a limiting factor for robotic systems, which can be controlled and commanded potentially from various places in the world. Innovative technologies can be implemented for acute stroke patient management soon. Artificial intelligence (AI) and robotics are used increasingly often without the exception of medicine. Their implementation can be achieved in every level of stroke care. In this article, all steps of stroke health care processes are discussed in terms of how to improve them (including prehospital diagnosis, consultation, transfer of the patient, diagnosis, techniques of the treatment as well as rehabilitation and usage of AI). New ethical problems have also been discovered. Everything must be aligned to the concept of “time is brain”.
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Affiliation(s)
- Kamil Zeleňák
- Clinic of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 03659 Martin, Slovakia
- ESMINT Artificial Intelligence and Robotics Ad hoc Committee, ESMINT, 8008 Zurich, Switzerland; (E.A.I.R.A.h.C.); (D.B.); (D.B.); (J.C.); (A.A.C.); (V.D.R.); (J.-C.G.); (J.H.); (O.K.-H.); (Ö.K.); (J.L.); (E.P.); (I.V.)
- Correspondence: ; Tel.: +421-43-4203-990
| | - Antonín Krajina
- Department of Radiology, Charles University Faculty of Medicine and University Hospital, CZ-500 05 Hradec Králové, Czech Republic;
| | - Lukas Meyer
- Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (J.F.)
| | - Jens Fiehler
- Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (J.F.)
| | | | - Daniel Behme
- ESMINT Artificial Intelligence and Robotics Ad hoc Committee, ESMINT, 8008 Zurich, Switzerland; (E.A.I.R.A.h.C.); (D.B.); (D.B.); (J.C.); (A.A.C.); (V.D.R.); (J.-C.G.); (J.H.); (O.K.-H.); (Ö.K.); (J.L.); (E.P.); (I.V.)
- University Clinic for Neuroradiology, Medical Faculty, Otto-von-Guericke University Magdeburg, 39120 Magdeburg, Germany
| | - Deniz Bulja
- ESMINT Artificial Intelligence and Robotics Ad hoc Committee, ESMINT, 8008 Zurich, Switzerland; (E.A.I.R.A.h.C.); (D.B.); (D.B.); (J.C.); (A.A.C.); (V.D.R.); (J.-C.G.); (J.H.); (O.K.-H.); (Ö.K.); (J.L.); (E.P.); (I.V.)
- Diagnostic-Interventional Radiology Department, Clinic of Radiology, Clinical Center of University of Sarajevo, 71000 Sarajevo, Bosnia and Herzegovina
| | - Jildaz Caroff
- ESMINT Artificial Intelligence and Robotics Ad hoc Committee, ESMINT, 8008 Zurich, Switzerland; (E.A.I.R.A.h.C.); (D.B.); (D.B.); (J.C.); (A.A.C.); (V.D.R.); (J.-C.G.); (J.H.); (O.K.-H.); (Ö.K.); (J.L.); (E.P.); (I.V.)
- Department of Interventional Neuroradiology–NEURI Brain Vascular Center, Bicêtre Hospital, APHP, 94270 Paris, France
| | - Amar Ajay Chotai
- ESMINT Artificial Intelligence and Robotics Ad hoc Committee, ESMINT, 8008 Zurich, Switzerland; (E.A.I.R.A.h.C.); (D.B.); (D.B.); (J.C.); (A.A.C.); (V.D.R.); (J.-C.G.); (J.H.); (O.K.-H.); (Ö.K.); (J.L.); (E.P.); (I.V.)
- Department of Neuroradiology, Royal Victoria Infirmary, Newcastle upon Tyne NE14LP, UK
| | - Valerio Da Ros
- ESMINT Artificial Intelligence and Robotics Ad hoc Committee, ESMINT, 8008 Zurich, Switzerland; (E.A.I.R.A.h.C.); (D.B.); (D.B.); (J.C.); (A.A.C.); (V.D.R.); (J.-C.G.); (J.H.); (O.K.-H.); (Ö.K.); (J.L.); (E.P.); (I.V.)
- Department of Biomedicine and Prevention, University Hospital of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Jean-Christophe Gentric
- ESMINT Artificial Intelligence and Robotics Ad hoc Committee, ESMINT, 8008 Zurich, Switzerland; (E.A.I.R.A.h.C.); (D.B.); (D.B.); (J.C.); (A.A.C.); (V.D.R.); (J.-C.G.); (J.H.); (O.K.-H.); (Ö.K.); (J.L.); (E.P.); (I.V.)
- Interventional Neuroradiology Unit, Hôpital de la Cavale Blanche, 29200 Brest, France
| | - Jeremy Hofmeister
- ESMINT Artificial Intelligence and Robotics Ad hoc Committee, ESMINT, 8008 Zurich, Switzerland; (E.A.I.R.A.h.C.); (D.B.); (D.B.); (J.C.); (A.A.C.); (V.D.R.); (J.-C.G.); (J.H.); (O.K.-H.); (Ö.K.); (J.L.); (E.P.); (I.V.)
- Unité de Neuroradiologie Interventionnelle, Service de Neuroradiologie Diagnostique et Interventionnelle, 1205 Genève, Switzerland
| | - Omar Kass-Hout
- ESMINT Artificial Intelligence and Robotics Ad hoc Committee, ESMINT, 8008 Zurich, Switzerland; (E.A.I.R.A.h.C.); (D.B.); (D.B.); (J.C.); (A.A.C.); (V.D.R.); (J.-C.G.); (J.H.); (O.K.-H.); (Ö.K.); (J.L.); (E.P.); (I.V.)
- Stroke and Neuroendovascular Surgery, Rex Hospital, University of North Carolina, 4207 Lake Boone Trail, Suite 220, Raleigh, NC 27607, USA
| | - Özcan Kocatürk
- ESMINT Artificial Intelligence and Robotics Ad hoc Committee, ESMINT, 8008 Zurich, Switzerland; (E.A.I.R.A.h.C.); (D.B.); (D.B.); (J.C.); (A.A.C.); (V.D.R.); (J.-C.G.); (J.H.); (O.K.-H.); (Ö.K.); (J.L.); (E.P.); (I.V.)
- Balikesir Atatürk City Hospital, Gaziosmanpaşa Mahallesi 209., Sok. No: 26, 10100 Altıeylül/Balıkesir, Turkey
| | - Jeremy Lynch
- ESMINT Artificial Intelligence and Robotics Ad hoc Committee, ESMINT, 8008 Zurich, Switzerland; (E.A.I.R.A.h.C.); (D.B.); (D.B.); (J.C.); (A.A.C.); (V.D.R.); (J.-C.G.); (J.H.); (O.K.-H.); (Ö.K.); (J.L.); (E.P.); (I.V.)
- Department of Neuroradiology, Toronto Western Hospital, Toronto, ON M5T 2S8, Canada
| | - Ernesto Pearson
- ESMINT Artificial Intelligence and Robotics Ad hoc Committee, ESMINT, 8008 Zurich, Switzerland; (E.A.I.R.A.h.C.); (D.B.); (D.B.); (J.C.); (A.A.C.); (V.D.R.); (J.-C.G.); (J.H.); (O.K.-H.); (Ö.K.); (J.L.); (E.P.); (I.V.)
- CH Bergerac-Centre Hospitalier, Samuel Pozzi 9 Boulevard du Professeur Albert Calmette, 24100 Bergerac, France
| | - Ivan Vukasinovic
- ESMINT Artificial Intelligence and Robotics Ad hoc Committee, ESMINT, 8008 Zurich, Switzerland; (E.A.I.R.A.h.C.); (D.B.); (D.B.); (J.C.); (A.A.C.); (V.D.R.); (J.-C.G.); (J.H.); (O.K.-H.); (Ö.K.); (J.L.); (E.P.); (I.V.)
- Department of Neuroradiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
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Dundamadappa S, Iyer K, Agrawal A, Choi DJ. Multiphase CT Angiography: A Useful Technique in Acute Stroke Imaging-Collaterals and Beyond. AJNR Am J Neuroradiol 2020; 42:221-227. [PMID: 33384289 DOI: 10.3174/ajnr.a6889] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 08/21/2020] [Indexed: 11/07/2022]
Abstract
Multiphase CTA offers several important advantages over the traditional single-phase CTA technique in acute ischemic stroke, including improved detection of large-vessel occlusion, improved characterization of collateral status, improved tolerance of patient motion and poor hemodynamics, and higher interrater reliability. These benefits are gleaned at little additional cost in terms of time, risk to the patient, and capital expense. Existing data suggest that there are important benefits to using multiphase CTA in lieu of single-phase CTA in the initial vessel assessment of patients with acute stroke.
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Affiliation(s)
- S Dundamadappa
- From the Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts
| | - K Iyer
- From the Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts
| | - A Agrawal
- From the Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts
| | - D J Choi
- From the Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts.
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McDougall CC, Chan L, Sachan S, Guo J, Sah RG, Menon BK, Demchuk AM, Hill MD, Forkert ND, d'Esterre CD, Barber PA. Dynamic CTA-Derived Perfusion Maps Predict Final Infarct Volume: The Simple Perfusion Reconstruction Algorithm. AJNR Am J Neuroradiol 2020; 41:2034-2040. [PMID: 33004342 DOI: 10.3174/ajnr.a6783] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/07/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Infarct core volume measurement using CTP (CT perfusion) is a mainstay paradigm for stroke treatment decision-making. Yet, there are several downfalls with cine CTP technology that can be overcome by adopting the simple perfusion reconstruction algorithm (SPIRAL) derived from multiphase CTA. We compare SPIRAL with CTP parameters for the prediction of 24-hour infarction. MATERIALS AND METHODS Seventy-two patients had admission NCCT, multiphase CTA, CTP, and 24-hour DWI. All patients had successful/quality reperfusion. Patient-level and cohort-level receiver operator characteristic curves were generated to determine accuracy. A 10-fold cross-validation was performed on the cohort-level data. Infarct core volume was compared for SPIRAL, CTP-time-to-maximum, and final DWI by Bland-Altman analysis. RESULTS When we compared the accuracy in patients with early and late reperfusion for cortical GM and WM, there was no significant difference at the patient level (0.83 versus 0.84, respectively), cohort level (0.82 versus 0.81, respectively), or the cross-validation (0.77 versus 0.74, respectively). In the patient-level receiver operating characteristic analysis, the SPIRAL map had a slightly higher, though nonsignificant (P < .05), average receiver operating characteristic area under the curve (cortical GM/WM, r = 0.82; basal ganglia = 0.79, respectively) than both the CTP-time-to-maximum (cortical GM/WM = 0.82; basal ganglia = 0.78, respectively) and CTP-CBF (cortical GM/WM = 0.74; basal ganglia = 0.78, respectively) parameter maps. The same relationship was observed at the cohort level. The Bland-Altman plot limits of agreement for SPIRAL and time-to-maximum infarct volume were similar compared with 24-hour DWI. CONCLUSIONS We have shown that perfusion maps generated from a temporally sampled helical CTA are an accurate surrogate for infarct core.
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Affiliation(s)
- C C McDougall
- From the Department of Clinical Neurosciences (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d., P.A.B.), Calgary Stroke Program.,Department of Radiology (C.C.M., B.K.M., N.D.F., C.D.d.E., P.A.B.).,Hotchkiss Brain Institute (C.C.M., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E., P.A.B.).,Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.).,Seaman Family Centre (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d.E., P.A.B.), Foothills Medical Centre, Calgary, Alberta, Canada
| | - L Chan
- Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.)
| | - S Sachan
- Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.)
| | - J Guo
- Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.)
| | - R G Sah
- From the Department of Clinical Neurosciences (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d., P.A.B.), Calgary Stroke Program.,Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.).,Seaman Family Centre (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d.E., P.A.B.), Foothills Medical Centre, Calgary, Alberta, Canada
| | - B K Menon
- From the Department of Clinical Neurosciences (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d., P.A.B.), Calgary Stroke Program.,Department of Radiology (C.C.M., B.K.M., N.D.F., C.D.d.E., P.A.B.).,Hotchkiss Brain Institute (C.C.M., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E., P.A.B.).,Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.).,Seaman Family Centre (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d.E., P.A.B.), Foothills Medical Centre, Calgary, Alberta, Canada
| | - A M Demchuk
- From the Department of Clinical Neurosciences (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d., P.A.B.), Calgary Stroke Program.,Hotchkiss Brain Institute (C.C.M., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E., P.A.B.).,Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.).,Seaman Family Centre (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d.E., P.A.B.), Foothills Medical Centre, Calgary, Alberta, Canada
| | - M D Hill
- From the Department of Clinical Neurosciences (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d., P.A.B.), Calgary Stroke Program.,Hotchkiss Brain Institute (C.C.M., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E., P.A.B.).,Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.).,Seaman Family Centre (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d.E., P.A.B.), Foothills Medical Centre, Calgary, Alberta, Canada
| | - N D Forkert
- Department of Radiology (C.C.M., B.K.M., N.D.F., C.D.d.E., P.A.B.).,Hotchkiss Brain Institute (C.C.M., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E., P.A.B.).,Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.).,Alberta Children's Hospital Research Institute (N.D.F.), University of Calgary, Calgary, Alberta, Canada
| | - C D d'Esterre
- From the Department of Clinical Neurosciences (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d., P.A.B.), Calgary Stroke Program.,Department of Radiology (C.C.M., B.K.M., N.D.F., C.D.d.E., P.A.B.).,Hotchkiss Brain Institute (C.C.M., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E., P.A.B.).,Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.).,Seaman Family Centre (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d.E., P.A.B.), Foothills Medical Centre, Calgary, Alberta, Canada
| | - P A Barber
- From the Department of Clinical Neurosciences (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d., P.A.B.), Calgary Stroke Program .,Department of Radiology (C.C.M., B.K.M., N.D.F., C.D.d.E., P.A.B.).,Hotchkiss Brain Institute (C.C.M., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E., P.A.B.).,Seaman Family Centre (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d.E., P.A.B.), Foothills Medical Centre, Calgary, Alberta, Canada
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Abstract
PURPOSE OF REVIEW Multimodal CT imaging (non-contrast CT, NCCT; CT angiography, CTA; and CT Perfusion, CTP) is central to acute ischemic stroke diagnosis and treatment. We reviewed the purpose and interpretation of each component of multimodal CT, as well as the evidence for use in routine care. RECENT FINDINGS Acute stroke thrombolysis can be administered immediately following NCCT in acute ischemic stroke patients assessed within 4.5 h of symptom onset. Definitive identification of a large vessel occlusion (LVO) requires vascular imaging, which is easily achieved with CTA. This is critical, as the standard of care for LVO within 6 h of onset is now endovascular thrombectomy (EVT). CTA source images can also be used to estimate the efficacy of collateral flow in LVO patients. The final component (CTP) permits a more accurate assessment of the extent of the ischemic penumbra. Complete multimodal CT, including objective penumbral measurement with CTP, has been used to extend the EVT window to 24 h. There is also randomized controlled trial evidence for extension of the IV thrombolysis window to 9 h with multimodal CT. Although there have been attempts to assess for responders to reperfusion strategies beyond 6 h ("late window") using collateral grades, the only evidence for treatment of this group of patients is based on selection using multimodal CT including CTP. The development of fully automated software providing quantitative ischemic penumbral and core volumes has facilitated the adoption of CTP and complete multimodal CT into routine clinical use. Multimodal CT is a powerful imaging algorithm that is central to current ischemic stroke patient care.
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