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Wayer DR, Nigogosyan Z, Xie V, Mian AY, Holder DL, Kim TA, Vo KD, Chatterjee AR, Goyal MS. Finding MeVO: Identifying Intracranial Medium-Vessel Occlusions at CT Angiography. Radiographics 2024; 44:e240010. [PMID: 39365727 DOI: 10.1148/rg.240010] [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: 10/06/2024]
Abstract
The development of methods to detect and treat intracranial large-vessel occlusions (LVOs) has revolutionized the management of acute ischemic stroke. CT angiography (CTA) of the head and neck is effective in depicting LVOs and widely used in the evaluation of patients who have had a stroke. Ongoing efforts are now focused on the potential to detect and treat intracranial medium-vessel occlusions (MeVOs), which by definition are smaller than LVOs and thus more difficult to detect with CTA. The authors review common and variant anatomies of medium-sized cerebral arteries and the appearance of a variety of MeVOs on CT angiograms. Possible pitfalls in MeVO detection include rare anatomic variants, calcified thrombi, and stump occlusions. Current recommendations for performing CTA and ancillary methods that might aid in MeVO detection are discussed. Understanding the relevant anatomy and the variety of appearances of MeVOs aids radiologists in identifying these occlusions, particularly in the setting of urgent stroke. ©RSNA, 2024 See the invited commentary by Ospel and Nguyen in this issue.
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Affiliation(s)
- Daniel R Wayer
- From the Mallinckrodt Institute of Radiology (D.R.W., Z.N., V.X., A.Y.M., T.A.K., K.D.V., A.R.C., M.S.G.) and Department of Neurology (D.L.H., M.S.G.), Washington University School of Medicine, 510 S. Kingshighway Blvd, Box 8131-50-5, St. Louis, MO 63110
| | - Zack Nigogosyan
- From the Mallinckrodt Institute of Radiology (D.R.W., Z.N., V.X., A.Y.M., T.A.K., K.D.V., A.R.C., M.S.G.) and Department of Neurology (D.L.H., M.S.G.), Washington University School of Medicine, 510 S. Kingshighway Blvd, Box 8131-50-5, St. Louis, MO 63110
| | - Victoria Xie
- From the Mallinckrodt Institute of Radiology (D.R.W., Z.N., V.X., A.Y.M., T.A.K., K.D.V., A.R.C., M.S.G.) and Department of Neurology (D.L.H., M.S.G.), Washington University School of Medicine, 510 S. Kingshighway Blvd, Box 8131-50-5, St. Louis, MO 63110
| | - Ali Y Mian
- From the Mallinckrodt Institute of Radiology (D.R.W., Z.N., V.X., A.Y.M., T.A.K., K.D.V., A.R.C., M.S.G.) and Department of Neurology (D.L.H., M.S.G.), Washington University School of Medicine, 510 S. Kingshighway Blvd, Box 8131-50-5, St. Louis, MO 63110
| | - Derek L Holder
- From the Mallinckrodt Institute of Radiology (D.R.W., Z.N., V.X., A.Y.M., T.A.K., K.D.V., A.R.C., M.S.G.) and Department of Neurology (D.L.H., M.S.G.), Washington University School of Medicine, 510 S. Kingshighway Blvd, Box 8131-50-5, St. Louis, MO 63110
| | - Thomas A Kim
- From the Mallinckrodt Institute of Radiology (D.R.W., Z.N., V.X., A.Y.M., T.A.K., K.D.V., A.R.C., M.S.G.) and Department of Neurology (D.L.H., M.S.G.), Washington University School of Medicine, 510 S. Kingshighway Blvd, Box 8131-50-5, St. Louis, MO 63110
| | - Katie D Vo
- From the Mallinckrodt Institute of Radiology (D.R.W., Z.N., V.X., A.Y.M., T.A.K., K.D.V., A.R.C., M.S.G.) and Department of Neurology (D.L.H., M.S.G.), Washington University School of Medicine, 510 S. Kingshighway Blvd, Box 8131-50-5, St. Louis, MO 63110
| | - Arindam Rano Chatterjee
- From the Mallinckrodt Institute of Radiology (D.R.W., Z.N., V.X., A.Y.M., T.A.K., K.D.V., A.R.C., M.S.G.) and Department of Neurology (D.L.H., M.S.G.), Washington University School of Medicine, 510 S. Kingshighway Blvd, Box 8131-50-5, St. Louis, MO 63110
| | - Manu S Goyal
- From the Mallinckrodt Institute of Radiology (D.R.W., Z.N., V.X., A.Y.M., T.A.K., K.D.V., A.R.C., M.S.G.) and Department of Neurology (D.L.H., M.S.G.), Washington University School of Medicine, 510 S. Kingshighway Blvd, Box 8131-50-5, St. Louis, MO 63110
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Ashayeri Ahmadabad R, Tran KH, Zhang Y, Kate MP, Mishra S, Buck BH, Khan KA, Rempel J, Albers GW, Shuaib A. Utility of automated CT perfusion software in acute ischemic stroke with large and medium vessel occlusion. Ann Clin Transl Neurol 2024. [PMID: 39375881 DOI: 10.1002/acn3.52207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2024] [Revised: 09/05/2024] [Accepted: 08/29/2024] [Indexed: 10/09/2024] Open
Abstract
BACKGROUND Early diagnosis of large vessel occlusion (LVO) in acute stroke often requires CT angiography (CTA). Automated CT perfusion (CTP) software, which identifies blood flow abnormalities, enhances LVO diagnosis and patient selection for endovascular thrombectomy (EVT). This study evaluates the sensitivity of automated CTP images in detecting perfusion abnormalities in patients with acute ischemic stroke (AIS) and LVO or medium vessel occlusion (MeVO), compared to CTA. METHODS We screened acute ischemic stroke patients presenting within 24 h who underwent CT, CTA, and CTP as per institutional protocol. RAPID AI software processed CTP images, while neuroradiologists reviewed CTA for intracranial arterial occlusions. Sensitivity, specificity, and accuracy of automated CTP maps in detecting occlusions were assessed. RESULTS Of 790 screened patients, 31 were excluded due to lack of RAPID CTP data or poor-quality scans, leaving 759 for analysis. The median age was 71 years (IQR: 61-81), with 47% female. Among them, 678 had AIS, and 81 had AIS ruled out. CTA identified arterial occlusion in 562 patients (74%), with corresponding CTP abnormalities in 537 patients (Tmax > 6 sec). In the 197 without occlusion, CTP was negative in 161. Automated CTP maps had a sensitivity of 95.55% (CI 95: 93.50-97.10%), specificity of 81.73% (CI 95: 75.61-86.86%), negative predictive value of 98.22% (CI 95: 97.39-98.79%), positive predictive value of 63.54% (CI 95: 56.46-70.09%), and overall accuracy of 85.18% (CI 95: 82.45-87.64%). CONCLUSIONS Automated CTP maps demonstrated high sensitivity and negative predictive value for LVOs and MeVOs, suggesting their usefulness as a rapid diagnostic tool, especially in settings without expert neuroradiologists.
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Affiliation(s)
| | - Kim H Tran
- Division of Neurology, University of Alberta, Edmonton, Canada
| | - Yiran Zhang
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
| | - Mahesh P Kate
- Division of Neurology, University of Alberta, Edmonton, Canada
| | - Sachin Mishra
- Division of Neurology, University of Alberta, Edmonton, Canada
| | - Brian H Buck
- Division of Neurology, University of Alberta, Edmonton, Canada
| | - Khurshid A Khan
- Division of Neurology, University of Alberta, Edmonton, Canada
| | - Jeremy Rempel
- Division of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Canada
| | | | - Ashfaq Shuaib
- Division of Neurology, University of Alberta, Edmonton, Canada
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Alotaibi FF, Alshahrani A, Mohamed G, AlShamrani MA, Bin Amir H, Alsaeed A, Heji A, Alghanmi S, Alqurishi M, Alanazi A, Aldraye H, Asiri M, Alqahtani M, Alreshaid AA, AlKawi A, AlHazzani A, AlZawahmah M, Alokaili RN, Shuaib A, Al-Ajlan FS. Diagnostic accuracy of large and medium vessel occlusions in acute stroke imaging by neurology residents and stroke fellows: A comparison of CT angiography alone and CT angiography with CT perfusion. Eur Stroke J 2024; 9:356-365. [PMID: 37990504 PMCID: PMC11318430 DOI: 10.1177/23969873231214218] [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: 08/16/2023] [Accepted: 10/30/2023] [Indexed: 11/23/2023] Open
Abstract
INTRODUCTION Neurology senior residents and stroke fellows are first to clinically assess and interpret imaging studies of patients presenting to the emergency department with acute stroke. The aim of this study was to compare the diagnostic accuracy of brain CT angiography (CTA) with and without CT perfusion (CTP) between neurology senior residents and stroke fellows. METHODS In this neuroimaging study, nine practitioners (four senior neurology residents (SNRs) and five stroke fellows (SFs)) clinically assessed and interpreted the imaging data of 50 cases (15 normal images, 21 large vessel occlusions (LVOs) and 14 medium vessel occlusions (MeVOs) in two sessions, 1 week apart in comparison to final diagnosis of experienced neuroradiologist and experienced stroke neurologist consensus. Interrater agreement of CTA alone and CTA with CTP was quantified using kappa statistics, sensitivity, specificity and overall accuracy. RESULTS Overall, arterial occlusions were correctly identified in 221/315 (70.1%) with CTA alone and in 266/315 (84.4%) with CTA and CTP (p < 0.001). The sensitivity of overall arterial occlusions detection with CTA alone was 94.2% (95% CI: 90.8%-96.6%) while with addition of CTP was 98% (95% CI: 95.6%-99.3%), The specificity of CTA alone was 74.7% (95% CI: 67.2%-81.3%) which increased with CTP to 84.4% (95% CI: 77.7%-89.8%). The likelihood of correct identification with CTA alone was 156/189 (82.54%) for LVOs and 65/126 (51.59%) for MeVOs. This increased to 169/189 (89.42%; p = 0.054) for LVOs and 97/126 (76.98%; p < 0.001) for MeVOs when the CTA images with CTP were viewed. There was good overall interrater agreement between readers when using CTA alone (k 0.71, 95% CI, 0.62-0.80) and almost perfect (k 0.85, 95% CI, 0.76-0.94) when CTP was added to the image for interpretation. CTA and CTP had a significantly lower median interquartile range (IQR) interpretation time than CTA alone (114 [IQR, 103-120] s vs 156 [IQR, 133-160] s, p < 0.001). DISCUSSION In cerebral arterial occlusions, the rate of LVO and MeVOs detections increases when adding CTP to CTA. The accuracy and time for diagnosing arterial occlusion can be significantly improved if CTP is added to CTA. As MeVOs are commonly missed by front-line neurology senior residents or stroke fellows, cases with significant deficits and no apparent arterial occlusions need to be reviewed with neuroradiological expertise.
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Affiliation(s)
- Fawaz F Alotaibi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Asma Alshahrani
- Department of Biostatistics, Epidemiology, and Scientific Computing, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Gamal Mohamed
- Department of Biostatistics, Epidemiology, and Scientific Computing, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mohamed A AlShamrani
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hussain Bin Amir
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ali Alsaeed
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Alaa Heji
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Suwaidi Alghanmi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mohammed Alqurishi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Azhar Alanazi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hamad Aldraye
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Muhannad Asiri
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mohammed Alqahtani
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Abdulrahman A Alreshaid
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
| | - Ammar AlKawi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
| | - Adel AlHazzani
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
| | - Mohamed AlZawahmah
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Riyadh N Alokaili
- Department of Radiology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ashfaq Shuaib
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Fahad S Al-Ajlan
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
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Marburg M, Rudolf LF, Matthis C, Neumann A, Schareck C, Schacht H, Schulz R, Machner B, Schramm P, Royl G, Koch PJ. The lesion core extent modulates the impact of early perfusion mismatch imaging on outcome variability after thrombectomy in stroke. Front Neurol 2024; 15:1366240. [PMID: 38841692 PMCID: PMC11150589 DOI: 10.3389/fneur.2024.1366240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/29/2024] [Indexed: 06/07/2024] Open
Abstract
Introduction Despite profitable group effects on functional outcomes after mechanical thrombectomy (MT) in large vessel occlusion (LVO), many patients with successful reperfusion show a non-favorable long-term outcome, highlighting the necessity to identify potential biomarkers predicting outcome variability. In this regard, the role of perfusion mismatch imaging for outcome variability in the early time window within 6 h after symptom onset is a matter of debate. We attempted to investigate under which conditions early perfusion mismatch imaging accounts for variability in functional outcomes after mechanical thrombectomy. Patients and methods In a retrospective single-center study, we examined 190 consecutive patients with LVO who were admitted to the Medical Center Lübeck within 6 h after symptom onset, all of whom underwent MT. Perfusion mismatch was quantified by applying the Alberta Stroke Program Early CT score (ASPECTS) on CT-measured cerebral blood flow (CBF-ASPECTS) and subtracting it from an ASPECTS application on cerebral blood volume (CBV-ASPECTS), i.e., ASPECTS mismatch. Using multivariate ordinal regression models, associations between ASPECTS mismatch and modified Rankin Scale (mRS) after 90 days were assessed. Furthermore, the interaction between ASPECTS mismatch and the core lesion volume was calculated to evaluate conditional associations. Results ASPECTS mismatch did not correlate with functional outcomes when corrected for multiple influencing covariables. However, interactions between ASPECTS mismatch and CBV-ASPECTS [OR: 1.12 (1.06-1.18), p-value < 0.001], as well as NCCT-ASPECTS [OR: 1.15 (1.06-1.25), p-value < 0.001], did show a significant association with functional outcomes. Model comparisons revealed that, profoundly, in patients with large core lesion volumes (CBV-ASPECTS < 6 or NCCT-ASPECTS < 6), perfusion mismatch showed a negative correlation with the mRS. Discussion and conclusion Perfusion mismatch imaging within the first 6 h of symptom onset provides valuable insights into the outcome variability of LVO stroke patients receiving thrombectomy but only in patients with large ischemic core lesions.
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Affiliation(s)
- Maria Marburg
- Department of Neurology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Linda F. Rudolf
- Department of Neuroradiology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Christine Matthis
- Department of Social Medicine and Epidemiology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Alexander Neumann
- Department of Neuroradiology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Constantin Schareck
- Department of Radiology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Hannes Schacht
- Department of Neuroradiology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Robert Schulz
- Department of Neurology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Björn Machner
- Department of Neurology, Schoen Clinic Neustadt, Neustadt in Holstein, Germany
| | - Peter Schramm
- Department of Neuroradiology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Georg Royl
- Department of Neurology, University Hospital Schleswig-Holstein, Lübeck, Germany
- Center of Brain, Behavior and Metabolism, University of Lübeck, Lübeck, Germany
| | - Philipp J. Koch
- Department of Neurology, University Hospital Schleswig-Holstein, Lübeck, Germany
- Center of Brain, Behavior and Metabolism, University of Lübeck, Lübeck, Germany
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Vos EM, Kappelhof M, den Hartog SJ, Coutinho JM, Emmer BJ, Roozenbeek B, van Zwam WH, van Oostenbrugge RJ, van der Worp HB, Uyttenboogaart M, van Es ACGM, Majoie CBLM, Dippel DWJ, Peeters-Scholte CMPCD, van den Wijngaard IR. Endovascular treatment of patients with stroke caused by anterior cerebral artery occlusions. Acta Neurol Belg 2024; 124:621-630. [PMID: 37828269 DOI: 10.1007/s13760-023-02395-8] [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: 07/01/2023] [Accepted: 09/21/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Occlusion of the anterior cerebral artery (ACA) is uncommon but may lead to significant disability. The benefit of endovascular treatment (EVT) for ACA occlusions remains uncertain. METHODS We included patients treated with EVT and compared patients with ACA occlusions with patients who had internal carotid artery (ICA) or proximal (M1/M2) middle cerebral artery (MCA) occlusions from the MR CLEAN Registry. Primary outcome was the modified Rankin Scale score (mRS). Secondary outcomes were functional independence (mRS 0-2), National Institutes of Health Stroke Scale (NIHSS) score, delta-NIHSS (baseline minus NIHSS score at 24-48 h), and successful recanalization (expanded thrombolysis in cerebral infarction (eTICI) score 2b-3). Safety outcomes were symptomatic intracranial hemorrhage (sICH), periprocedural complications, and mortality. RESULTS Of 5193 patients, 11 (0.2%) had primary ACA occlusions. Median NIHSS at baseline was lower in patients with ACA versus ICA/MCA occlusions (11, IQR 9-14; versus 15, IQR 11-19). Functional outcome did not differ from patients with ICA/MCA occlusions. Functional independence was 4/11 (36%) in patients with ACA versus 1949/4815 (41%) in ICA/MCA occlusions; median delta-NIHSS was - 1 (IQR - 7 to 2) and - 4 (IQR - 9 to 0), respectively. Successful recanalization was 4/9 (44%), versus 3083/4787 (64%) in ICA/MCA occlusions. Mortality was 3/11 (27%) versus 1263/4815 (26%). One patient with ACA occlusion had sICH; no other complications occurred. CONCLUSION In this cohort ACA occlusions were uncommon. Functional outcome did not differ between patients with ACA occlusions and ICA/MCA occlusions. Prospective research is needed to determine feasibility, safety, and outcomes of EVT for ACA occlusions.
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Affiliation(s)
- Erik M Vos
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands.
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Sanne J den Hartog
- Department of Neurology, Radiology and Nuclear Medicine, Erasmus Medical Center, Public Health, Rotterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Radiology and Nuclear Medicine, Erasmus Medical Center, Public Health, Rotterdam, The Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, School for Cardiovascular Diseases (CARIM), Maastricht UMC+, Maastricht, The Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, School for Cardiovascular Diseases (CARIM), School for Mental Health and Neuroscience, Maastricht UMC+, Maastricht, The Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | - Adriaan C G M van Es
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
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van Voorst H, Hoving JW, Koopman MS, Daems JD, Peerlings D, Buskens E, Lingsma HF, Beenen LFM, de Jong HWAM, Berkhemer OA, van Zwam WH, Roos YBWEM, van Walderveen MAA, van den Wijngaard I, Dippel DWJ, Yoo AJ, Campbell BCV, Kunz WG, Emmer BJ, Majoie CBLM. Cost-effectiveness of CT perfusion for the detection of large vessel occlusion acute ischemic stroke followed by endovascular treatment: a model-based health economic evaluation study. Eur Radiol 2024; 34:2152-2167. [PMID: 37728778 PMCID: PMC10957700 DOI: 10.1007/s00330-023-10119-y] [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: 03/16/2023] [Revised: 06/22/2023] [Accepted: 07/01/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVES CT perfusion (CTP) has been suggested to increase the rate of large vessel occlusion (LVO) detection in patients suspected of acute ischemic stroke (AIS) if used in addition to a standard diagnostic imaging regime of CT angiography (CTA) and non-contrast CT (NCCT). The aim of this study was to estimate the costs and health effects of additional CTP for endovascular treatment (EVT)-eligible occlusion detection using model-based analyses. METHODS In this Dutch, nationwide retrospective cohort study with model-based health economic evaluation, data from 701 EVT-treated patients with available CTP results were included (January 2018-March 2022; trialregister.nl:NL7974). We compared a cohort undergoing NCCT, CTA, and CTP (NCCT + CTA + CTP) with a generated counterfactual where NCCT and CTA (NCCT + CTA) was used for LVO detection. The NCCT + CTA strategy was simulated using diagnostic accuracy values and EVT effects from the literature. A Markov model was used to simulate 10-year follow-up. We adopted a healthcare payer perspective for costs in euros and health gains in quality-adjusted life years (QALYs). The primary outcome was the net monetary benefit (NMB) at a willingness to pay of €80,000; secondary outcomes were the difference between LVO detection strategies in QALYs (ΔQALY) and costs (ΔCosts) per LVO patient. RESULTS We included 701 patients (median age: 72, IQR: [62-81]) years). Per LVO patient, CTP-based occlusion detection resulted in cost savings (ΔCosts median: € - 2671, IQR: [€ - 4721; € - 731]), a health gain (ΔQALY median: 0.073, IQR: [0.044; 0.104]), and a positive NMB (median: €8436, IQR: [5565; 11,876]) per LVO patient. CONCLUSION CTP-based screening of suspected stroke patients for an endovascular treatment eligible large vessel occlusion was cost-effective. CLINICAL RELEVANCE STATEMENT Although CTP-based patient selection for endovascular treatment has been recently suggested to result in worse patient outcomes after ischemic stroke, an alternative CTP-based screening for endovascular treatable occlusions is cost-effective. KEY POINTS • Using CT perfusion to detect an endovascular treatment-eligible occlusions resulted in a health gain and cost savings during 10 years of follow-up. • Depending on the screening costs related to the number of patients needed to image with CT perfusion, cost savings could be considerable (median: € - 3857, IQR: [€ - 5907; € - 1916] per patient). • As the gain in quality adjusted life years was most affected by the sensitivity of CT perfusion-based occlusion detection, additional studies for the diagnostic accuracy of CT perfusion for occlusion detection are required.
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Affiliation(s)
- Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
- Department of Biomedical Engineering and Physics, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands.
| | - Jan W Hoving
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Miou S Koopman
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Jasper D Daems
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Daan Peerlings
- Department of Biomedical Engineering and Physics, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Erik Buskens
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ludo F M Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Hugo W A M de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Olvert A Berkhemer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
| | | | | | - Diederik W J Dippel
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Albert J Yoo
- Department of Radiology, Texas Stroke Institute, Dallas-Fort Worth, TX, USA
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Center, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
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Liu H, Wu D, Chen ZB, Xiao Q, Cheng JW, Xie XY, Qu DX, Tao J, Wang WZ, Peng YF, Li GY, Weng YF. Preliminary findings on diagnostic performance of computed tomography perfusion images for intracranial arterial stenosis: a retrospective study. BMC Neurol 2024; 24:59. [PMID: 38336624 PMCID: PMC10854082 DOI: 10.1186/s12883-024-03554-x] [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: 11/24/2023] [Accepted: 01/28/2024] [Indexed: 02/12/2024] Open
Abstract
OBJECTIVES Computed tomographic perfusion (CTP) can play an auxiliary role in the selection of patients with acute ischemic stroke for endovascular treatment. However, data on CTP in non-stroke patients with intracranial arterial stenosis are scarce. We aimed to investigate images in patients with asymptomatic intracranial arterial stenosis to determine the detection accuracy and interpretation time of large/medium-artery stenosis or occlusion when combining computed tomographic angiography (CTA) and CTP images. METHODS We retrospectively reviewed 39 patients with asymptomatic intracranial arterial stenosis from our hospital database from January 2021 to August 2023 who underwent head CTP, head CTA, and digital subtraction angiography (DSA). Head CTA images were generated from the CTP data, and the diagnostic performance for each artery was assessed. Two readers independently interpreted the CTA images before and after CTP, and the results were analyzed. RESULTS After adding CTP maps, the accuracy (area under the curve) of diagnosing internal carotid artery (R1: 0.847 vs. 0.907, R2: 0.776 vs. 0.887), middle cerebral artery (R1: 0.934 vs. 0.933, R2: 0.927 vs. 0.981), anterior cerebral artery (R1: 0.625 vs. 0.750, R2: 0.609 vs. 0.750), vertebral artery (R1: 0.743 vs. 0.764, R2: 0.748 vs. 0.846), and posterior cerebral artery (R1: 0.390 vs. 0.575, R2: 0.390 vs. 0.585) occlusions increased for both readers (p < 0.05). Mean interpretation time (R1: 72.4 ± 6.1 s vs. 67.7 ± 6.4 s, R2: 77.7 ± 3.8 s vs. 72.6 ± 4.7 s) decreased when using a combination of both images both readers (p < 0.001). CONCLUSIONS The addition of CTP images improved the accuracy of interpreting CTA images and reduced the interpretation time in asymptomatic intracranial arterial stenosis. These findings support the use of CTP imaging in patients with asymptomatic intracranial arterial stenosis.
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Affiliation(s)
- Hui Liu
- Department of Neurology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, P.R. China
| | - Dan Wu
- Department of Radiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, P.R. China
| | - Zhi-Bin Chen
- Department of Neurology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, P.R. China
| | - Qian Xiao
- Department of Neurology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, P.R. China
| | - Ji-Wei Cheng
- Department of Neurology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, P.R. China
| | - Xiao-Yan Xie
- Department of Radiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, P.R. China
| | - Dong-Xiao Qu
- Central Laboratory, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, P.R. China
| | - Jie Tao
- Central Laboratory, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, P.R. China
| | - Wei-Zhong Wang
- Department of Radiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, P.R. China
| | - Yi-Feng Peng
- Department of Radiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, P.R. China
| | - Guo-Yi Li
- Department of Neurology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, P.R. China
| | - Ying-Feng Weng
- Department of Neurology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, P.R. China.
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Seners P, Baron JC, Olivot JM, Albers GW. Does imaging of the ischemic penumbra have value in acute ischemic stroke with large vessel occlusion? Curr Opin Neurol 2024; 37:1-7. [PMID: 38038427 DOI: 10.1097/wco.0000000000001235] [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: 12/02/2023]
Abstract
PURPOSE OF REVIEW In this review, we summarize current evidence regarding potential benefits and limitations of using perfusion imaging to estimate presence and extent of irreversibly injured ischemic brain tissue ('core') and severely ischemic yet salvageable tissue ('penumbra') in acute stroke patients with large vessel occlusion (LVO). RECENT FINDINGS Core and penumbra volumes are strong prognostic biomarkers in LVO patients. Greater benefits of both intravenous thrombolysis and endovascular therapy (EVT) are observed in patients with small core and large penumbra volumes. However, some current definitions of clinically relevant penumbra may be too restrictive and exclude patients who may benefit from reperfusion therapies. Alongside other clinical and radiological factors, penumbral imaging may enhance the discussion regarding the benefit/risk ratio of EVT in common clinical situations, such as patients with large core - for whom EVT's benefit is established but associated with a high rate of severe disability -, or patients with mild symptoms or medium vessel occlusions - for whom EVT's benefit is currently unknown. Beyond penumbral evaluation, perfusion imaging is clinically relevant for optimizing patient's selection for neuroprotection trials. SUMMARY In an emerging era of precision medicine, perfusion imaging is a valuable tool in LVO-related acute stroke.
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Affiliation(s)
- Pierre Seners
- Neurology Department, A. de Rothschild Foundation Hospital
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM U1266
| | - Jean-Claude Baron
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM U1266
- Neurology Department, GHU Paris Psychiatrie et Neurosciences, Paris
| | - Jean-Marc Olivot
- Acute Stroke Unit, Hôpital Pierre-Paul Riquet, CHU Toulouse and CIC 1436, Toulouse University, Toulouse, France
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Sousa JA, Sondermann A, Bernardo-Castro S, Varela R, Donato H, Sargento-Freitas J. CTA and CTP for Detecting Distal Medium Vessel Occlusions: A Systematic Review and Meta-analysis. AJNR Am J Neuroradiol 2023; 45:51-56. [PMID: 38164544 PMCID: PMC10756569 DOI: 10.3174/ajnr.a8080] [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: 08/03/2023] [Accepted: 10/31/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND The optimal imaging method for detecting distal medium vessel occlusions (DMVOs) remains undefined. PURPOSE The objective of this study is to compare the diagnostic performance of CTA with CTP in detecting DMVOs. DATA SOURCES We searched PubMed, EMBASE, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials up to March 31, 2023 (PROSPERO: CRD42022344006). STUDY SELECTION A total of 12 studies reporting accuracy values of CTA and/or CTP were included, comprising 2607 patients with 479 cases (18.3%) of DMVOs. DATA ANALYSIS Pooled sensitivity and specificity of both imaging methods were compared using a random-effects model. Subgroup analyses were performed based on the technique used in CTA (multi or single-phase) and the subtype of DMVOs (M2-only vs. M2 and other DMVOs). We applied Quality Assessment of Diagnostic Accuracy (QUADAS-2) tool and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) quality assessment criteria. DATA SYNTHESIS CTA demonstrated significantly lower sensitivity compared to CTP in detecting DMVOs [0.74, 95%CI (0.63-0.82) vs. 0.89, 95% CI (0.82-0.93), P < 0.01]. When subgrouped into single-phase and multi-phase CTA, multi-phase CTA exhibited higher sensitivity for DMVO detection than single-phase CTA [0.91, 95%CI (0.85-0.94) vs. 0.64, 95%CI (0.56-0.71), P < .01], while reaching similar levels to CTP. The sensitivity of single-phase CTA substantially decreased when extending from M2 to other non-M2 DMVOs [0.74, 95%CI (0.63-0.83) vs. 0.61, 0.95%CI (0.53-0.68), P = .02]. LIMITATIONS We identified an overall high risk of bias and low quality of evidence, attributable to the design and reference standards of most studies. CONCLUSIONS Our findings highlight a significantly lower sensitivity of single-phase CTA compared to multi-phase CTA and CTP in diagnosing DMVOs.
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Affiliation(s)
- João André Sousa
- From the Neurology Department (J.A.S., S.B.-C., J.S.-F.), Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Anton Sondermann
- Neurologeriatrie Department (A.S.), Christian-Albrechts-Universität zu Kiel, Kiel, Germany
| | - Sara Bernardo-Castro
- From the Neurology Department (J.A.S., S.B.-C., J.S.-F.), Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculdade de Medicina da Universidade de Coimbra (S.B.-C., J.S.-F.), Coimbra, Portugal
| | - Ricardo Varela
- Neurology Department (R.V.), Centro Hospitalar e Universitário de Santo António, Porto, Portugal
| | - Helena Donato
- Documentation and Scientific Information Service (H.D.), Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - João Sargento-Freitas
- From the Neurology Department (J.A.S., S.B.-C., J.S.-F.), Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculdade de Medicina da Universidade de Coimbra (S.B.-C., J.S.-F.), Coimbra, Portugal
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Chung KJ, Pandey SK, Khaw AV, Lee TY. Multiphase CT angiography perfusion maps for predicting target mismatch and ischemic lesion volumes. Sci Rep 2023; 13:21976. [PMID: 38081878 PMCID: PMC10713587 DOI: 10.1038/s41598-023-48832-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 11/30/2023] [Indexed: 12/18/2023] Open
Abstract
The complexity of CT perfusion (CTP) acquisition protocols may limit the availability of target mismatch assessment at resource-limited hospitals. We compared CTP mismatch with a mismatch surrogate generated from a simplified dynamic imaging sequence comprising widely available non-contrast CT (NCCT) and multiphase CT angiography (mCTA). Consecutive patients with anterior circulation acute ischemic stroke who received NCCT, mCTA, and CTP were retrospectively included in this study. An mCTA-perfusion (mCTA-P) dynamic series was formed by co-registering NCCT and mCTA. We simulated an ideal mCTA-P study by down-sampling CTP (dCTP) dynamic images according to mCTA timing. Ischemic core and penumbra volumes were estimated by cerebral blood flow and Tmax thresholding, respectively, on perfusion maps calculated independently for CTP, dCTP, and mCTA-P by deconvolution. Concordance in target mismatch (core < 70 ml, penumbra ≥ 15 ml, mismatch ratio ≥ 1.8) determination by dCTP and mCTA-P versus CTP was assessed. Of sixty-one included patients, forty-six had a CTP target mismatch. Concordance with CTP profiles was 90% and 82% for dCTP and mCTA-P, respectively. Lower mCTA-P concordance was likely from differences in collimation width between NCCT and mCTA, which worsened perfusion map quality due to a CT number shift at mCTA. Moderate diagnostic agreement between CTP and mCTA-P was found and may improve with optimal mCTA scan parameter selection as simulated by dCTP. mCTA-P may be a pragmatic alternative where CTP is unavailable or the risks of additional radiation dose, contrast injections, and treatment delays outweigh the potential benefit of a separate CTP scan.
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Affiliation(s)
- Kevin J Chung
- Department of Medical Biophysics, The University of Western Ontario, London, ON, Canada
- Robarts Research Institute and Lawson Health Research Institute, London, ON, Canada
| | - Sachin K Pandey
- Department of Medical Imaging, The University of Western Ontario, RRI 1200D, 1151 Richmond Street N, London, ON, N6A 5B7, Canada
| | - Alexander V Khaw
- Department of Clinical Neurological Sciences, The University of Western Ontario, London, ON, Canada
| | - Ting-Yim Lee
- Department of Medical Biophysics, The University of Western Ontario, London, ON, Canada.
- Robarts Research Institute and Lawson Health Research Institute, London, ON, Canada.
- Department of Medical Imaging, The University of Western Ontario, RRI 1200D, 1151 Richmond Street N, London, ON, N6A 5B7, Canada.
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Temmen SE, Becks MJ, Schalekamp S, van Leeuwen KG, Meijer FJA. Duration and accuracy of automated stroke CT workflow with AI-supported intracranial large vessel occlusion detection. Sci Rep 2023; 13:12551. [PMID: 37532773 PMCID: PMC10397283 DOI: 10.1038/s41598-023-39831-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/31/2023] [Indexed: 08/04/2023] Open
Abstract
The Automation Platform (AP) is a software platform to support the workflow of radiologists and includes a stroke CT package with integrated artificial intelligence (AI) based tools. The aim of this study was to evaluate the diagnostic performance of the AP for the detection of intracranial large vessel occlusions (LVO) on conventional CT angiography (CTA), and the duration of CT processing in a cohort of acute stroke patients. The diagnostic performance for intracranial LVO detection on CTA by the AP was evaluated in a retrospective cohort of 100 acute stroke patients and compared to the diagnostic performance of five radiologists with different levels of experience. The reference standard was set by an independent neuroradiologist, with access to the readings of the different radiologists, clinical data, and follow-up. The data processing time of the AP for ICH detection on non-contrast CT, LVO detection on CTA, and the processing of CTP maps was assessed in a subset 60 patients of the retrospective cohort. This was compared to 13 radiologists, who were prospectively timed for the processing and reading of 21 stroke CTs. The AP showed shorter processing time of CTA (mean 60 versus 395 s) and CTP (mean 196 versus 243-349 s) as compared to radiologists, but showed lower sensitivity for LVO detection (sensitivity 77% of the AP vs mean sensitivity 87% of radiologists). If the AP would have been used as a stand-alone system, 1 ICA occlusion, 2 M1 occlusions and 8 M2 occlusions would have been missed, which would be eligible for mechanical thrombectomy. In conclusion, the AP showed shorter processing time of CTA and CTP as compared with radiologists, which illustrates the potential of the AP to speed-up the diagnostic work-up. However, its performance for LVO detection was lower as compared with radiologists, especially for M2 vessel occlusions.
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Affiliation(s)
- Sander E Temmen
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein Zuid 10, 766, PO Box 9101, 6500HB, Nijmegen, The Netherlands
| | - Marinus J Becks
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein Zuid 10, 766, PO Box 9101, 6500HB, Nijmegen, The Netherlands
| | - Steven Schalekamp
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein Zuid 10, 766, PO Box 9101, 6500HB, Nijmegen, The Netherlands
| | - Kicky G van Leeuwen
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein Zuid 10, 766, PO Box 9101, 6500HB, Nijmegen, The Netherlands
| | - Frederick J A Meijer
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein Zuid 10, 766, PO Box 9101, 6500HB, Nijmegen, The Netherlands.
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12
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Peerlings D, de Jong HWAM, Bennink E, Dankbaar JW, Velthuis BK, Emmer BJ, Majoie CBLM, Marquering HA. Spatial CT perfusion data helpful in automatically locating vessel occlusions for acute ischemic stroke patients. Front Neurol 2023; 14:1136232. [PMID: 37064186 PMCID: PMC10090274 DOI: 10.3389/fneur.2023.1136232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 03/06/2023] [Indexed: 03/30/2023] Open
Abstract
IntroductionLocating a vessel occlusion is important for clinical decision support in stroke healthcare. The advent of endovascular thrombectomy beyond proximal large vessel occlusions spurs alternative approaches to locate vessel occlusions. We explore whether CT perfusion (CTP) data can help to automatically locate vessel occlusions.MethodsWe composed an atlas with the downstream regions of particular vessel segments. Occlusion of these segments should result in the hypoperfusion of the corresponding downstream region. We differentiated between seven-vessel occlusion locations (ICA, proximal M1, distal M1, M2, M3, ACA, and posterior circulation). We included 596 patients from the DUtch acute STroke (DUST) multicenter study. Each patient CTP data set was processed with perfusion software to determine the hypoperfused region. The downstream region with the highest overlap with the hypoperfused region was considered to indicate the vessel occlusion location. We assessed the indications from CTP against expert annotations from CTA.ResultsOur atlas-based model had a mean accuracy of 86% and could achieve substantial agreement with the annotations from CTA according to Cohen's kappa coefficient (up to 0.68). In particular, anterior large vessel occlusions and occlusions in the posterior circulation could be located with an accuracy of 80 and 92%, respectively.ConclusionThe spatial layout of the hypoperfused region can help to automatically indicate the vessel occlusion location for acute ischemic stroke patients. However, variations in vessel architecture between patients seemed to limit the capacity of CTP data to distinguish between vessel occlusion locations more accurately.
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Affiliation(s)
- Daan Peerlings
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
- *Correspondence: Daan Peerlings
| | | | - Edwin Bennink
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, Netherlands
| | - Jan W. Dankbaar
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Birgitta K. Velthuis
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Bart J. Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands
| | - Charles B. L. M. Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands
| | - Henk A. Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands
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Dhillon PS, White P, Goyal M, van Zwam WH, Lenthall R. Perfusion imaging in acute ischaemic stroke - the beginning of the end? Clin Med (Lond) 2023; 23:185-186. [PMID: 36958844 PMCID: PMC11046506 DOI: 10.7861/clinmed.2022-0554] [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] [Indexed: 03/25/2023]
Abstract
Endovascular thrombectomy (EVT) for large vessel occlusion in acute ischaemic stroke is the standard of care when initiated within 6 hours of stroke onset, and is performed between 6-24 hours using advanced neuroimaging (CT perfusion or MR imaging) for patients who meet the strict imaging selection criteria. However, adherence to the restrictive imaging criteria recommended by current guidelines is impeded in many parts of the world, including the UK, by resource constraints and limited access to advanced neuroimaging in the emergency setting. Furthermore, recent randomised and non-randomised studies have demonstrated that patients selected without advanced neuroimaging (with non-contrast CT and CT angiography only) using less restrictive imaging criteria for EVT eligibility beyond 6 hours from onset still benefited from EVT treatment, thereby increasing the proportion of patients eligible for EVT and widening the potential treatment impact at a population level. Hence, current guidelines should be updated expeditiously to reflect the level I evidence in support of more liberal imaging selection criteria for patients presenting with acute ischaemic stroke due to a large vessel occlusion.
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Affiliation(s)
| | - Phil White
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Wim H van Zwam
- Maastricht University Medical Center, Maastricht, the Netherlands
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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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