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Karimian-Jazi K, Vollherbst DF, Schwarz D, Fischer M, Schregel K, Bauer G, Kocharyan A, Sturm V, Neuberger U, Jesser J, Herweh C, Ulfert C, Hilgenfeld T, Seker F, Preisner F, Schmitt N, Charlet T, Hamelmann S, Sahm F, Heiland S, Wick W, Ringleb PA, Schirmer L, Bendszus M, Möhlenbruch MA, Breckwoldt MO. MR microscopy to assess clot composition following mechanical thrombectomy predicts recanalization and clinical outcome. J Neurointerv Surg 2024; 16:830-837. [PMID: 37527928 DOI: 10.1136/jnis-2023-020594] [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: 05/17/2023] [Accepted: 07/16/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND Mechanical thrombectomy (MT) is the standard of care for patients with a stroke and large vessel occlusion. Clot composition is not routinely assessed in clinical practice as no specific diagnostic value is attributed to it, and MT is performed in a standardized 'non-personalized' approach. Whether different clot compositions are associated with intrinsic likelihoods of recanalization success or treatment outcome is unknown. METHODS We performed a prospective, non-randomized, single-center study and analyzed the clot composition in 60 consecutive patients with ischemic stroke undergoing MT. Clots were assessed by ex vivo multiparametric MRI at 9.4 T (MR microscopy), cone beam CT, and histopathology. Clot imaging was correlated with preinterventional CT and clinical data. RESULTS MR microscopy showed red blood cell (RBC)-rich (21.7%), platelet-rich (white,38.3%) or mixed clots (40.0%) as distinct morphological entities, and MR microscopy had high accuracy of 95.4% to differentiate clots. Clot composition could be further stratified on preinterventional non-contrast head CT by quantification of the hyperdense artery sign. During MT, white clots required more passes to achieve final recanalization and were not amenable to contact aspiration compared with mixed and RBC-rich clots (maneuvers: 4.7 vs 3.1 and 1.2 passes, P<0.05 and P<0.001, respectively), whereas RBC-rich clots showed higher probability of first pass recanalization (76.9%) compared with white clots (17.4%). White clots were associated with poorer clinical outcome at discharge and 90 days after MT. CONCLUSION Our study introduces MR microscopy to show that the hyperdense artery sign or MR relaxometry could guide interventional strategy. This could enable a personalized treatment approach to improve outcome of patients undergoing MT.
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Affiliation(s)
| | - Dominik F Vollherbst
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Daniel Schwarz
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Manuel Fischer
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Katharina Schregel
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Gregor Bauer
- Neurology Clinic, University Hospital Heidelberg, Heidelberg, Germany
| | - Anna Kocharyan
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Volker Sturm
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Ulf Neuberger
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jessica Jesser
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Herweh
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Ulfert
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Tim Hilgenfeld
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Fatih Seker
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Fabian Preisner
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Niclas Schmitt
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Tobias Charlet
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Hamelmann
- Department of Neuropathology, University of Heidelberg, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Felix Sahm
- Department of Neuropathology, University of Heidelberg, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Sabine Heiland
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Wolfgang Wick
- Neurology Clinic and National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, Germany
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Peter A Ringleb
- Neurology Clinic, University Hospital Heidelberg, Heidelberg, Germany
| | - Lucas Schirmer
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Michael O Breckwoldt
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
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Shinohara Y, Ohmura T, Sasaki F, Sato Y, Inomata T, Itoh T, Kinoshita T. Dual-Energy Computed Tomography Virtual Noncalcium Imaging of Intracranial Arteries in Acute Ischemic Stroke: Differentiation Between Acute Thrombus and Calcification. J Comput Assist Tomogr 2024:00004728-990000000-00315. [PMID: 38657159 DOI: 10.1097/rct.0000000000001623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
OBJECTIVE Hyperdense artery sign (HAS) on noncontrast brain computed tomography (CT) indicates an acute thrombus within the cerebral artery. It is a valuable imaging biomarker for diagnosing large-vessel occlusion; however, its identification may be challenging with the presence of vascular calcification. Dual-energy CT virtual noncalcium (VNCa) imaging using a 3-material decomposition algorithm is helpful for differentiating between calcification and hemorrhage. This study aimed to clarify the potential of VNCa imaging for differentiating HAS from vascular calcification. METHODS Patients with acute ischemic stroke and large-vessel occlusion identified on MR angiography, who also underwent noncontrast dual-energy CT, were included. The 80 kV/Sn 140 kV mixed images, with a weighting factor of 0.4, were considered 120 kVp-equivalent images. Postprocessing using a 3-material decomposition algorithm to differentiate between calcium (Ca), cerebrospinal fluid, and hemorrhage was performed via a commercially available 3-dimensional workstation. A mixed image, VNCa image, color-coded Ca image, and color-coded Ca image with VNCa image overlay (color-coded Ca-overlay image) were obtained, and axial reconstruction with a 1-mm slice thickness was performed for each image type. Two experienced neuroradiologists conducted imaging evaluations in consensus. RESULTS Thirty-four patients (mean age, 76.0 years; 21 male and 13 female patients) were included. The mixed and VNCa images revealed an HAS (indicating an acute clot) corresponding to the large-vessel occlusion site in 30 patients. Among them, the VNCa and color-coded Ca-overlay images enabled clear differentiation between the acute thrombus and adjacent vessel wall calcification in 5 patients. Among the other 4 patients, the VNCa, Ca-overlay, and Ca images identified calcified cerebral emboli in the M1 segment in 1 patient. For the other 3 patients, no high attenuation corresponding to magnetic resonance angiography findings was observed in any of the mixed, VNCa, Ca-overlay, or Ca images. CONCLUSIONS VNCa and color-coded Ca-overlay images obtained via dual-energy brain CT enabled differentiation of acute thrombus from vessel wall calcification and calcified cerebral emboli in patients with acute ischemic stroke.
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Affiliation(s)
- Yuki Shinohara
- From the Department of Radiology and Nuclear Medicine, Research Institute for Brain and Blood Vessels-Akita, Akita, Japan
| | - Tomomi Ohmura
- From the Department of Radiology and Nuclear Medicine, Research Institute for Brain and Blood Vessels-Akita, Akita, Japan
| | - Fumiaki Sasaki
- From the Department of Radiology and Nuclear Medicine, Research Institute for Brain and Blood Vessels-Akita, Akita, Japan
| | - Yuichiro Sato
- From the Department of Radiology and Nuclear Medicine, Research Institute for Brain and Blood Vessels-Akita, Akita, Japan
| | - Takato Inomata
- From the Department of Radiology and Nuclear Medicine, Research Institute for Brain and Blood Vessels-Akita, Akita, Japan
| | - Toshihide Itoh
- CT Research and Collaboration Department, Diagnostic Imaging Division, Siemens Healthcare K.K., Tokyo, Japan
| | - Toshibumi Kinoshita
- From the Department of Radiology and Nuclear Medicine, Research Institute for Brain and Blood Vessels-Akita, Akita, Japan
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3
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Informe radiológico de la TC multimodal en los pacientes con ictus isquémico agudo. RADIOLOGIA 2022. [DOI: 10.1016/j.rx.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Baykal T, Unal Akoglu E, Akoglu T, Cimilli Ozturk T, Akoglu H. The middle cerebral artery density and ratio for the diagnosis of acute ischaemic stroke in the Emergency Department. Int J Clin Pract 2021; 75:e14799. [PMID: 34482600 DOI: 10.1111/ijcp.14799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/31/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Non-contrast computed tomography (ncCT) is the first-line imaging modality for acute ischaemic stroke diagnosis. Recognition of the early diagnostic signs of a stroke on computed tomography (CT) is crucial. The hyperdense middle cerebral artery (MCA) sign is one of these findings. We investigated the diagnostic utility of absolute MCA density (MCAD) in patients with acute MCA stroke confirmed with diffusion-weighted magnetic resonance imaging (dwMRI). METHODS We retrospectively included all patients who presented to the Emergency Department with symptoms related to an acute stroke and confirmed with a dwMRI and ncCT to this diagnostic case-control study. An expert radiologist with more than four years of experience in neuroradiology re-evaluated all ncCT images. The evaluation of MCAD and ratio were measured on axial images in Hounsfield units (HU). RESULTS We included 407 patients in our study (MCA infarction: 55%, n = 225; Control: 45%, n = 182). We calculated the threshold for the highest sensitivity (20%) and specificity (94%) as 49 HU with the Youden J index test for MCAD and as 1.1 for MCAD ratio (sensitivity 20% and specificity 95%). MCAD >49 HU or MCAD ratio >1.1 alone or joint use of MCAD >47 HU and MCAD ratio >1.1 are useful markers to confirm the diagnosis of MCA AIS with a specificity of at least 94%. Higher MCAD values are associated with larger infarction volumes. CONCLUSION MCAD and MCAD ratio can be used to identify patients who need early treatment, especially in situations where computed tomography angiogram or dwMRI are not readily available.
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Affiliation(s)
- Taygun Baykal
- Emergency Service, Bursa Karacabey State Hospital, Bursa, Turkey
| | - Ebru Unal Akoglu
- Department of Emergency Medicine, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Tayfun Akoglu
- Department of Radiology, MEDAR Hospital, Kocaeli, Turkey
| | | | - Haldun Akoglu
- Department of Emergency Medicine, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
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Chieng JSL, Singh DR, Chawla A, Peh WC. The hyperdense vessel sign in cerebral computed tomography: pearls and pitfalls. Singapore Med J 2021; 61:230-237. [PMID: 32754771 DOI: 10.11622/smedj.2020074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | | | - Ashish Chawla
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore
| | - Wilfred Cg Peh
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore
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Zhou H, Tashi T, Zhao D, Tsring S, Liang H, Zhang J. CT assessment of the increased density of cerebral vessels in plateau region. Sci Rep 2021; 11:5851. [PMID: 33712677 PMCID: PMC7954789 DOI: 10.1038/s41598-021-85448-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 03/01/2021] [Indexed: 11/21/2022] Open
Abstract
In this study, the relationship between the brain parenchymal density, the cerebral vessel density, the mean corpuscular hemoglobin (MCH) content, the mean corpuscular hemoglobin concentration (MCHC), and the morbidity associated with lacunar infarction of residents living in either the plains or the plateau regions were analyzed and compared for their potential clinical implications. Clinical data from the brain CT scans of individuals living in either the plain or plateau regions (129 each) were collected. Specifically, the CT values for basal ganglia, the middle cerebral artery, and the superior sagittal sinus, along with the number of patients with lacunar infarction, were collected. In addition, the MCH and MCHC values were measured in blood samples collected within 48 h following the CT scans. For statistical analysis, an independent sample t-test, Pearson's correlation test (permutation test), and Chi-squared test were employed. The inhabitants of the plateau had a significantly higher CT value of basal ganglia, the middle cerebral artery, and superior sagittal sinus and also higher levels of MCH and MCHC in the blood (ps < 0.001) than the inhabitants of the plains region. Further, there was a significant positive correlation between the three aforementioned CT values and the MCH and MCHC findings. However, no significant differences were found in the morbidity of lacunar infarction between these two regions (p > 0.05). The inhabitants in the plateau have a significantly higher brain parenchymal density, higher CT value for cerebral vessels density, and higher blood MCH and MCHC levels in comparison with individuals occupying the plains. Concurrently, the parenchymal density and the CT values are shown to be positively correlated with the MCH and MCHC content in the blood.
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Affiliation(s)
- Haiting Zhou
- Department of Computed Tomography, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150086, China
| | - Tsering Tashi
- Department of Radiology, Rinbung County Health Service Center, Xigaze, Tibet, 857200, China
| | - Deli Zhao
- Department of Computed Tomography, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150086, China
| | - Sonam Tsring
- Department of Radiology, Rinbung County Health Service Center, Xigaze, Tibet, 857200, China
| | - Hongwei Liang
- Department of Computed Tomography, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150086, China
| | - Jinling Zhang
- Department of Computed Tomography, The Second Affiliated Hospital of Harbin Medical University, Harbin, 150086, China.
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Kokuzawa J, Kaku Y, Sasaki N, Kano K, Oka N, Matsuda A, Sasaki Y. Attempt to delineate occluded arteries with initial plain computed tomography in acute cerebral arterial occlusion. J Stroke Cerebrovasc Dis 2020; 29:105390. [PMID: 33254376 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105390] [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: 03/09/2020] [Revised: 09/15/2020] [Accepted: 10/04/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND We used initial plain computed tomography to delineate acutely occluded internal carotid arteries or horizontal segments of middle cerebral arteries. If affected arteries could be delineated using initial plain computed tomography, useful information might be obtained that could support endovascular thrombectomies. METHODS In 15 patients with occluded internal carotid arteries or horizontal segments of middle cerebral arteries, the affected middle cerebral artery was automatically traced using the extender function for blood vessel tracing with reference to the default value (window setting, 40; window width, 90) on Ziostation 2 (Ziosoft Inc., Tokyo, Japan) based on initial plain computed tomography data. RESULTS The horizontal and sylvian segments of the middle cerebral artery were delineated in 15 and nine patients, respectively, based on plain computed tomography volume data. Images of occluded vessels delineated by plain computed tomography closely correlated with digital subtraction angiography. CONCLUSIONS Initial plain computed tomography combined with a new generation workstation enabled the rapid delineation of occluded segments of intracranial vessels and could provide useful information that might improve the safety of endovascular thrombectomy.
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Affiliation(s)
- Jouji Kokuzawa
- Department of Neurosurgery, Asahi University Hospital, 3-23 Hashimotocho, Gifu 500-8523, Japan.
| | - Yasuhiko Kaku
- Department of Neurosurgery, Asahi University Hospital, 3-23 Hashimotocho, Gifu 500-8523, Japan.
| | - Nozomi Sasaki
- Department of Neurosurgery, Asahi University Hospital, 3-23 Hashimotocho, Gifu 500-8523, Japan.
| | - Kiyomitsu Kano
- Department of Neurosurgery, Asahi University Hospital, 3-23 Hashimotocho, Gifu 500-8523, Japan
| | - Naoki Oka
- Department of Neurosurgery, Asahi University Hospital, 3-23 Hashimotocho, Gifu 500-8523, Japan.
| | - Akihide Matsuda
- Department of Neurosurgery, Asahi University Hospital, 3-23 Hashimotocho, Gifu 500-8523, Japan
| | - Yousuke Sasaki
- Department of Neurosurgery, Asahi University Hospital, 3-23 Hashimotocho, Gifu 500-8523, Japan.
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McCarron MO, Wade C, McKee J, McVerry F. Stroke scan agnosia - What radiologists may not see. Clin Neurol Neurosurg 2020; 195:106052. [PMID: 32683231 DOI: 10.1016/j.clineuro.2020.106052] [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: 03/06/2020] [Revised: 05/09/2020] [Accepted: 06/27/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Neuroimaging helps neurologists make accurate diagnoses. We used a multidisciplinary review system to search for perceptual discrepancies in stroke lesions. We sought to identify recurrent pitfalls in the detection of neuroimaging stroke lesions. PATIENTS AND METHODS Patients were selected from a neuroimaging database of second opinions if cerebrovascular lesions had been missed at initial reporting. Patient demographics, scanning modality and stroke type were recorded. RESULTS A neuroradiologist second opinion was provided for 1336 patients. Forty-four patients, 18 women and 26 men, mean age 59.9 (SD 14.2) years, were identified in whom a vascular lesion was not detected on initial reporting. The lesions included cerebellar infarcts in 17 patients (bilateral in 7), pontine infarction/ischaemia (n=5), pontine and cerebellar lesions (n=1) and spinal infarction (n=1). Supratentorial infarction occurred in 10 patients of which 3 were thalamic infarcts. Vessel abnormalities were present in 8 patients (hyperdense vessel n=3, dissection n=3, middle cerebral artery occlusion on CTA n=1 and cerebral venous sinus thrombosis n=1). Convexity subarachnoid hemorrhage was missed and a subdural hematoma was not identified in one patient. In 10 (23 %) patients the missed lesions occurred solely on CT brain scanning. The missed lesions were symptomatic in 28 (64 %) patients and presentations were acute in 14 (32 %) patients. CONCLUSION Some cerebrovascular lesions are prone to perceptual errors with CT and MRI brain scanning. Radiologists and neurologists should be aware that posterior fossa lesions (particularly in the cerebellum and pons) and hyperdense vessel signs may be missed. Better identification of radiological cerebrovascular lesions should enhance management of acute and chronic stroke patients.
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Affiliation(s)
- Mark O McCarron
- Department of Neurology and Stroke Service, Altnagelvin Hospital, Derry, N. Ireland, BT47 6SB, UK.
| | - Carrie Wade
- Department of Neurology, Altnagelvin Hospital, Derry, N. Ireland, BT47 6SB, UK
| | - Jacqueline McKee
- Stroke Service, Altnagelvin Hospital, Derry, N. Ireland, BT47 6SB, UK
| | - Ferghal McVerry
- Department of Neurology and Stroke Service, Altnagelvin Hospital, Derry, N. Ireland, BT47 6SB, UK
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Abstract
Acute stroke is the clinical manifestation of disrupted blood flow or bleeding in the central nervous system. Imaging supports the clinical diagnosis and can aide in acute treatment decision making and guide information on prognosis. Features that are delineated include the parenchyma and the blood vessels. Parenchymal characteristics include early ischemic changes, established infarct and tissue at risk (penumbra), and hemorrhage. Vessel pathology includes arterial and venous steno-occlusive disease and vascular malformations. In the presence of a vessel occlusion, vessel imaging can assess collateral flow. This article outlines the role of neuroimaging as applied to patients presenting with acute stroke.
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Affiliation(s)
- Ashutosh P Jadhav
- Neurology, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15222, USA.
| | - Shashvat M Desai
- Neurology, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15222, USA
| | - David S Liebeskind
- Neurology, University of California Los Angeles, 635 Charles E Young Drive South, Suite 225, Los Angeles, CA 90095, USA
| | - Lawrence R Wechsler
- Neurology, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15222, USA
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