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Liu Z, Zhang S, Wang Y, Xu H, Gao Y, Jin H, Zhang Y, Wu H, Lu J, Chen P, Qiao PG, Yang Z. Posterior circulation ischemic stroke: radiomics-based machine learning approach to identify onset time from magnetic resonance imaging. Neuroradiology 2024; 66:1141-1152. [PMID: 38592454 DOI: 10.1007/s00234-024-03353-8] [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: 02/27/2024] [Accepted: 04/02/2024] [Indexed: 04/10/2024]
Abstract
PURPOSE Posterior circulation ischemic stroke (PCIS) possesses unique features. However, previous studies have primarily or exclusively relied on anterior circulation stroke cases to build machine learning (ML) models for predicting onset time. To date, there is no research reporting the effectiveness and stability of ML in identifying PCIS onset time. We aimed to build diffusion-weighted imaging-based ML models to identify the onset time of PCIS patients. METHODS Consecutive PCIS patients within 24 h of definite symptom onset were included (112 in the training set and 49 in the independent test set). Images were processed as follows: volume of interest segmentation, image feature extraction, and feature selection. Five ML models, naïve Bayes, logistic regression, tree ensemble, k-nearest neighbor, and random forest, were built based on the training set to estimate the stroke onset time (binary classification: ≤ 4.5 h or > 4.5 h). Relative standard deviations (RSD), receiver operating characteristic (ROC) curves, and the calibration plot was performed to evaluate the stability and performance of the five models. RESULTS The random forest model had the best performance in the test set, with the highest area under the curve (AUC, 0.840; 95% CI: 0.706, 0.974). This model also achieved the highest accuracy, sensitivity, specificity, positive predictive value, and negative predictive value (83.7%, 64.3%, 91.4%, 75.0%, and 86.5%, respectively). Furthermore, the model had high stability (RSD = 0.0094). CONCLUSION The PCIS case-based ML model was effective for estimating the symptom onset time and achieved considerably high specificity and stability.
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Affiliation(s)
- Zhenhao Liu
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, 95 YongAn Road, Xicheng District, Beijing, 100050, People's Republic of China
- Department of Radiology, Affiliated Hospital of Changzhi Institute of Traditional Chinese Medicine, No. 2, Zifang Lane, Hero South Road, Luzhou District, Changzhi, 046000, People's Republic of China
| | - Shiyu Zhang
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, 95 YongAn Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Yuxin Wang
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, 95 YongAn Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Hui Xu
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, 95 YongAn Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Yongqiang Gao
- Department of Radiology, Affiliated Hospital of Changzhi Institute of Traditional Chinese Medicine, No. 2, Zifang Lane, Hero South Road, Luzhou District, Changzhi, 046000, People's Republic of China
| | - Hong Jin
- Department of Radiology, Affiliated Hospital of Changzhi Institute of Traditional Chinese Medicine, No. 2, Zifang Lane, Hero South Road, Luzhou District, Changzhi, 046000, People's Republic of China
| | - Yufeng Zhang
- Department of Radiology, Affiliated Hospital of Changzhi Institute of Traditional Chinese Medicine, No. 2, Zifang Lane, Hero South Road, Luzhou District, Changzhi, 046000, People's Republic of China
| | - Hongyang Wu
- Department of Radiology, Affiliated Hospital of Changzhi Institute of Traditional Chinese Medicine, No. 2, Zifang Lane, Hero South Road, Luzhou District, Changzhi, 046000, People's Republic of China
| | - Jun Lu
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, 95 YongAn Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Peipei Chen
- Department of Radiology, Affiliated Hospital of Changzhi Institute of Traditional Chinese Medicine, No. 2, Zifang Lane, Hero South Road, Luzhou District, Changzhi, 046000, People's Republic of China
| | - Peng-Gang Qiao
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, 95 YongAn Road, Xicheng District, Beijing, 100050, People's Republic of China.
| | - Zhenghan Yang
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, 95 YongAn Road, Xicheng District, Beijing, 100050, People's Republic of China.
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Tanaka K, Kaveeta C, Pensato U, Zhang J, Bala F, Alhabli I, Horn M, Ademola A, Almekhlafi M, Ganesh A, Buck B, Tkach A, Catanese L, Dowlatshahi D, Shankar J, Poppe AY, Shamy M, Qiu W, Swartz RH, Hill MD, Sajobi TT, Menon BK, Demchuk AM, Singh N. Combining Early Ischemic Change and Collateral Extent for Functional Outcomes After Endovascular Therapy: An Analysis From AcT Trial. Stroke 2024; 55:1758-1766. [PMID: 38785076 DOI: 10.1161/strokeaha.123.046056] [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: 12/10/2023] [Accepted: 04/12/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Early ischemic change and collateral extent are colinear with ischemic core volume (ICV). We investigated the relationship between a combined score using the Alberta Stroke Program Early Computed Tomography Score and multiphase computed tomography angiography (mCTA) collateral extent, named mCTA-ACE score, on functional outcomes in endovascular therapy-treated patients. METHODS We performed a post hoc analysis of a subset of endovascular therapy-treated patients from the Alteplase Compared to Tenecteplase trial which was conducted between December 2019 and January 2022 at 22 centers across Canada. Ten-point mCTA collateral corresponding to M2 to M6 regions of the Alberta Stroke Program Early Computed Tomography Score grid was evaluated as 0 (poor), 1 (moderate), or 2 (normal) and additively combined with the 10-point Alberta Stroke Program Early Computed Tomography Score to produce a 20-point mCTA-ACE score. We investigated the association of mCTA-ACE score with modified Rankin Scale score ≤2 and return to prestroke level of function at 90 to 120 days using mixed-effects logistic regression. In the subset of patients who underwent baseline computed tomography perfusion imaging, we compared the mCTA-ACE score and ICV for outcome prediction. RESULTS Among 1577 intention-to-treat population in the trial, 368 (23%; 179 men; median age, 73 years) were included, with Alberta Stroke Program Early Computed Tomography Score, mCTA collateral, and combination of both (mCTA-ACE score: median [interquartile range], 8 [7-10], 9 [8-10], and 17 [16-19], respectively). The probability of modified Rankin Scale score ≤2 and return to prestroke level of function increased for each 1-point increase in mCTA-ACE score (odds ratio, 1.16 [95% CI, 1.06-1.28] and 1.22 [95% CI, 1.06-1.40], respectively). Among 173 patients in whom computed tomography perfusion data was assessable, the mCTA-ACE score was inversely correlated with ICV (ρ=-0.46; P<0.01). The mCTA-ACE score was comparable to ICV to predict a modified Rankin Scale score ≤2 and return to prestroke level of function (C statistics 0.71 versus 0.69 and 0.68 versus 0.64, respectively). CONCLUSIONS The mCTA-ACE score had a significant positive association with functional outcomes after endovascular therapy and had a similar predictive performance as ICV.
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Affiliation(s)
- Koji Tanaka
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Chitapa Kaveeta
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand (C.K.)
| | - Umberto Pensato
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Biomedical Sciences, Humanitas University, Milan, Italy (U.P.)
- IRCCS Humanitas Research Hospital, Milan, Italy (U.P.)
| | - Jianhai Zhang
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Fouzi Bala
- Department of Radiology (F.B., I.A., M.A., M.D.H., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, France (F.B.)
| | - Ibrahim Alhabli
- Department of Radiology (F.B., I.A., M.A., M.D.H., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - MacKenzie Horn
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Ayoola Ademola
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences (A.A., M.A., A.G., M.D.H., T.T.S., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (F.B., I.A., M.A., M.D.H., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute (M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Aravind Ganesh
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (F.B., I.A., M.A., M.D.H., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences (A.A., M.A., A.G., M.D.H., T.T.S., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute (M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Brian Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada (B.B.)
| | - Aleksander Tkach
- Department of Neurosciences, Kelowna General Hospital, BC, Canada (A.T.)
| | - Luciana Catanese
- Department of Medicine, McMaster University, Hamilton, ON, Canada (L.C.)
| | - Dar Dowlatshahi
- Department of Medicine and Ottawa Hospital Research Institute, University of Ottawa, ON, Canada (D.D., M.S.)
| | - Jai Shankar
- Department of Radiology, Health Sciences Center (J.S.), University of Manitoba, Winnipeg, Canada
| | - Alexandre Y Poppe
- Department of Clinical Neurosciences, Université de Montréal, QC, Canada (A.Y.P.)
| | - Michel Shamy
- Department of Medicine and Ottawa Hospital Research Institute, University of Ottawa, ON, Canada (D.D., M.S.)
| | - Wu Qiu
- Department of Biomedical Engineering, Huazhong University of Science and Technology, Wuhan, China (W.Q.)
| | - Richard H Swartz
- Department of Medicine, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (R.H.S.)
| | - Michael D Hill
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (F.B., I.A., M.A., M.D.H., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences (A.A., M.A., A.G., M.D.H., T.T.S., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute (M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Medicine (M.D.H.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Tolulope T Sajobi
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences (A.A., M.A., A.G., M.D.H., T.T.S., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute (M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (F.B., I.A., M.A., M.D.H., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences (A.A., M.A., A.G., M.D.H., T.T.S., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute (M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute (M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Nishita Singh
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Internal Medicine, Rady Faculty of Health Sciences (N.S.), University of Manitoba, Winnipeg, Canada
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Inoue M, Yoshimoto T, Yamagami H, Toyoda K, Sakai N, Matsumaru Y, Matsumoto Y, Kimura K, Ishikura R, Uchida K, Beppu M, Sakakibara F, Morimoto T, Yoshimura S. Expanding the Treatable Imaging Profile in Patients With Large Ischemic Stroke: Subanalysis From a Randomized Clinical Trial. Stroke 2024; 55:1730-1738. [PMID: 38804134 DOI: 10.1161/strokeaha.124.046828] [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: 02/14/2024] [Accepted: 04/24/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND We aimed to examine the boundary of the ischemic core volume in patients undergoing endovascular thrombectomy (EVT) versus those receiving medical management to determine the minimum optimal size for favorable treatment outcomes. METHODS This is a prespecified substudy of the RESCUE-Japan LIMIT (Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism-Japan Large Ischemic Core Trial). Patients with large vessel occlusion were enrolled between November 2018 and September 2021 with a National Institutes of Health Stroke Scale score of at least 6 on admission and an Alberta Stroke Program Early Computed Tomography Score value of 3 to 5. We investigated the correlation between optimal quantified ischemic core volume, assessed solely using magnetic resonance diffusion-weighted imaging, and functional outcomes (modified Rankin Scale score, 0-3) at 90 days by predictive marginal plots. Final infarct volume and safety outcomes (symptomatic intracerebral hemorrhage and mortality) were also assessed. RESULTS Of the 203 cases, 168 patients (85 in the EVT group versus 83 in the medical management group) were included. The median (interquartile range) core volume was 94 (65-160) mL in patients with EVT and 115 (71-141) mL in the medical management group (P=0.72). The predictive marginal probabilities of the 2 groups intersected at 128 mL for estimating functional outcomes. Symptomatic intracerebral hemorrhage and mortality within 90 days had overlay margins through all core volumes in both groups. The median final infarct volume (interquartile range) was smaller in the EVT group (142 [80-223] mL versus 211 [123-289] mL in the medical management group; P<0.001). CONCLUSIONS In this prespecified analysis of a randomized clinical trial involving patients with large ischemic strokes, patients with an estimated core volume of up to 128 mL on diffusion-weighted imaging benefit from EVT. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03702413.
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Affiliation(s)
- Manabu Inoue
- Division of Stroke Care Unit (M.I.), National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Cerebrovascular Medicine (M.I., K.T.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takeshi Yoshimoto
- Department of Neurology (T.Y.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroshi Yamagami
- Division of Stroke Prevention and Treatment, Institute of Medicine (H.Y.), University of Tsukuba, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine (M.I., K.T.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - Nobuyuki Sakai
- Neurovascular Research and Neuroendovascular Therapy (N.S.), Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yuji Matsumaru
- Department of Neurosurgery, Faculty of Medicine (Y. Matsumaru), University of Tsukuba, Japan
| | - Yasushi Matsumoto
- Division of Development and Discovery of Interventional Therapy, Tohoku University Hospital, Japan (Y. Matsumoto)
| | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan (K.K.)
| | - Reiichi Ishikura
- Department of Diagnostic Radiology (R.I.), Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kazutaka Uchida
- Department of Neurosurgery (K.U., M.B., F.S., S.Y.), Hyogo Medical University, Nishinomiya, Japan
- Department of Clinical Epidemiology (K.U., F.S., T.M.), Hyogo Medical University, Nishinomiya, Japan
| | - Mikiya Beppu
- Department of Neurosurgery (K.U., M.B., F.S., S.Y.), Hyogo Medical University, Nishinomiya, Japan
| | - Fumihiro Sakakibara
- Department of Neurosurgery (K.U., M.B., F.S., S.Y.), Hyogo Medical University, Nishinomiya, Japan
- Department of Clinical Epidemiology (K.U., F.S., T.M.), Hyogo Medical University, Nishinomiya, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology (K.U., F.S., T.M.), Hyogo Medical University, Nishinomiya, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery (K.U., M.B., F.S., S.Y.), Hyogo Medical University, Nishinomiya, Japan
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Tymianski M. Role of Neuroprotective Approaches in the Recanalization Era. Stroke 2024; 55:1927-1931. [PMID: 38323414 DOI: 10.1161/strokeaha.123.044229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Affiliation(s)
- Michael Tymianski
- Department of Surgery, University of Toronto, ON, Canada. Krembil Research Institute, University Health Network, Toronto, ON, Canada
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Lucas L, Georget A, Rouxel L, Briau P, Couture M, Liegey JS, Debruxelles S, Poli M, Sagnier S, Renou P, Olindo S, Rouanet F, Maurin X, Benard A, Sibon I. Remote neurological evaluation reliably identifies patients eligible to endovascular therapy while non-eligible to intravenous thrombolysis. Rev Neurol (Paris) 2024:S0035-3787(24)00553-8. [PMID: 38918135 DOI: 10.1016/j.neurol.2024.05.006] [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: 11/01/2023] [Revised: 03/16/2024] [Accepted: 05/22/2024] [Indexed: 06/27/2024]
Abstract
INTRODUCTION/BACKGROUND Early identification of suspected stroke patients who might be eligible for a reperfusion strategy is a daily challenge in the management of patient referrals. The aim of this study was to evaluate the performance of a remote medical assessment in identifying patients eligible for endovascular therapy (EVT) while not eligible for intravenous thrombolysis (IVT), compared with a decision based on bedside clinico-radiological data. METHODS Patients admitted to the emergency department for acute neurological symptoms lasting for less than 24h were prospectively included. Assessment of the clinical severity and medical history was performed simultaneously by two vascular neurologists (VNs), one remotely using a mobile telemedicine solution (NOMADEEC), the other at the bedside. RACE score was calculated from the NIHSS score. At the end of the evaluation, both VNs quoted their treatment convictions (IVT/EVT). Final therapeutic decision following brain and vascular imaging was recorded and compared to remote and bedside predictions. The performances of three different conditions were evaluated: complete medical evaluation (NIHSS+medical history), NIHSS score alone, and RACE score alone. Remote and bedside performances were also compared. Diagnostic accuracy parameters (sensitivity, specificity, positive and negative predictive values) of each condition were estimated, along with their two-sided 95% binomial confidence intervals. RESULTS Out of 215 enrolled patients, 186 had a complete evaluation, 91 (54.3%) were diagnosed with an ischemic stroke or transient ischemic attack and 46 (24.7%) had an intracranial occlusion. Considering the three conditions evaluated remotely, RACE score-based decision provided the best sensitivity 54.6% [95% CI 23.4; 83.2]/specificity 80.6% [73.9; 86.2] combination. However, the complete medical evaluation had the best specificity (88.6% [82.9; 92.9] compared to RACE scores alone (P=0.038). Remote and bedside performances did not differ (κ=0.68 [0.59; 0.77]). DISCUSSION/CONCLUSION This real-life study performed in the setting of emergency demonstrates that remote medical evaluations including recording of extensive medical information and NIHSS examination to address patient's eligibility to revascularization treatment is swiftly feasible and is as effective as bedside prediction to EVT and/or IVT. Remote standardized medical evaluation might improve the decision of patients' primary orientation and avoid overcrowding of comprehensive stroke centres.
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Affiliation(s)
- L Lucas
- Bordeaux University Hospital, Stroke Unit, Bordeaux, France.
| | - A Georget
- Bordeaux University Hospital, Methodology Department, Bordeaux, France.
| | - L Rouxel
- Enovacom-NOMADEEC, Bordeaux, France.
| | - P Briau
- Bordeaux University Hospital, Stroke Unit, Bordeaux, France.
| | - M Couture
- Bordeaux University Hospital, Stroke Unit, Bordeaux, France.
| | - J-S Liegey
- Bordeaux University Hospital, Stroke Unit, Bordeaux, France.
| | - S Debruxelles
- Bordeaux University Hospital, Stroke Unit, Bordeaux, France.
| | - M Poli
- Bordeaux University Hospital, Stroke Unit, Bordeaux, France.
| | - S Sagnier
- Bordeaux University Hospital, Stroke Unit, Bordeaux, France.
| | - P Renou
- Bordeaux University Hospital, Stroke Unit, Bordeaux, France.
| | - S Olindo
- Bordeaux University Hospital, Stroke Unit, Bordeaux, France.
| | - F Rouanet
- Bordeaux University Hospital, Stroke Unit, Bordeaux, France.
| | - X Maurin
- Enovacom-NOMADEEC, Bordeaux, France.
| | - A Benard
- Bordeaux University Hospital, Methodology Department, Bordeaux, France.
| | - I Sibon
- Bordeaux University Hospital, Stroke Unit, Bordeaux, France.
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Bani-Sadr A, Mechtouff L, Hermier M, Eker OF, Rascle L, de Bourguignon C, Boutelier T, Martin A, Tommasino E, Ong E, Fontaine J, Cho TH, Derex L, Nighoghossian N, Berthezene Y. Cerebral collaterals are associated with pre-treatment brain-blood barrier permeability in acute ischemic stroke patients. Eur Radiol 2024:10.1007/s00330-024-10830-4. [PMID: 38861162 DOI: 10.1007/s00330-024-10830-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 04/08/2024] [Accepted: 05/16/2024] [Indexed: 06/12/2024]
Abstract
INTRODUCTION To investigate the relationship between collaterals and blood-brain barrier (BBB) permeability on pre-treatment MRI in a cohort of acute ischemic stroke (AIS) patients treated with thrombectomy. METHODS We conducted a retrospective analysis of the HIBISCUS-STROKE cohort, a single-center observational study that enrolled patients treated with thrombectomy from 2016 to 2022. Dynamic-susceptibility MRIs were post-processed to generate K2 maps with arrival-time correction, which were co-registered with apparent diffusion coefficient (ADC) maps. The 90th percentile of K2 was extracted from the infarct core-defined by an ADC ≤ 620 × 10-6 mm2/s with manual adjustments-and expressed as a percentage change compared to the contralateral white matter. Collaterals were assessed using pre-thrombectomy digital subtraction arteriography with an ASITN/SIR score < 3 defining poor collaterals. RESULTS Out of 249 enrolled, 101 (40.6%) were included (median age: 72.0 years, 52.5% of males, median NIHSS score at admission: 15.0). Patients with poor collaterals (n = 44) had worse NIHSS scores (median: 16.0 vs 13.0, p = 0.04), larger infarct core volumes (median: 43.7 mL vs 9.5 mL, p < 0.0001), and higher increases in K2 (median: 346.3% vs 152.7%, p = 0.003). They were less likely to achieve successful recanalization (21/44 vs 51/57, p < 0.0001) and experienced more frequent hemorrhagic transformation (16/44 vs 9/57, p = 0.03). On multiple variable analysis, poor collaterals were associated with larger infarct cores (odds ratio (OR) = 1.12, 95% confidence interval (CI): [1.07, 1.17], p < 0.0001) and higher increases in K2 (OR = 6.63, 95% CI: [2.19, 20.08], p = 0.001). CONCLUSION Poor collaterals are associated with larger infarct cores and increased BBB permeability at admission MRI. CLINICAL RELEVANCE STATEMENT Poor collaterals are associated with a larger infarct core and increased BBB permeability at admission MRI of AIS patients treated with thrombectomy. These findings may have translational interests for extending thrombolytic treatment eligibility and developing neuroprotective strategies. KEY POINTS In AIS, collaterals and BBB disruption have been both linked to hemorrhagic transformation. Poor collaterals were associated with larger ischemic cores and increased BBB permeability on pre-treatment MRI. These findings could contribute to hemorrhagic transformation risk stratification, thereby refining clinical decision-making for reperfusion therapies.
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Affiliation(s)
- Alexandre Bani-Sadr
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, Bron, France.
- CREATIS Laboratory, CNRS UMR 5220, INSERM U1294, Claude Bernard Lyon I University, Villeurbanne, France.
| | - Laura Mechtouff
- Stroke Department, East Group Hospital, Hospices Civils de Lyon, Bron, France
- CarMeN Laboratory, INSERM U1060/INRA U1397, Claude Bernard Lyon I University, Bron, France
| | - Marc Hermier
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, Bron, France
| | - Omer F Eker
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, Bron, France
- CREATIS Laboratory, CNRS UMR 5220, INSERM U1294, Claude Bernard Lyon I University, Villeurbanne, France
| | - Lucie Rascle
- Stroke Department, East Group Hospital, Hospices Civils de Lyon, Bron, France
| | | | | | - Anna Martin
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, Bron, France
| | - Emanuele Tommasino
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, Bron, France
| | - Elodie Ong
- Stroke Department, East Group Hospital, Hospices Civils de Lyon, Bron, France
| | - Julia Fontaine
- Stroke Department, East Group Hospital, Hospices Civils de Lyon, Bron, France
| | - Tae-Hee Cho
- Stroke Department, East Group Hospital, Hospices Civils de Lyon, Bron, France
- CarMeN Laboratory, INSERM U1060/INRA U1397, Claude Bernard Lyon I University, Bron, France
| | - Laurent Derex
- Stroke Department, East Group Hospital, Hospices Civils de Lyon, Bron, France
| | - Norbert Nighoghossian
- Stroke Department, East Group Hospital, Hospices Civils de Lyon, Bron, France
- CarMeN Laboratory, INSERM U1060/INRA U1397, Claude Bernard Lyon I University, Bron, France
| | - Yves Berthezene
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, Bron, France
- CREATIS Laboratory, CNRS UMR 5220, INSERM U1294, Claude Bernard Lyon I University, Villeurbanne, France
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Zheng L, Nie X, Wang M, Liu X, Duan W, Zhang Z, Liu J, Wei Y, Wen M, Yang Z, Leung TW, Ma G, Huo X, Pan Y, Nguyen TN, Leng X, Miao Z, Liu L. Endovascular therapy in acute ischaemic stroke with large infarction with matched or mismatched clinical-radiological severities: a post-hoc analysis of the ANGEL-ASPECT trial. EClinicalMedicine 2024; 72:102595. [PMID: 38638180 PMCID: PMC11024914 DOI: 10.1016/j.eclinm.2024.102595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/23/2024] [Accepted: 03/26/2024] [Indexed: 04/20/2024] Open
Abstract
Background Endovascular therapy (EVT) was demonstrated effective in acute large vessel occlusion (LVO) with large infarction. Revealing subgroups of patients who would or would not benefit from EVT will further inform patient selection for EVT. Methods This post-hoc analysis of the ANGEL-ASPECT trial, a randomised controlled trial of 456 adult patients with acute anterior-circulation LVO and large infarction, defined by ASPECTS 3-5 or infarct core volume 70-100 mL, enrolled from 46 centres across China, between October 2, 2020 and May 18, 2022. Patients were randomly assigned (1:1) to receiving EVT and medical management or medical management alone. One patient withdrew consent, 455 patients were included in this post-hoc analysis and categorised into 4 subgroups by lower or higher NIHSS (< or ≥16) and smaller or larger infarct core (< or ≥70 mL). Those with lower NIHSS & smaller core, and higher NIHSS & larger core were considered clinical-radiological matched subgroups; otherwise clinical-radiological mismatched subgroups. Primary outcome was 90-day modified Rankin Scale (mRS). ANGEL-ASPECT is registered with ClinicalTrials.gov, NCT04551664. Findings Overall, 139 (30.5%) patients had lower NIHSS & smaller core, 106 (23.3%) higher NIHSS & larger core, 130 (28.6%) higher NIHSS & smaller core, and 80 (17.6%) lower NIHSS & larger core. There was significant ordinal shift in the 90-day mRS toward a better outcome with EVT in clinical-radiological matched subgroups: lower NIHSS & smaller core (generalised OR, 1.76; 95% CI, 1.18-2.62; p = 0.01) and higher NIHSS & larger core (1.64; 1.06-2.54; 0.01); but not in the two clinical-radiological mismatched subgroups. Interpretation Our findings suggested that in patients with anterior-circulation LVO and large infarction, EVT was associated with improved 90-day functional outcomes in those with matched clinical and radiological severities, but not in those with mismatched clinical and radiological severities. Simultaneous consideration of stroke severity and infarct core volume may inform patient selection for EVT. Funding Unrestricted grants from industry [Covidien Healthcare International Trading (Shanghai), Johnson & Johnson MedTech, Genesis MedTech (Shanghai), and Shanghai HeartCare Medical Technology].
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Affiliation(s)
- Lina Zheng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Ximing Nie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Mengxing Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Xin Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Wanying Duan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Zhe Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Jingyi Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Yufei Wei
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Miao Wen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhonghua Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Thomas W. Leung
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Gaoting Ma
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaochuan Huo
- Cerebrovascular Disease Department, Neurological Disease Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yuesong Pan
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Thanh N. Nguyen
- Department of Neurology, Radiology Boston Medical Centre, MA, USA
| | - Xinyi Leng
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Zhongrong Miao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
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Sarraj A, Pujara DK, Campbell BC. Current State of Evidence for Neuroimaging Paradigms in Management of Acute Ischemic Stroke. Ann Neurol 2024; 95:1017-1034. [PMID: 38606939 DOI: 10.1002/ana.26925] [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: 08/29/2023] [Revised: 03/08/2024] [Accepted: 03/11/2024] [Indexed: 04/13/2024]
Abstract
Stroke is the chief differential diagnosis in patient presenting to the emergency room with abrupt onset focal neurological deficits. Neuroimaging, including non-contrast computed tomography (CT), magnetic resonance imaging (MRI), vascular and perfusion imaging, is a cornerstone in the diagnosis and treatment decision-making. This review examines the current state of evidence behind the different imaging paradigms for acute ischemic stroke diagnosis and treatment, including current recommendations from the guidelines. Non-contrast CT brain, or in some centers MRI, can help differentiate ischemic stroke and intracerebral hemorrhage (ICH), a pivotal juncture in stroke diagnosis and treatment algorithm, especially for early window thrombolytics. Advanced imaging such as MRI or perfusion imaging can also assist making a diagnosis of ischemic stroke versus mimics such as migraine, Todd's paresis, or functional disorders. Identification of medium-large vessel occlusions with CT or MR angiography triggers consideration of endovascular thrombectomy (EVT), with additional perfusion imaging help identify salvageable brain tissue in patients who are likely to benefit from reperfusion therapies, particularly in the ≥6 h window. We also review recent advances in neuroimaging and ongoing trials in key therapeutic areas and their imaging selection criteria to inform the readers on potential future transitions into use of neuroimaging for stroke diagnosis and treatment decision making. ANN NEUROL 2024;95:1017-1034.
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Affiliation(s)
- Amrou Sarraj
- University Hospital Cleveland Medical Center-Case Western Reserve University, Neurology, Cleveland, Ohio, USA
| | - Deep K Pujara
- University Hospital Cleveland Medical Center-Case Western Reserve University, Neurology, Cleveland, Ohio, USA
| | - Bruce Cv Campbell
- The Royal Melbourne Hospital-The Florey Institute for Neuroscience and Mental Health, Medicine and Neurology, Parkville, Australia
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Reddy RP, Herman ZJ, Como M, James MG, Steuer FW, Adida S, Singh-Varma A, Nazzal EM, Njoku-Austin C, Karimi A, Lin A. Reversing chronic pseudoparesis secondary to massive, irreparable rotator cuff tear: superior capsular reconstruction vs. reverse total shoulder arthroplasty. J Shoulder Elbow Surg 2024; 33:S16-S24. [PMID: 38104716 DOI: 10.1016/j.jse.2023.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 10/13/2023] [Accepted: 10/30/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION Recent studies have defined pseudoparesis as limited active forward elevation between 45° and 90° and maintained passive range of motion (ROM) in the setting of a massive rotator cuff tear (RCT). Although pseudoparesis can be reliably reversed with reverse total shoulder arthroplasty (RSA) or superior capsular reconstruction (SCR), the optimal treatment for this indication remains unknown. The purpose of this study was to compare the clinical outcomes of RSA to SCR in patients with pseudoparesis secondary to massive, irreparable RCT (miRCT). METHODS This was a retrospective cohort study of consecutive patients aged 40-70 years with pseudoparesis secondary to miRCT who were treated with either RSA or SCR by a single fellowship-trained shoulder surgeon from 2016 to 2021 with a minimum 12-month follow-up. Multivariate linear regression modeling was used to compare active ROM, visual analog pain scale (VAS), Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score between RSA and SCR while controlling for confounding variables. RESULTS Twenty-seven patients were included in the RSA cohort and 23 patients were included in the SCR cohort with similar mean follow-up times (26.2 ± 21.1 vs. 21.9 ± 14.7 months, respectively). The patients in the RSA group were significantly older than those in the SCR group (65.2 ± 4.4 vs. 54.2 ± 7.8 years, P < .001) and had more severe arthritis (1.8 ± 0.9 vs. 1.2 ± 0.5 Samilson-Prieto, P = .019). The pseudoparesis reversal rate among the RSA and SCR cohorts was 96.3% and 91.3%, respectively. On univariate analysis, the RSA cohort demonstrated significantly greater mean improvement in active FF (89° ± 26° vs. 73° ± 30° change, P = .048), greater postoperative SSV (91 ± 8% vs. 69 ± 25%, P < .001), lower postoperative VAS pain scores (0.6 ± 1.2 vs. 2.2 ± 2.9, P = .020), and less postoperative internal rotation (IR; 4.6° ± 1.6° vs. 6.9° ± 1.8°, P = .004) compared with SCR. On multivariate analysis controlling for age and osteoarthritis, RSA remained a significant predictor of greater SSV (β = 21.5, P = .021) and lower VAS scores (β = -1.4, P = .037), whereas SCR was predictive of greater IR ROM (β = 3.0, P = .043). CONCLUSION Although both RSA and SCR effectively reverse pseudoparesis, patients with RSA have higher SSV and lower pain scores but less IR after controlling for age and osteoarthritis. The results of this study may inform surgical decision making for patients who are suitable candidates for either procedure.
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Affiliation(s)
- Rajiv P Reddy
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, PA, USA
| | - Zachary J Herman
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, PA, USA
| | - Matthew Como
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, PA, USA
| | - Michael G James
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, PA, USA
| | - Fritz W Steuer
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, PA, USA
| | - Samuel Adida
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, PA, USA
| | - Anya Singh-Varma
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, PA, USA
| | - Ehab M Nazzal
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, PA, USA
| | - Confidence Njoku-Austin
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, PA, USA
| | - Amin Karimi
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, PA, USA
| | - Albert Lin
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, PA, USA.
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Ma Y, He J, Tan D, Han X, Feng R, Xiong H, Peng X, Pu X, Zhang L, Li Y, Chen S. The clinical and imaging data fusion model for single-period cerebral CTA collateral circulation assessment. JOURNAL OF X-RAY SCIENCE AND TECHNOLOGY 2024:XST240083. [PMID: 38820061 DOI: 10.3233/xst-240083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
Background The Chinese population ranks among the highest globally in terms of stroke prevalence. In the clinical diagnostic process, radiologists utilize computed tomography angiography (CTA) images for diagnosis, enabling a precise assessment of collateral circulation in the brains of stroke patients. Recent studies frequently combine imaging and machine learning methods to develop computer-aided diagnostic algorithms. However, in studies concerning collateral circulation assessment, the extracted imaging features are primarily composed of manually designed statistical features, which exhibit significant limitations in their representational capacity. Accurately assessing collateral circulation using image features in brain CTA images still presents challenges. Methods To tackle this issue, considering the scarcity of publicly accessible medical datasets, we combined clinical data with imaging data to establish a dataset named RadiomicsClinicCTA. Moreover, we devised two collateral circulation assessment models to exploit the synergistic potential of patients' clinical information and imaging data for a more accurate assessment of collateral circulation: data-level fusion and feature-level fusion. To remove redundant features from the dataset, we employed Levene's test and T-test methods for feature pre-screening. Subsequently, we performed feature dimensionality reduction using the LASSO and random forest algorithms and trained classification models with various machine learning algorithms on the data-level fusion dataset after feature engineering. Results Experimental results on the RadiomicsClinicCTA dataset demonstrate that the optimized data-level fusion model achieves an accuracy and AUC value exceeding 86% . Subsequently, we trained and assessed the performance of the feature-level fusion classification model. The results indicate the feature-level fusion classification model outperforms the optimized data-level fusion model. Comparative experiments show that the fused dataset better differentiates between good and bad side branch features relative to the pure radiomics dataset. Conclusions Our study underscores the efficacy of integrating clinical and imaging data through fusion models, significantly enhancing the accuracy of collateral circulation assessment in stroke patients.
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Affiliation(s)
- Yuqi Ma
- College of Computer and Information Science, Southwest University, Chongqing, China
| | - Jingliu He
- College of Computer and Information Science, Southwest University, Chongqing, China
| | - Duo Tan
- The Second People's Hospital of Guizhou Province, Guizhou, China
| | - Xu Han
- School of Electrical and Information Engineering, Tianjin University, Tianjin, China
| | - Ruiqi Feng
- College of Computer and Information Science, Southwest University, Chongqing, China
| | - Hailing Xiong
- College of Electronic and Information Engineering, Southwest University, Chongqing, China
| | - Xihua Peng
- College of Computer and Information Science, Southwest University, Chongqing, China
| | - Xun Pu
- College of Computer and Information Science, Southwest University, Chongqing, China
| | - Lin Zhang
- College of Computer and Information Science, Southwest University, Chongqing, China
| | - Yongmei Li
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shanxiong Chen
- College of Computer and Information Science, Southwest University, Chongqing, China
- Big Data & Intelligence Engineering School, Chongqing College of International Business and Economics, Chongqing, China
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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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Psychogios K, Theodorou A, Kargiotis O, Safouris A, Velonakis G, Palaiodimou L, Spiliopoulos S, Giannopoulos S, Magoufis G, Tsivgoulis G. Hypoperfusion index ratio and pretreatment with intravenous thrombolysis are independent predictors of good functional outcome in acute ischemic stroke patients with large vessel occlusion treated with acute reperfusion therapies. Neurol Sci 2024:10.1007/s10072-024-07558-w. [PMID: 38761259 DOI: 10.1007/s10072-024-07558-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 04/22/2024] [Indexed: 05/20/2024]
Abstract
INTRODUCTION We aimed to investigate the performance of several neuroimaging markers provided by perfusion imaging of Acute Ischemic Stroke (AIS) patients with large vessel occlusion (LVO) in order to predict clinical outcomes following reperfusion treatments. METHODS We prospectively evaluated consecutive AIS patients with LVO who were treated with reperfusion therapies, during a six-year period. In order to compare patients with good (mRS scores 0-2) and poor (mRS scores 3-6) functional outcomes, data regarding clinical characteristics, the Alberta Stroke Programme Early Computed Tomography Score (ASPECTS) based on unenhanced computed tomography (CT), CT angiography collateral status and perfusion parameters including ischemic core, hypoperfusion volume, mismatch volume between core and penumbra, Tmax > 10 s volume, CBV index and the Hypoperfusion Index Ratio (HIR) were assessed. RESULTS A total of 84 acute stroke patients with LVO who met all the inclusion criteria were enrolled. In multivariable logistic regression models increasing age (odds ratio [OR]: 0.93; 95%CI: 0.88-0.96, p = 0.001), lower admission National Institute of Health Stroke Scale (NIHSS)-score (OR: 0.88; 95%CI: 0.80-0.95, p = 0.004), pretreatment with intravenous thrombolysis (OR: 3.83; 95%CI: 1.29-12.49, p = 0.019) and HIR (OR:0.36; 95%CI: 0.10-0.95, p = 0.042) were independent predictors of good functional outcome at 3 months. The initial univariable associations between HIR and higher likelihood for symptomatic intracranial hemorrhage (sICH) and parenchymal hematoma type 2 (PH2) were attenuated in multivariable analyses failing to reach statistical significance. DISCUSSION Our pilot observational study of unselected AIS patients with LVO treated with reperfusion therapies demonstrated that pre-treatment low HIR in perfusion imaging and IVT were associated with better functional outcomes.
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Affiliation(s)
- Klearchos Psychogios
- Stroke Unit, Metropolitan Hospital, 18547, Piraeus, Greece
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, 12462, Chaidari, Athens, Greece
| | - Aikaterini Theodorou
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, 12462, Chaidari, Athens, Greece
| | | | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, 18547, Piraeus, Greece
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, 12462, Chaidari, Athens, Greece
| | - Georgios Velonakis
- Second Department of Radiology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462, Athens, Greece
| | - Lina Palaiodimou
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, 12462, Chaidari, Athens, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462, Athens, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, 12462, Chaidari, Athens, Greece
| | - Georgios Magoufis
- Second Department of Radiology, Interventional Radiology Unit, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462, Athens, Greece
- Neuroradiology Department, Metropolitan Hospital, 18547, Piraeus, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, 12462, Chaidari, Athens, Greece.
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, 38163, USA.
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van Voorst H, Hoving JW, Koopman MS, Daems JD, Peerlings D, Buskens E, Lingsma H, Marquering HA, de Jong HWAM, Berkhemer OA, van Zwam WH, van Walderveen MAA, van den Wijngaard IR, Dippel DWJ, Yoo AJ, Campbell B, Kunz WG, Majoie CB, Emmer BJ. Costs and health effects of CT perfusion-based selection for endovascular thrombectomy within 6 hours of stroke onset: a model-based health economic evaluation. J Neurol Neurosurg Psychiatry 2024; 95:515-527. [PMID: 38124162 DOI: 10.1136/jnnp-2023-331862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 11/19/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Although CT perfusion (CTP) is often incorporated in acute stroke workflows, it remains largely unclear what the associated costs and health implications are in the long run of CTP-based patient selection for endovascular treatment (EVT) in patients presenting within 6 hours after symptom onset with a large vessel occlusion. METHODS Patients with a large vessel occlusion were included from a Dutch nationwide cohort (n=703) if CTP imaging was performed before EVT within 6 hours after stroke onset. Simulated cost and health effects during 5 and 10 years follow-up were compared between CTP based patient selection for EVT and providing EVT to all patients. Outcome measures were the net monetary benefit at a willingness-to-pay of €80 000 per quality-adjusted life year, incremental cost-effectiveness ratio), difference in costs from a healthcare payer perspective (ΔCosts) and quality-adjusted life years (ΔQALY) per 1000 patients for 1000 model iterations as outcomes. RESULTS Compared with treating all patients, CTP-based selection for EVT at the optimised ischaemic core volume (ICV≥110 mL) or core-penumbra mismatch ratio (MMR≤1.4) thresholds resulted in losses of health (median ΔQALYs for ICV≥110 mL: -3.3 (IQR: -5.9 to -1.1), for MMR≤1.4: 0.0 (IQR: -1.3 to 0.0)) with median ΔCosts for ICV≥110 mL of -€348 966 (IQR: -€712 406 to -€51 158) and for MMR≤1.4 of €266 513 (IQR: €229 403 to €380 110)) per 1000 patients. Sensitivity analyses did not yield any scenarios for CTP-based selection of patients for EVT that were cost-effective for improving health, including patients aged ≥80 years CONCLUSION: In EVT-eligible patients presenting within 6 hours after symptom onset, excluding patients based on CTP parameters was not cost-effective and could potentially harm patients.
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Affiliation(s)
- Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, 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 AMC, Amsterdam, North Holland, The Netherlands
| | - Miou S Koopman
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
| | - Jasper D Daems
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Daan Peerlings
- Department of Radiology, University Medical Center Utrecht, Utrecht, Utrecht, The Netherlands
| | - Erik Buskens
- Epidemiology, University Medical Centre Groningen, Groningen, Groningen, The Netherlands
| | - Hester Lingsma
- Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henk A Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
- Biomedical Engineering and Physics, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
| | | | - Olvert A Berkhemer
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Wim H van Zwam
- Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Ido R van den Wijngaard
- Neurology, HMC Westeinde, The Hague, Zuid-Holland, The Netherlands
- Neurology, Leiden University, Leiden, The Netherlands
| | | | - Albert J Yoo
- Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - Bruce Campbell
- The Royal Melbourne Hospital, Parkville, Melbourne, Australia
| | | | - Charles B Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
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14
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Lakhani DA, Mehta TR, Balar AB, Koneru M, Wen S, Ozkara BB, Caplan J, Dmytriw AA, Wang R, Lu H, Hoseinyazdi M, Nabi M, Mazumdar I, Cho A, Chen K, Sepehri S, Hyson N, Xu R, Urrutia V, Luna L, Hillis AH, Heit JJ, Albers GW, Rai AT, Faizy TD, Wintermark M, Nael K, Yedavalli VS. The Los Angeles motor scale (LAMS) is independently associated with CT perfusion collateral status markers. J Clin Neurosci 2024; 125:32-37. [PMID: 38735251 DOI: 10.1016/j.jocn.2024.05.005] [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: 01/03/2024] [Revised: 03/31/2024] [Accepted: 05/07/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND AND AIM The Los Angeles Motor Scale (LAMS) is an objective tool that has been used to rapidly assess and predict the presence of large vessel occlusion (LVO) in the pre-hospital setting successfully in several studies. However, studies assessing the relationship between LAMS score and CT perfusion collateral status (CS) markers such as cerebral blood volume (CBV) index, and hypoperfusion intensity ratio (HIR) are sparse. Our study therefore aims to assess the association of admission LAMS score with established CTP CS markers CBV Index and HIR in AIS-LVO cases. MATERIALS AND METHODS In this prospectively collected, retrospectively reviewed analysis, inclusion criteria were as follows: a) CT angiography (CTA) confirmed anterior circulation LVO from 9/1/2017 to 10/01/2023, and b) diagnostic CT perfusion (CTP). Logistic regression analysis was performed to assess the relationship between admission LAMS with CTP CS markers HIR and CBV Index. p ≤ 0.05 was considered significant. RESULTS In total, 285 consecutive patients (median age = 69 years; 56 % female) met our inclusion criteria. Multivariable logistic regression analysis adjusting for sex, age, ASPECTS, tPA, premorbid mRS, admission NIH stroke scale, prior history of TIA, stroke, atrial fibrillation, diabetes mellitus, hyperlipidemia, coronary artery disease and hypertension, admission LAMS was found to be independently associated with CBV Index (adjusted OR:0.82, p < 0.01), and HIR (adjusted OR:0.59, p < 0.05). CONCLUSION LAMS is independently associated with CTP CS markers, CBV index and HIR. This finding suggests that LAMS may also provide an indirect estimate of CS.
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Affiliation(s)
- Dhairya A Lakhani
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA.
| | - Tejas R Mehta
- Department of Neurology, University of missouri, Columbia, MO, USA
| | - Aneri B Balar
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Manisha Koneru
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Sijin Wen
- Department of Biostatistics, West Virginia University, Morgantown, WV, USA
| | | | - Justin Caplan
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Adam A Dmytriw
- Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Richard Wang
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Hanzhang Lu
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Meisam Hoseinyazdi
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Mehreen Nabi
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Ishan Mazumdar
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Andrew Cho
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Kevin Chen
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Sadra Sepehri
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Nathan Hyson
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Risheng Xu
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Victor Urrutia
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Licia Luna
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Argye H Hillis
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Jeremy J Heit
- Department of Neurology, Stanford University, Stanford, CA, USA
| | - Greg W Albers
- Department of Neurology, Stanford University, Stanford, CA, USA
| | - Ansaar T Rai
- Department of Neuroradiology, West Virginia University, Morgantown, WV, USA
| | - Tobias D Faizy
- Department of Radiology, Neuroendovascular Division - University Medical Center Münster, Germany
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson Medical Center, Houston, TX
| | - Kambiz Nael
- Division of Neuroradiology, Department of Radiology, University of California San Francisco, CA, USA
| | - Vivek S Yedavalli
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
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15
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Broocks G, McDonough RV, Bechstein M, Klapproth S, Faizy TD, Schön G, Kniep HC, Bester M, Hanning U, Kemmling A, Zeleñák K, Fiehler J, Meyer L. Thrombectomy in Patients With Ischemic Stroke Without Salvageable Tissue on CT Perfusion. Stroke 2024; 55:1317-1325. [PMID: 38572635 DOI: 10.1161/strokeaha.123.044916] [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: 08/21/2023] [Accepted: 02/22/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Computed tomography perfusion (CTP) imaging is regularly used to guide patient selection for mechanical thrombectomy (MT). However, the effect of MT in patients without salvageable tissue on CTP has not been investigated. The purpose of this study was to assess the effect of MT in patients with stroke without perfusion mismatch profiles. METHODS This observational study analyzed patients with ischemic stroke consecutively treated between March 1, 2015, and January 31, 2022, triaged by multimodal-computed tomography undergoing MT. CTP lesion-core mismatch profiles were defined using a mismatch volume/ratio of ≥10 mL/1.2, respectively. The primary end point was the rate of functional independence at 90 days, defined as the modified Rankin Scale score of 0 to 2. Recanalization was evaluated with the modified Thrombolysis in Cerebral Infarction scale. The effect of baseline variables on functional outcome was assessed using multivariable logistic regression analysis. Outcomes of patients with and without CTP-mismatch profiles were compared using 1:1 propensity score matching. RESULTS Of 724 patients who met the inclusion criteria of this retrospective observational study, 110 (15%) patients had no CTP mismatch and were analyzed. The median age was 74 (interquartile range, 62-80) years and 53% were women. Successful recanalization (modified Thrombolysis in Cerebral Infarction score, ≥2b) was achieved in 66% (73) and associated with functional independence at 90 days (adjusted odds ratio, 7.33 [95% CI, 1.22-43.70]; P=0.03). A significant interaction was observed between recanalization and age, as well as the extent of infarction, indicating MT to be most effective in patients <70 years and with a baseline Alberta Stroke Program Early Computed Tomography Score range between 3 and 7. These findings remained stable after propensity score matching, analyzing 152 matched pairs with similar rates of functional independence between patients with and without CTP-mismatch profiles (17% versus 23%; P=0.42). CONCLUSIONS In patients without CTP-mismatch profiles defined according to the EXTEND (Extending the Time for Thrombolysis in Emergency Neurological Deficits) criteria, recanalization was associated with improved functional outcomes. This effect was associated with baseline Alberta Stroke Program Early Computed Tomography Score and age, but not with the time from onset to imaging.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
- Department of Neuroradiology, HELIOS Medical Center, Campus of MSH Medical School Hamburg, Schwerin, Germany (G.B.)
| | | | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Susan Klapproth
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology (G.S.) University Medical Center Hamburg-Eppendorf, Germany
| | - Helge C Kniep
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Maxim Bester
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - André Kemmling
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Marburg, Marburg, Germany (A.K.)
| | - Kamil Zeleñák
- Department of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia (K.Z.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
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16
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Sui Y, Chen W, Chen C, Chang Y, Bivard A, Wang P, Geng Y, Parsons M, Lin L. CTP-Defined Large Core Is a Better Predictor of Poor Outcome for Endovascular Treatment Than ASPECTS-Defined Large Core. Stroke 2024; 55:1227-1234. [PMID: 38488357 DOI: 10.1161/strokeaha.123.045091] [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: 09/05/2023] [Accepted: 01/31/2024] [Indexed: 04/24/2024]
Abstract
BACKGROUND Recent trials confirmed the effectiveness of endovascular therapy in patients with large ischemic cores. Yet the optimal neuroimaging modalities to define large core remains unclear. We tried to address this question by comparing the functional outcomes in patients receiving thrombectomy selected by either noncontrast computed tomography Alberta Stroke Program Early Computed Tomography Score (ASPECTS) or computed tomography perfusion (CTP). METHODS This study retrospectively selected patients enrolled in the International Stroke Perfusion Registry between August 2011 and April 2022. Patients with acute stroke with large vessel occlusion in anterior circulation treated with endovascular therapy were included. All received both CTP and noncontrast computed tomography. The primary outcome was defined as poor functional outcome represented by a modified Rankin Scale score of 5 to 6 at 3 months. Large cores were defined in terms of either (1) noncontrast computed tomography ASPECTS ≤5 or (2) core volume ≥70 mL on CTP. RESULTS A total of 1115 patients were included in the analysis, of which 90 patients had ASPECTS ≤5 (8.1%) and 97 patients CTP core ≥70 mL (8.7%). A fair agreement between ASPECTS and CTP with a κ value of 0.31 (0.21-0.40) was found. Compared with patients with neither CTP nor ASPECTS large cores, those with only ASPECTS-defined large cores (ie, ASPECTS ≤5; n=56) did not have a higher adjusted odds of poor outcome (29%; odds ratio, 1.84 [0.91-3.73]; P=0.089). However, patients with CTP large core but not ASPECTS-defined large core (n=63) had a higher adjusted odds of poor outcome (60%; odds ratio, 3.91 [2.01-7.60]; P<0.001). In time-stratified subgroup analysis (>6 versus ≤6 hours), ASPECTS showed no discriminative difference between ≤5 and >5 in poor outcome for patients receiving endovascular therapy within 6 hours. CONCLUSIONS CTP core ≥70 mL-defined large cores are more predictive of poor outcome than ASPECTS ≤5-defined core in endovascular therapy patients, particularly within 6 hours after stroke onset.
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Affiliation(s)
- Yi Sui
- Department of Neurology, Shenyang First People's Hospital, Shenyang Medical College Affiliated Brain Hospital, Shenyang Clinical Research Center for Neurological Diseases, China (Y.S.)
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China (Y.S.)
| | - Wenhuo Chen
- Zhangzhou Affiliated Hospital of Fujian Medical University, China (W.C.)
| | - Chushuang Chen
- Faculty of Health, University of Newcastle, Australia (C.C., M.P., L.L.)
| | - Yanting Chang
- School of Public Health, China Medical University, Shenyang, China (Y.C.)
| | - Andrew Bivard
- Melbourne Brain Centre, University of Melbourne, Australia (A.B.)
| | - Peng Wang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China (P.W., Y.G.)
| | - Yu Geng
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China (P.W., Y.G.)
| | - Mark Parsons
- Faculty of Health, University of Newcastle, Australia (C.C., M.P., L.L.)
- South Western Clinical School, University of New South Wales, Sydney, Australia (M.P., L.L.)
| | - Longting Lin
- Faculty of Health, University of Newcastle, Australia (C.C., M.P., L.L.)
- South Western Clinical School, University of New South Wales, Sydney, Australia (M.P., L.L.)
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17
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Wang Z, Li L. Long term outcome after endovascular treatment for large ischemic core acute stroke is associated with hypoperfusion intensity ratio and onset-to-reperfusion time. Neurosurg Rev 2024; 47:182. [PMID: 38649539 DOI: 10.1007/s10143-024-02417-w] [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: 07/31/2023] [Revised: 03/08/2024] [Accepted: 04/09/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Endovascular treatment (EVT) is effective for large vessel occlusion (LVO) stroke with smaller volumes of CT perfusion (CTP)-defined core. However, the influence of perfusion imaging during thrombectomy on the functional outcomes of patients with large ischemic core (LIC) stroke at both early and late time windows is uncertain in real-world practice. METHOD A retrospective analysis was performed on 99 patients who underwent computed tomography angiography (CTA) and CT perfusion (CTP)-Rapid Processing of Perfusion and Diffusion (RAPID) before EVT and had a baseline ischemic core ≥ 50 mL and/or Alberta Stroke Program Early CT Score (ASPECTS) score of 0-5. The primary outcome was the three-month modified Rankin Scale (mRS) score. Data were analyzed by binary logistic regression and receiver operating characteristic (ROC) curves. RESULTS A fair outcome (mRS, 0-3) was found in 34 of the 99 patients while 65 had a poor prognosis (mRS, 4-6). The multivariate logistic regression analysis showed that onset-to-reperfusion (OTR) time (odds ratio [OR], 1.004; 95% confidence interval [CI], 1.001-1.007; p = 0.008), ischemic core (OR, 1.066; 95% CI, 1.024-1.111; p = 0.008), and the hypoperfusion intensity ratio (HIR) (OR, 70.898; 95% CI, 1.130-4450.152; p = 0.044) were independent predictors of outcome. The combined results of ischemic core, HIR, and OTR time showed good performance with an area under the ROC curve (AUC) of 0.937, significantly higher than the individual variables (p < 0.05) using DeLong's test. CONCLUSIONS Higher HIR and longer OTR time in large core stroke patients were independently associated with unfavorable three-month outcomes after EVT.
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Affiliation(s)
- Zhengyang Wang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Ling Li
- Department of Neurology, Taizhou Clinical Medical School of Nanjing Medical University, Jiangsu Taizhou People's Hospital, Taizhou, 225300, China
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18
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Kalincik T, Roos I, Sharmin S, Malpas CB. Methodological considerations for observational studies of treatment effectiveness in neurology: a clinician's guide. J Neurol Neurosurg Psychiatry 2024; 95:454-460. [PMID: 37890986 DOI: 10.1136/jnnp-2022-330038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 09/20/2023] [Indexed: 10/29/2023]
Abstract
Data from cohorts, registries, randomised trials, electronic medical records and administrative claims databases have increasingly been used to inform the use of therapies for neurological diseases. While novel sophisticated methods are enabling us to use existing data to guide treatment decisions, the complexity of statistical methodology is making appraisal of clinical evidence increasingly demanding. In this narrative review, we provide a brief overview of the most commonly used methods for evaluation of treatment effectiveness in neurology. This primer discusses complementarity of randomised and non-randomised study designs, sources of observational data, different forms of bias and the appropriate mitigation strategies, statistical significance, Bayesian approaches and provides an overview of multivariable regression models, propensity score-based models, causal inference, mediation analysis and Mendelian randomisation.
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Affiliation(s)
- Tomas Kalincik
- CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Izanne Roos
- CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Sifat Sharmin
- CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Charles B Malpas
- CORe, Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Neuroimmunology Centre, Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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19
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Zeng H, Zhu Q. Application of imaging modalities for endovascular thrombectomy of large core infarcts in clinical practice. Front Neurol 2024; 15:1272890. [PMID: 38665995 PMCID: PMC11043533 DOI: 10.3389/fneur.2024.1272890] [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: 08/04/2023] [Accepted: 03/13/2024] [Indexed: 04/28/2024] Open
Abstract
Four randomized controlled trials of large infarct core volume (LICV) included three imaging modalities: non-contrast CT (NCCT)-Alberta Stroke Program Early CT Score (ASPECTS), diffusion-weighted imaging (DWI)-ASPECTS, and NCCT-ASPECTS combined with CTP (CT perfusion). However, there is no clear consensus on the optimal imaging modality for endovascular thrombectomy (EVT) trials of large core infarcts. The variety and complexity of imaging modalities make it difficult to apply them in clinical practice. By familiarizing ourselves with these imaging modalities, we can better apply them in the clinic and correctly screen patients with large core infarcts in the anterior circulation who can benefit from EVT therapy.
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Affiliation(s)
| | - Qingfeng Zhu
- Neurosurgery, Second Hospital of Shanxi Medical University, Taiyuan, China
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20
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Rowling H, Italiano D, Churilov L, Palanikumar L, Harvey J, Kleinig T, Parsons M, Mitchell P, Davis S, Kruyt N, Campbell B, Zhao H. Large vessel occlusive stroke with milder baseline severity shows better collaterals and reduced harm from thrombectomy transfer delays. Int J Stroke 2024:17474930241242954. [PMID: 38506406 DOI: 10.1177/17474930241242954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
BACKGROUND Patients with large vessel occlusion (LVO) stroke presenting with milder baseline clinical severity are common and require endovascular thrombectomy. However, such patients are difficult to recognize using pre-hospital severity-based triage tools and therefore are likely to require a secondary inter-hospital transfer if transported to a non-thrombectomy center. Given the potential for milder severity to represent better underlying cerebrovascular collateral circulation, it is unknown whether transfer delays are still associated with poorer post-stroke outcomes in this patient group. AIMS We primarily aimed to examine whether the harmful effect of inter-hospital transfer delay for thrombectomy was different for LVO patients with mild or severe deficits. Secondarily, we also investigated whether imaging markers of collateral circulation were different between severity groups. METHODS Registry data from two large Australian thrombectomy centers were used to identify all directly presenting and secondarily transferred LVO patients undergoing thrombectomy, divided into those with lower (NIHSS < 10) and higher (NIHSS ⩾ 10) baseline deficits. The primary outcome was the functional independence or return to baseline defined as modified Rankin Scale 0-2 or baseline at 90 days. Patients with complete baseline CT-perfusion data were analyzed for imaging markers of collateral circulation by baseline severity group. RESULTS A total of 1210 LVO patients undergoing thrombectomy were included, of which 273 (22.6%) had lower baseline severity. Despite similar thrombolysis and recanalization rates, transferred patients had lower odds of achieving the primary outcome compared to the primary presentation to a thrombectomy center, where baseline severity was higher (adjusted odds ratio (aOR) 0.759 (95% CI 0.576-0.999)), but not when severity was lower (aOR 1.357 (95% CI 0.764-2.409), p-interaction = 0.122). In the imaging analysis of 436 patients, those with milder severity showed smaller median ischemic core volumes (12.6 (IQR 0.0-17.9) vs 27.5 (IQR 6.5-37.1) mL, p < 0.001)), higher median perfusion mismatch ratio (10.8 (IQR 4.8-54.5) vs 6.6 (IQR 3.5-16.5), p < 0.001), and lower median hypoperfusion intensity ratio (0.25 (IQR 0.18-0.38) vs 0.40 (IQR 0.22-0.57), p < 0.001). DISCUSSION Patients receiving secondary inter-hospital transfer for thrombectomy had poorer outcomes compared to those presenting directly to a thrombectomy center if baseline deficits were severe, but this difference was not observed when baseline deficits were milder. This result may potentially be due to our secondary findings of significantly improved collateral circulation markers in lower-severity LVO patients. As such, failure of pre-hospital screening tools to detect lower-severity LVO patients for pre-hospital bypass to a thrombectomy center may not necessarily deleteriously affect outcome. DATA ACCESS STATEMENT Anonymized data not published within this article will be made available on request from any qualified investigator.
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Affiliation(s)
- Hannah Rowling
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Dominic Italiano
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | - Leonid Churilov
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | - Logesh Palanikumar
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Jackson Harvey
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Mark Parsons
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
- South Western Sydney Clinical School, University of New South Wales, Warwick Farm, NSW, Australia
- Department of Neurology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Peter Mitchell
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Stephen Davis
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | - Nyika Kruyt
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Bruce Campbell
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | - Henry Zhao
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
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21
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Zhang Y, Joshi J, Hadi M. AI in Acute Cerebrovascular Disorders: What can the Radiologist Contribute? Semin Roentgenol 2024; 59:137-147. [PMID: 38880512 DOI: 10.1053/j.ro.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 01/13/2024] [Accepted: 01/27/2024] [Indexed: 06/18/2024]
Affiliation(s)
- Yi Zhang
- Department of Radiology, University of Louisville, 530 South Jackson Street, CCB-C07, Louisville, KY
| | - Jonathan Joshi
- Department of Radiology, University of Louisville, 530 South Jackson Street, CCB-C07, Louisville, KY
| | - Mohiuddin Hadi
- Department of Radiology, University of Louisville, 530 South Jackson Street, CCB-C07, Louisville, KY.
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22
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Diestro JDB, Fahed R, Omar AT, Hawkes C, Hendriks EJ, Enriquez C, Eesa M, Stotts G, Lee H, Nagendra S, Poppe A, Ducroux C, Lim T, Narvacan K, Rizzuto M, Alfalahi A, Nishi H, Sarma P, Itsekson Hayosh Z, Ignacio K, Boisseau W, Pimenta Ribeiro Pontes Almeida E, Benomar A, Almekhlafi MA, Milot G, Deshmukh A, Kishore K, Tampieri D, Wang J, Srivastava A, Roy D, Carpani F, Kashani N, Candale-Radu C, Singh N, Bres Bullrich M, Sarmiento R, Muir RT, Parra-Fariñas C, Reiter S, Deschaintre Y, Singh RJ, Bodani V, Katsanos A, Agid R, Zafar A, Pereira VM, Spears J, Marotta TR, Djiadeu P, Sharma S, Farrokhyar F. Clinical uncertainty in large vessel occlusion ischemic stroke: does automated perfusion imaging make a difference? An intra-rater and inter-rater agreement study. J Neurointerv Surg 2024:jnis-2023-021429. [PMID: 38453461 DOI: 10.1136/jnis-2023-021429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 02/18/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Limited research exists regarding the impact of neuroimaging on endovascular thrombectomy (EVT) decisions for late-window cases of large vessel occlusion (LVO) stroke. OBJECTIVE T0 assess whether perfusion CT imaging: (1) alters the proportion of recommendations for EVT, and (2) enhances the reliability of EVT decision-making compared with non-contrast CT and CT angiography. METHODS We conducted a survey using 30 patients drawn from an institutional database of 3144 acute stroke cases. These were presented to 29 Canadian physicians with and without perfusion imaging. We used non-overlapping 95% confidence intervals and difference in agreement classification as criteria to suggest a difference between the Gwet AC1 statistics (κG). RESULTS The percentage of EVT recommendations differed by 1.1% with or without perfusion imaging. Individual decisions changed in 21.4% of cases (11.3% against EVT and 10.1% in favor). Inter-rater agreement (κG) among the 29 raters was similar between non-perfusion and perfusion CT neuroimaging (κG=0.487; 95% CI 0.327 to 0.647 and κG=0.552; 95% CI 0.430 to 0.675). The 95% CIs overlapped with moderate agreement in both. Intra-rater agreement exhibited overlapping 95% CIs for all 28 raters. κG was either substantial or excellent (0.81-1) for 71.4% (20/28) of raters in both groups. CONCLUSIONS Despite the minimal difference in overall EVT recommendations with either neuroimaging protocol one in five decisions changed with perfusion imaging. Regarding agreement we found that the use of automated CT perfusion images does not significantly impact the reliability of EVT decisions for patients with late-window LVO.
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Affiliation(s)
- Jose Danilo Bengzon Diestro
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Divison of Neurology, Department of Medicine, St. Michael's Hospital- Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Insitute, St. Michael's Hospital- Unity Health Toronto, Toronto, Ontario, Canada
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, St. Michael's Hospital- Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Robert Fahed
- Division Neurology, Department of Medicine, The Ottawa Hospital - Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Abdelsimar Tan Omar
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Christine Hawkes
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eef J Hendriks
- Division of Interventional Neuroradiology, Joint Department of Medical Imaging (JDMI), Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Clare Enriquez
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Muneer Eesa
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Grant Stotts
- Division Neurology, Department of Medicine, The Ottawa Hospital - Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Hubert Lee
- Division of Neurointerventional Neuroradiology, Division of Neurosurgery, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Shashank Nagendra
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alexandre Poppe
- Department of Neurosciences, Faculté de Médecine, Université de Montréal, Montréal, Quebec, Canada
| | - Célina Ducroux
- Division Neurology, Department of Medicine, The Ottawa Hospital - Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Timothy Lim
- Division of Diagnostic Neuroradiology, Department of Medical Imaging, Unity Health- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Karl Narvacan
- Department of Medical Imaging, St Michael's Hospital- Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Michael Rizzuto
- Division of Neurosurgery, Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Afra Alfalahi
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, St. Michael's Hospital- Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Hidehisa Nishi
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, St. Michael's Hospital- Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
- Department of Neurosurgery, Koseikai Takeda hospital, Kyoto, Japan
| | - Pragyan Sarma
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, St. Michael's Hospital- Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Ze'ev Itsekson Hayosh
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, St. Michael's Hospital- Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
- Division of Interventional Neuroradiology, Joint Department of Medical Imaging (JDMI), Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Katrina Ignacio
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - William Boisseau
- Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | | | - Anass Benomar
- Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | - Mohammed A Almekhlafi
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute and O'Brien Institute for Public Health, Cumming School of Medicine at the University of Calgary, Calgary, Alberta, Canada
| | - Genvieve Milot
- Department of Surgery (Neurosurgery), Centre Hospitalier de Quebec, Université Laval, Laval, Quebec, Canada
| | - Aviraj Deshmukh
- Division of Clinical Sciences, Health Sciences North, Northern Ontario School of Medicine University, Sudbury, Ontario, Canada
| | - Kislay Kishore
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Donatella Tampieri
- Department of Radiology, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Jeffrey Wang
- Divison of Neurology, Department of Medicine, St. Michael's Hospital- Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Abhilekh Srivastava
- Division of Neurology, Department of Medicine, Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Daniel Roy
- Département de Radiologie, Radio-Oncologie et Médecine Nucléaire, Université de Montréal, Montréal, Quebec, Canada
| | - Federico Carpani
- Division of Neurology, Department of Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Nima Kashani
- Department of Medical Imaging, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Claudia Candale-Radu
- Division of Neurology, Department of Internal Medicine, Health Sciences Center, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nishita Singh
- Division of Neurology, Department of Internal Medicine, Health Sciences Center, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Maria Bres Bullrich
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Robert Sarmiento
- Division of Neurology, Department of Medicine, Vancouver General Hospital- University of British Columbia, Vancouver, British Columbia, Canada
| | - Ryan T Muir
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Carmen Parra-Fariñas
- Divisions of Neuroradiology & Neurointervention, Department of Diagnostic & Interventional Radiology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Stephanie Reiter
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Yan Deschaintre
- Department of Neurosciences, Faculté de Médecine, Université de Montréal, Montréal, Quebec, Canada
| | - Ravinder-Jeet Singh
- Division of Clinical Sciences, Health Sciences North, Northern Ontario School of Medicine University, Sudbury, Ontario, Canada
| | - Vivek Bodani
- Division of Interventional Neuroradiology, Joint Department of Medical Imaging (JDMI), Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Aristeidis Katsanos
- Division of Neurology, Department of Medicine, Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Ronit Agid
- Division of Interventional Neuroradiology, Joint Department of Medical Imaging (JDMI), Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Atif Zafar
- Divison of Neurology, Department of Medicine, St. Michael's Hospital- Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Vitor M Pereira
- Li Ka Shing Knowledge Insitute, St. Michael's Hospital- Unity Health Toronto, Toronto, Ontario, Canada
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, St. Michael's Hospital- Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital- Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Julian Spears
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital- Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Thomas R Marotta
- Li Ka Shing Knowledge Insitute, St. Michael's Hospital- Unity Health Toronto, Toronto, Ontario, Canada
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, St. Michael's Hospital- Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Pascal Djiadeu
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Global Health, McMaster University, Hamilton, Ontario, Canada
| | - Sunjay Sharma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Forough Farrokhyar
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Global Health, McMaster University, Hamilton, Ontario, Canada
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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23
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Sarraj A, Hassan AE, Abraham MG, Ortega-Gutierrez S, Kasner SE, Hussain MS, Chen M, Churilov L, Johns H, Sitton CW, Yogendrakumar V, Ng FC, Pujara DK, Blackburn S, Sundararajan S, Hu YC, Herial NA, Arenillas JF, Tsai JP, Budzik RF, Hicks WJ, Kozak O, Yan B, Cordato DJ, Manning NW, Parsons MW, Cheung A, Hanel RA, Aghaebrahim AN, Wu TY, Portela PC, Gandhi CD, Al-Mufti F, Pérez de la Ossa N, Schaafsma JD, Blasco J, Sangha N, Warach S, Kleinig TJ, Shaker F, Al Shaibi F, Toth G, Abdulrazzak MA, Sharma G, Ray A, Sunshine J, Opaskar A, Duncan KR, Xiong W, Samaniego EA, Maali L, Lechtenberg CG, Renú A, Vora N, Nguyen T, Fifi JT, Tjoumakaris SI, Jabbour P, Tsivgoulis G, Pereira VM, Lansberg MG, DeGeorgia M, Sila CA, Bambakidis N, Hill MD, Davis SM, Wechsler L, Grotta JC, Ribo M, Albers GW, Campbell BC. Endovascular Thrombectomy for Large Ischemic Stroke Across Ischemic Injury and Penumbra Profiles. JAMA 2024; 331:750-763. [PMID: 38324414 PMCID: PMC10851143 DOI: 10.1001/jama.2024.0572] [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: 09/28/2023] [Accepted: 01/16/2024] [Indexed: 02/09/2024]
Abstract
Importance Whether endovascular thrombectomy (EVT) efficacy for patients with acute ischemic stroke and large cores varies depending on the extent of ischemic injury is uncertain. Objective To describe the relationship between imaging estimates of irreversibly injured brain (core) and at-risk regions (mismatch) and clinical outcomes and EVT treatment effect. Design, Setting, and Participants An exploratory analysis of the SELECT2 trial, which randomized 352 adults (18-85 years) with acute ischemic stroke due to occlusion of the internal carotid or middle cerebral artery (M1 segment) and large ischemic core to EVT vs medical management (MM), across 31 global centers between October 2019 and September 2022. Intervention EVT vs MM. Main Outcomes and Measures Primary outcome was functional outcome-90-day mRS score (0, no symptoms, to 6, death) assessed by adjusted generalized OR (aGenOR; values >1 represent more favorable outcomes). Benefit of EVT vs MM was assessed across levels of ischemic injury defined by noncontrast CT using ASPECTS score and by the volume of brain with severely reduced blood flow on CT perfusion or restricted diffusion on MRI. Results Among 352 patients randomized, 336 were analyzed (median age, 67 years; 139 [41.4%] female); of these, 168 (50%) were randomized to EVT, and 2 additional crossover MM patients received EVT. In an ordinal analysis of mRS at 90 days, EVT improved functional outcomes compared with MM within ASPECTS categories of 3 (aGenOR, 1.71 [95% CI, 1.04-2.81]), 4 (aGenOR, 2.01 [95% CI, 1.19-3.40]), and 5 (aGenOR, 1.85 [95% CI, 1.22-2.79]). Across strata for CT perfusion/MRI ischemic core volumes, aGenOR for EVT vs MM was 1.63 (95% CI, 1.23-2.16) for volumes ≥70 mL, 1.41 (95% CI, 0.99-2.02) for ≥100 mL, and 1.47 (95% CI, 0.84-2.56) for ≥150 mL. In the EVT group, outcomes worsened as ASPECTS decreased (aGenOR, 0.91 [95% CI, 0.82-1.00] per 1-point decrease) and as CT perfusion/MRI ischemic core volume increased (aGenOR, 0.92 [95% CI, 0.89-0.95] per 10-mL increase). No heterogeneity of EVT treatment effect was observed with or without mismatch, although few patients without mismatch were enrolled. Conclusion and Relevance In this exploratory analysis of a randomized clinical trial of patients with extensive ischemic stroke, EVT improved clinical outcomes across a wide spectrum of infarct volumes, although enrollment of patients with minimal penumbra volume was low. In EVT-treated patients, clinical outcomes worsened as presenting ischemic injury estimates increased. Trial Registration ClinicalTrials.gov Identifier: NCT03876457.
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Affiliation(s)
- Amrou Sarraj
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | | | | | | | | | | | - Michael Chen
- Rush University Medical Center, Chicago, Illinois
| | - Leonid Churilov
- The Melbourne Brain Centre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Hannah Johns
- The Melbourne Brain Centre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | | | - Vignan Yogendrakumar
- The Melbourne Brain Centre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Felix C. Ng
- The Melbourne Brain Centre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Deep K. Pujara
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | | | - Sophia Sundararajan
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | - Yin C. Hu
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | - Nabeel A. Herial
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Juan F. Arenillas
- Hospital Clínico Universitario Valladolid—University of Valladolid, Valladolid, Spain
| | | | | | | | - Osman Kozak
- Abington Jefferson Health, Abington, Pennsylvania
| | - Bernard Yan
- The Melbourne Brain Centre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | | | | | | | - Andrew Cheung
- Liverpool Hospital, Liverpool, New South Wales, Australia
| | | | | | - Teddy Y. Wu
- Christchurch Hospital, Christchurch, New Zealand
| | | | | | - Fawaz Al-Mufti
- Westchester Medical Center, New York Medical College, Valhalla
| | | | | | | | | | - Steven Warach
- Dell Medical School at The University of Texas at Austin–Ascension Texas, Austin
| | | | - Faris Shaker
- McGovern Medical School at UTHealth, Houston, Texas
| | - Faisal Al Shaibi
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | | | | | - Gagan Sharma
- The Melbourne Brain Centre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Abhishek Ray
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | - Jeffrey Sunshine
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | - Amanda Opaskar
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | - Kelsey R. Duncan
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | - Wei Xiong
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | | | - Laith Maali
- University of Kansas Medical Center, Kansas City
| | | | - Arturo Renú
- Hospital Clínic de Barcelona, Barcelona, Spain
| | - Nirav Vora
- Riverside Methodist Hospital, OhioHealth, Columbus
| | | | | | | | - Pascal Jabbour
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Georgios Tsivgoulis
- Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Michael DeGeorgia
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | - Cathy A. Sila
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | - Nicholas Bambakidis
- University Hospital Cleveland Medical Center—Case Western Reserve University, Cleveland, Ohio
| | | | - Stephen M. Davis
- The Melbourne Brain Centre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | | | | | - Marc Ribo
- Hospital Vall d’Hebrón, Barcelona, Spain
| | | | - Bruce C. Campbell
- The Melbourne Brain Centre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
- Florey Institute for Neuroscience and Mental Health, Parkville, Victoria, Australia
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24
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Liddle LJ, Huang YG, Kung TFC, Mergenthaler P, Colbourne F, Buchan AM. An Assessment of Physical and N6-Cyclohexyladenosine-Induced Hypothermia in Rodent Distal Focal Ischemic Stroke. Ther Hypothermia Temp Manag 2024; 14:36-45. [PMID: 37339459 DOI: 10.1089/ther.2023.0025] [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: 06/22/2023] Open
Abstract
Therapeutic hypothermia (TH) mitigates damage in ischemic stroke models. However, safer and easier TH methods (e.g., pharmacological) are needed to circumvent physical cooling complications. This study evaluated systemic and pharmacologically induced TH using the adenosine A1 receptor agonist, N6-cyclohexyladenosine (CHA), with control groups in male Sprague-Dawley rats. CHA was administered intraperitoneally 10 minutes following a 2-hour intraluminal middle cerebral artery occlusion. We used a 1.5 mg/kg induction dose, followed by three 1.0 mg/kg doses every 6 hours for a total of 4 doses, causing 20-24 hours of hypothermia. Animals assigned to physical hypothermia and CHA-hypothermia had similar induction rates and nadir temperatures, but forced cooling lasted ∼6 hours longer compared with CHA-treated animals. The divergence is likely attributable to individual differences in CHA metabolism, which led to varied durations at nadir, whereas physical hypothermia was better regulated. Physical hypothermia significantly reduced infarction (primary endpoint) on day 7 (mean reduction of 36.8 mm3 or 39% reduction; p = 0.021 vs. normothermic animals; Cohen's d = 0.75), whereas CHA-induced hypothermia did not (p = 0.33). Similarly, physical cooling improved neurological function (physical hypothermia median = 0, physical normothermia median = 2; p = 0.008) and CHA-induced cooling did not (p > 0.99). Our findings demonstrate that forced cooling was neuroprotective compared with controls, but prolonged CHA-induced cooling was not neuroprotective.
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Affiliation(s)
- Lane J Liddle
- Department of Psychology, University of Alberta, Edmonton, Alberta, Canada
| | - Yi-Ge Huang
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Tiffany F C Kung
- Department of Psychology, University of Alberta, Edmonton, Alberta, Canada
| | - Philipp Mergenthaler
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, NeuroCure Clinical Research Center, Berlin, Germany
| | - Frederick Colbourne
- Department of Psychology, University of Alberta, Edmonton, Alberta, Canada
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Alastair M Buchan
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
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25
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Al-Mufti F, Marden FA, Burkhardt JK, Raper D, Schirmer CM, Baker A, Chen PR, Bulsara KR, Narsinh KH, Amans MR, Cooper J, Yaghi S, Al-Kawaz M, Hetts SW. Endovascular therapy for anterior circulation emergent large vessel occlusion stroke in patients with large ischemic cores: a report of the SNIS Standards and Guidelines Committee. J Neurointerv Surg 2024:jnis-2023-021444. [PMID: 38395601 DOI: 10.1136/jnis-2023-021444] [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: 01/03/2024] [Accepted: 01/26/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Early clinical trials validating endovascular therapy (EVT) for emergent large vessel occlusion (ELVO) ischemic stroke in the anterior circulation initially focused on patients with small or absent completed infarctions (ischemic cores) to maximize the probability of detecting a clinically meaningful and statistically significant benefit of EVT. Subsequently, real-world experience suggested that patients with large core ischemic strokes (LCS) at presentation may also benefit from EVT. Several large, retrospective, and prospective randomized clinical trials have recently been published that further validate this approach. These guidelines aim to provide an update for endovascular treatment of LCS. METHODS A structured literature review of LCS studies available since 2019 and grading the strength and quality of the evidence was performed. Recommendations were made based on these new data by consensus of the authors, with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors. RESULTS The management of ELVO strokes with large ischemic cores continues to evolve. The expert panel agreed on several recommendations: Recommendation 1: In patients with anterior circulation ELVO who present within 24 hours of last known normal with large infarct core (70-149 mL or ASPECTS 3-5) and meet other criteria of RESCUE-Japan LIMIT, SELECT2, ANGEL-ASPECT, TESLA, TENSION, or LASTE trials, thrombectomy is indicated (Class I, Level A). Recommendations 2-7 flow directly from recommendation 1. Recommendation 2: EVT in patients with LCS aged 18-85 years is beneficial (Class I, Level A). Recommendation 3: EVT in patients with LCS >85 years of age may be beneficial (Class I, Level B-R). Recommendation 4: Patients with LCS and NIHSS score 6-30 benefit from EVT in LCS (Class I, Level A). Recommendation 5: Patients with LCS and NIHSS score <6 and >30 may benefit from EVT in LCS (Class IIa, Level A). Recommendation 6: Patients with LCS and low baseline mRS (0-1) benefit from EVT (Class I, Level A). Recommendation 7: Patients with LCS and time of last known well 0-24 hours benefit from EVT (Class I, Level A). Recommendation 8: It is recommended that patients with ELVO LCS who also meet the criteria for on-label or guideline-directed use of IV thrombolysis receive IV thrombolysis, irrespective of whether endovascular treatments are being considered (Class I, Level B-NR). CONCLUSIONS The indications for endovascular treatment of ELVO strokes continue to expand and now include patients with large ischemic cores on presentation. Further prospective randomized studies, including follow-up to assess the population-based efficacy of treating patients with LCS, are warranted.
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Affiliation(s)
- Fawaz Al-Mufti
- Departments of Neurology and Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Franklin A Marden
- Interventional Neuroradiology, Alexian Brothers Medical Center, Elk Grove Village, Illinois, USA
| | - Jan Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel Raper
- Departments of Neurological Surgery, Radiology, and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Clemens M Schirmer
- Department of Neurosurgery, Geisinger Health System, Wilkes-Barre, Pennsylvania, USA
| | - Amanda Baker
- Departments of Radiology, Biomedical Imaging, and Neurological Surgery, UCSF, San Francisco, California, USA
| | - Peng Roc Chen
- Neurosurgery, The University of Texas Health Science Center at Houston Vivian L Smith Department of Neurosurgery, Houston, Texas, USA
| | - Ketan R Bulsara
- Division of Neurosurgery, University of Connecticut, Farmington, Connecticut, USA
| | - Kazim H Narsinh
- Departments of Radiology, Biomedical Imaging, and Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Matthew Robert Amans
- Departments of Radiology, Biomedical Imaging, and Neurological Surgery, UCSF, San Francisco, California, USA
| | - Jared Cooper
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Shadi Yaghi
- Department of Neurology, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
- Department of Neurology, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Mais Al-Kawaz
- Departments of Neurology, Neurosurgery, and Radiology, University of Kentucky, Lexington, Kentucky, USA
- Mount Sinai Health System, New York, New York, USA
| | - Steven W Hetts
- Radiology, Biomedical Imaging, and Neurological Surgery, UCSF, San Francisco, California, USA
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Liu Q, Fang J, Jiang X, Duan T, Luo Y, Gao L, Dong S, Ma M, Zhou M, He L. Endovascular thrombectomy for acute ischemic stroke in elderly patients with large ischemic cores. Neurol Sci 2024; 45:663-670. [PMID: 37700175 DOI: 10.1007/s10072-023-06995-3] [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: 04/30/2023] [Accepted: 07/28/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Understanding the benefits and risks of endovascular therapy (EVT) is crucial for elderly patients with large ischemic cores, as the combination of advanced age and extensive brain infarction may negatively impact clinical outcomes. METHODS The study retrospectively analyzed clinical outcomes for elderly stroke patients (age ≥ 70) with large ischemic cores (Alberta Stroke Program Early CT Score [ASPECTS] < 6 or ischemic cores ≥ 70 ml) in the anterior circulation using data from our prospective database between June 2018 and January 2022. The effectiveness and risks of EVT in those patients were investigated, with the primary outcome being fair outcome (modified Rankin Scale, mRS ≤ 3). RESULTS Among 182 elderly patients with large ischemic core volume (120 in the EVT group and 62 in the non-EVT group), 20.9% (38/182, 22.5% in the EVT group vs. 17.7% in the non-EVT group) achieved a fair outcome. Meanwhile, 49.5% (90/182, 45.8% in the EVT group vs. 56.5% in the non-EVT group) of them died at 3 months. The benefits of EVT numerically exceeded non-EVT treatment for those aged ≤ ~ 85 years or with a mismatch volume ≥ ~ 50 ml. However, after adjustment, EVT was associated with an increased risk of symptomatic intracranial hemorrhage (aOR 4.24, 95%CI 1.262-14.247). CONCLUSIONS This study highlights the clinical challenges faced by elderly patients with large infarctions, resulting in poor outcomes at 3 months. EVT may still provide some benefits in this population, but it also carries an increased risk of intracranial hemorrhage.
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Affiliation(s)
- Qian Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jinghuan Fang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xin Jiang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Ting Duan
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yaxi Luo
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Lijie Gao
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Shuju Dong
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Mengmeng Ma
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Muke Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China.
| | - Li He
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China.
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Diestro JDB, Fahed R, Benomar A, Omar AT, Pereira VM, Spears J, Marotta TR, Djiadeu P, Sharma S, Farrokhyar F. Clinical Uncertainty in Large Vessel Occlusion ischemic stroke (CULVO): Does automated perfusion scanning make a difference? Protocol of an intrarater and interrater agreement study. PLoS One 2024; 19:e0297520. [PMID: 38289912 PMCID: PMC10826946 DOI: 10.1371/journal.pone.0297520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 01/04/2024] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Guidelines recommend the use of perfusion computed tomography (CT) to identify emergent large vessel ischemic stroke (ELVIS) patients who are likely to benefit from endovascular thrombectomy (EVT) if they present within 6-24 hour (late window) of stroke onset. We aim to determine if the interrater and intrarater reliability among physicians when recommending EVT is significantly different when perfusion CT or non-perfusion CT is reviewed. METHODS A total of 30 non-consecutive patients will be selected from our institutional database comprising 3144 cranial CT scans performed for acute stroke symptoms January 2018 to August 2022. The clinical and radiologic data of the 30 patients will be presented in random order to a group of 29 physicians in two separate sessions at least three weeks apart. In each session, the physicians will evaluate each patient once with automated perfusion images and once without. We will use non-overlapping 95% confidence intervals and difference in agreement classification as criteria to suggest a difference between the Gwet AC1 statistics (κG). DISCUSSION The results obtained from this study, combined with the clinical outcomes data of patients categorized through the two imaging techniques and a cost-effectiveness analysis, will offer a comprehensive evaluation of the clinical utility of perfusion CT neuroimaging. Should there be no significant disparity in the reliability of decisions made by clinicians using the two neuroimaging protocols, it may be necessary to revise existing recommendations regarding neuroimaging in the later time window to align with these findings.
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Affiliation(s)
- Jose Danilo Bengzon Diestro
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, Unity Health- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Robert Fahed
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Anass Benomar
- Department of Radiology, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Abdelsimar T. Omar
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Harvard TH Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
| | - Vitor Mendes Pereira
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, Unity Health- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Department of Surgery, Unity Health- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Julian Spears
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, Unity Health- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Department of Surgery, Unity Health- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Thomas R. Marotta
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, Unity Health- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Pascal Djiadeu
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Global Health, McMaster University, Hamilton, Ontario, Canada
| | - Sunjay Sharma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Forough Farrokhyar
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Global Health, McMaster University, Hamilton, Ontario, Canada
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Fladt J, Kaesmacher J, Meinel TR, Bütikofer L, Strbian D, Eker OF, Albucher JF, Desal H, Marnat G, Papagiannaki C, Richard S, Requena M, Lapergue B, Pagano P, Ernst M, Wiesmann M, Boulanger M, Liebeskind DS, Gralla J, Fischer U. MRI vs CT for Baseline Imaging Evaluation in Acute Large Artery Ischemic Stroke: A Subanalysis of the SWIFT-DIRECT Trial. Neurology 2024; 102:e207922. [PMID: 38165324 DOI: 10.1212/wnl.0000000000207922] [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: 06/30/2023] [Accepted: 09/18/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Whether MRI or CT is preferable for the evaluation of patients with suspected stroke remains a matter of debate, given that the imaging modality acquired at baseline may be a relevant determinant of workflow delays and outcomes with it, in patients with stroke undergoing acute reperfusion therapies. METHODS In this post hoc analysis of the SWIFT-DIRECT trial that investigated noninferiority of thrombectomy alone vs IV thrombolysis (IVT) + thrombectomy in patients with an acute ischemic anterior circulation large vessel occlusive stroke eligible to receive IVT within 4.5 hours after last seen well, we tested for a potential interaction between baseline imaging modality (MRI/MR-angiography [MRA] vs CT/CT-angiography [CTA]) and the effect of acute treatment (thrombectomy vs IVT + thrombectomy) on clinical and safety outcomes and procedural metrics (primary analysis). Moreover, we examined the association between baseline imaging modality and these outcomes using regression models adjusted for age, sex, baseline NIH Stroke Scale (NIHSS), occlusion location, and Alberta Stroke Program Early CT Score (ASPECTS) (secondary analysis). Endpoints included workflow times, the modified Rankin scale (mRS) score at 90 days, the rate of successful reperfusion, the odds for early neurologic deterioration within 24 hours, and the risk of symptomatic intracranial hemorrhage. The imaging modality acquired was chosen at the discretion of the treating physicians and commonly reflects center-specific standard procedures. RESULTS Four hundred five of 408 patients enrolled in the SWIFT-DIRECT trial were included in this substudy. Two hundred (49.4%) patients underwent MRI/MRA, and 205 (50.6%) underwent CT/CTA. Patients with MRI/MRA had lower NIHSS scores (16 [interquartile range (IQR) 12-20] vs 18 [IQR 14-20], p = 0.012) and lower ASPECTS (8 [IQR 6-9] vs 8 [IQR 7-9], p = 0.021) compared with those with CT/CTA. In terms of the primary analysis, we found no evidence for an interaction between baseline imaging modality and the effect of IVT + thrombectomy vs thrombectomy alone. Regarding the secondary analysis, MRI/MRA acquisition was associated with workflow delays of approximately 20 minutes, higher odds of functional independence at 90 days (adjusted odds ratio [aOR] 1.65, 95% CI 1.07-2.56), and similar mortality rates (aOR 0.73, 95% CI 0.36-1.47) compared with CT/CTA. DISCUSSION This post hoc analysis does not suggest treatment effect heterogeneity of IVT + thrombectomy vs thrombectomy alone in large artery stroke patients with different imaging modalities. There was no evidence that functional outcome at 90 days was less favorable following MRI/MRA at baseline compared with CT/CTA, despite significant workflow delays. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT03192332.
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Affiliation(s)
- Joachim Fladt
- From the Stroke Center and Department of Neurology (J.F., U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G.), and Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital and University of Bern; CTU Bern (L.B.), University of Bern, Switzerland; Department of Neurology (D.S.), Helsinki University Hospital, University of Helsinki, Finland; Department of Neuroradiology (O.F.E.), Hospices Civils de Lyon; Department of Diagnostic and Therapeutic Neuroradiology (J.-F.A.), Centre Hospitalier Universitaire de Toulouse; Department of Diagnostic and Interventional Neuroradiology (H.D.), Centre Hospitalier Universitaire de Nantes, Nantes Université; Interventional and Diagnostic Neuroradiology (G.M.), CHU Bordeaux, University of Bordeaux; Department of Radiology (C.P.), CHU Rouen; Stroke Unit (S.R.), Department of Neurology, CHRU-Nancy, Université de Lorraine, France; Stroke Unit (M.R.), Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain; Department of Stroke and Diagnostic and Interventional Neuroradiology (B.L.), Foch Hospital, Suresnes, France; Department of Neuroradiology (P.P.), CHU Reims, France; Department of Neuroradiology (M.E.), University Medical Center Goettingen; Department of Neuroradiology (M.W.), University Hospital RWTH Aachen, Germany; Department of Neurology (M.B.), CHU Caen Normandie, University Caen Normandie, INSERM U1237, France; and Department of Neurology and Comprehensive Stroke Center (D.S.L.), David Geffen School of Medicine, University of California, Los Angeles
| | - Johannes Kaesmacher
- From the Stroke Center and Department of Neurology (J.F., U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G.), and Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital and University of Bern; CTU Bern (L.B.), University of Bern, Switzerland; Department of Neurology (D.S.), Helsinki University Hospital, University of Helsinki, Finland; Department of Neuroradiology (O.F.E.), Hospices Civils de Lyon; Department of Diagnostic and Therapeutic Neuroradiology (J.-F.A.), Centre Hospitalier Universitaire de Toulouse; Department of Diagnostic and Interventional Neuroradiology (H.D.), Centre Hospitalier Universitaire de Nantes, Nantes Université; Interventional and Diagnostic Neuroradiology (G.M.), CHU Bordeaux, University of Bordeaux; Department of Radiology (C.P.), CHU Rouen; Stroke Unit (S.R.), Department of Neurology, CHRU-Nancy, Université de Lorraine, France; Stroke Unit (M.R.), Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain; Department of Stroke and Diagnostic and Interventional Neuroradiology (B.L.), Foch Hospital, Suresnes, France; Department of Neuroradiology (P.P.), CHU Reims, France; Department of Neuroradiology (M.E.), University Medical Center Goettingen; Department of Neuroradiology (M.W.), University Hospital RWTH Aachen, Germany; Department of Neurology (M.B.), CHU Caen Normandie, University Caen Normandie, INSERM U1237, France; and Department of Neurology and Comprehensive Stroke Center (D.S.L.), David Geffen School of Medicine, University of California, Los Angeles
| | - Thomas R Meinel
- From the Stroke Center and Department of Neurology (J.F., U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G.), and Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital and University of Bern; CTU Bern (L.B.), University of Bern, Switzerland; Department of Neurology (D.S.), Helsinki University Hospital, University of Helsinki, Finland; Department of Neuroradiology (O.F.E.), Hospices Civils de Lyon; Department of Diagnostic and Therapeutic Neuroradiology (J.-F.A.), Centre Hospitalier Universitaire de Toulouse; Department of Diagnostic and Interventional Neuroradiology (H.D.), Centre Hospitalier Universitaire de Nantes, Nantes Université; Interventional and Diagnostic Neuroradiology (G.M.), CHU Bordeaux, University of Bordeaux; Department of Radiology (C.P.), CHU Rouen; Stroke Unit (S.R.), Department of Neurology, CHRU-Nancy, Université de Lorraine, France; Stroke Unit (M.R.), Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain; Department of Stroke and Diagnostic and Interventional Neuroradiology (B.L.), Foch Hospital, Suresnes, France; Department of Neuroradiology (P.P.), CHU Reims, France; Department of Neuroradiology (M.E.), University Medical Center Goettingen; Department of Neuroradiology (M.W.), University Hospital RWTH Aachen, Germany; Department of Neurology (M.B.), CHU Caen Normandie, University Caen Normandie, INSERM U1237, France; and Department of Neurology and Comprehensive Stroke Center (D.S.L.), David Geffen School of Medicine, University of California, Los Angeles
| | - Lukas Bütikofer
- From the Stroke Center and Department of Neurology (J.F., U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G.), and Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital and University of Bern; CTU Bern (L.B.), University of Bern, Switzerland; Department of Neurology (D.S.), Helsinki University Hospital, University of Helsinki, Finland; Department of Neuroradiology (O.F.E.), Hospices Civils de Lyon; Department of Diagnostic and Therapeutic Neuroradiology (J.-F.A.), Centre Hospitalier Universitaire de Toulouse; Department of Diagnostic and Interventional Neuroradiology (H.D.), Centre Hospitalier Universitaire de Nantes, Nantes Université; Interventional and Diagnostic Neuroradiology (G.M.), CHU Bordeaux, University of Bordeaux; Department of Radiology (C.P.), CHU Rouen; Stroke Unit (S.R.), Department of Neurology, CHRU-Nancy, Université de Lorraine, France; Stroke Unit (M.R.), Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain; Department of Stroke and Diagnostic and Interventional Neuroradiology (B.L.), Foch Hospital, Suresnes, France; Department of Neuroradiology (P.P.), CHU Reims, France; Department of Neuroradiology (M.E.), University Medical Center Goettingen; Department of Neuroradiology (M.W.), University Hospital RWTH Aachen, Germany; Department of Neurology (M.B.), CHU Caen Normandie, University Caen Normandie, INSERM U1237, France; and Department of Neurology and Comprehensive Stroke Center (D.S.L.), David Geffen School of Medicine, University of California, Los Angeles
| | - Daniel Strbian
- From the Stroke Center and Department of Neurology (J.F., U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G.), and Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital and University of Bern; CTU Bern (L.B.), University of Bern, Switzerland; Department of Neurology (D.S.), Helsinki University Hospital, University of Helsinki, Finland; Department of Neuroradiology (O.F.E.), Hospices Civils de Lyon; Department of Diagnostic and Therapeutic Neuroradiology (J.-F.A.), Centre Hospitalier Universitaire de Toulouse; Department of Diagnostic and Interventional Neuroradiology (H.D.), Centre Hospitalier Universitaire de Nantes, Nantes Université; Interventional and Diagnostic Neuroradiology (G.M.), CHU Bordeaux, University of Bordeaux; Department of Radiology (C.P.), CHU Rouen; Stroke Unit (S.R.), Department of Neurology, CHRU-Nancy, Université de Lorraine, France; Stroke Unit (M.R.), Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain; Department of Stroke and Diagnostic and Interventional Neuroradiology (B.L.), Foch Hospital, Suresnes, France; Department of Neuroradiology (P.P.), CHU Reims, France; Department of Neuroradiology (M.E.), University Medical Center Goettingen; Department of Neuroradiology (M.W.), University Hospital RWTH Aachen, Germany; Department of Neurology (M.B.), CHU Caen Normandie, University Caen Normandie, INSERM U1237, France; and Department of Neurology and Comprehensive Stroke Center (D.S.L.), David Geffen School of Medicine, University of California, Los Angeles
| | - Omer F Eker
- From the Stroke Center and Department of Neurology (J.F., U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G.), and Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital and University of Bern; CTU Bern (L.B.), University of Bern, Switzerland; Department of Neurology (D.S.), Helsinki University Hospital, University of Helsinki, Finland; Department of Neuroradiology (O.F.E.), Hospices Civils de Lyon; Department of Diagnostic and Therapeutic Neuroradiology (J.-F.A.), Centre Hospitalier Universitaire de Toulouse; Department of Diagnostic and Interventional Neuroradiology (H.D.), Centre Hospitalier Universitaire de Nantes, Nantes Université; Interventional and Diagnostic Neuroradiology (G.M.), CHU Bordeaux, University of Bordeaux; Department of Radiology (C.P.), CHU Rouen; Stroke Unit (S.R.), Department of Neurology, CHRU-Nancy, Université de Lorraine, France; Stroke Unit (M.R.), Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain; Department of Stroke and Diagnostic and Interventional Neuroradiology (B.L.), Foch Hospital, Suresnes, France; Department of Neuroradiology (P.P.), CHU Reims, France; Department of Neuroradiology (M.E.), University Medical Center Goettingen; Department of Neuroradiology (M.W.), University Hospital RWTH Aachen, Germany; Department of Neurology (M.B.), CHU Caen Normandie, University Caen Normandie, INSERM U1237, France; and Department of Neurology and Comprehensive Stroke Center (D.S.L.), David Geffen School of Medicine, University of California, Los Angeles
| | - Jean-Francois Albucher
- From the Stroke Center and Department of Neurology (J.F., U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G.), and Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital and University of Bern; CTU Bern (L.B.), University of Bern, Switzerland; Department of Neurology (D.S.), Helsinki University Hospital, University of Helsinki, Finland; Department of Neuroradiology (O.F.E.), Hospices Civils de Lyon; Department of Diagnostic and Therapeutic Neuroradiology (J.-F.A.), Centre Hospitalier Universitaire de Toulouse; Department of Diagnostic and Interventional Neuroradiology (H.D.), Centre Hospitalier Universitaire de Nantes, Nantes Université; Interventional and Diagnostic Neuroradiology (G.M.), CHU Bordeaux, University of Bordeaux; Department of Radiology (C.P.), CHU Rouen; Stroke Unit (S.R.), Department of Neurology, CHRU-Nancy, Université de Lorraine, France; Stroke Unit (M.R.), Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain; Department of Stroke and Diagnostic and Interventional Neuroradiology (B.L.), Foch Hospital, Suresnes, France; Department of Neuroradiology (P.P.), CHU Reims, France; Department of Neuroradiology (M.E.), University Medical Center Goettingen; Department of Neuroradiology (M.W.), University Hospital RWTH Aachen, Germany; Department of Neurology (M.B.), CHU Caen Normandie, University Caen Normandie, INSERM U1237, France; and Department of Neurology and Comprehensive Stroke Center (D.S.L.), David Geffen School of Medicine, University of California, Los Angeles
| | - Hubert Desal
- From the Stroke Center and Department of Neurology (J.F., U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G.), and Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital and University of Bern; CTU Bern (L.B.), University of Bern, Switzerland; Department of Neurology (D.S.), Helsinki University Hospital, University of Helsinki, Finland; Department of Neuroradiology (O.F.E.), Hospices Civils de Lyon; Department of Diagnostic and Therapeutic Neuroradiology (J.-F.A.), Centre Hospitalier Universitaire de Toulouse; Department of Diagnostic and Interventional Neuroradiology (H.D.), Centre Hospitalier Universitaire de Nantes, Nantes Université; Interventional and Diagnostic Neuroradiology (G.M.), CHU Bordeaux, University of Bordeaux; Department of Radiology (C.P.), CHU Rouen; Stroke Unit (S.R.), Department of Neurology, CHRU-Nancy, Université de Lorraine, France; Stroke Unit (M.R.), Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain; Department of Stroke and Diagnostic and Interventional Neuroradiology (B.L.), Foch Hospital, Suresnes, France; Department of Neuroradiology (P.P.), CHU Reims, France; Department of Neuroradiology (M.E.), University Medical Center Goettingen; Department of Neuroradiology (M.W.), University Hospital RWTH Aachen, Germany; Department of Neurology (M.B.), CHU Caen Normandie, University Caen Normandie, INSERM U1237, France; and Department of Neurology and Comprehensive Stroke Center (D.S.L.), David Geffen School of Medicine, University of California, Los Angeles
| | - Gaultier Marnat
- From the Stroke Center and Department of Neurology (J.F., U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G.), and Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital and University of Bern; CTU Bern (L.B.), University of Bern, Switzerland; Department of Neurology (D.S.), Helsinki University Hospital, University of Helsinki, Finland; Department of Neuroradiology (O.F.E.), Hospices Civils de Lyon; Department of Diagnostic and Therapeutic Neuroradiology (J.-F.A.), Centre Hospitalier Universitaire de Toulouse; Department of Diagnostic and Interventional Neuroradiology (H.D.), Centre Hospitalier Universitaire de Nantes, Nantes Université; Interventional and Diagnostic Neuroradiology (G.M.), CHU Bordeaux, University of Bordeaux; Department of Radiology (C.P.), CHU Rouen; Stroke Unit (S.R.), Department of Neurology, CHRU-Nancy, Université de Lorraine, France; Stroke Unit (M.R.), Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain; Department of Stroke and Diagnostic and Interventional Neuroradiology (B.L.), Foch Hospital, Suresnes, France; Department of Neuroradiology (P.P.), CHU Reims, France; Department of Neuroradiology (M.E.), University Medical Center Goettingen; Department of Neuroradiology (M.W.), University Hospital RWTH Aachen, Germany; Department of Neurology (M.B.), CHU Caen Normandie, University Caen Normandie, INSERM U1237, France; and Department of Neurology and Comprehensive Stroke Center (D.S.L.), David Geffen School of Medicine, University of California, Los Angeles
| | - Chrysanthi Papagiannaki
- From the Stroke Center and Department of Neurology (J.F., U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G.), and Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital and University of Bern; CTU Bern (L.B.), University of Bern, Switzerland; Department of Neurology (D.S.), Helsinki University Hospital, University of Helsinki, Finland; Department of Neuroradiology (O.F.E.), Hospices Civils de Lyon; Department of Diagnostic and Therapeutic Neuroradiology (J.-F.A.), Centre Hospitalier Universitaire de Toulouse; Department of Diagnostic and Interventional Neuroradiology (H.D.), Centre Hospitalier Universitaire de Nantes, Nantes Université; Interventional and Diagnostic Neuroradiology (G.M.), CHU Bordeaux, University of Bordeaux; Department of Radiology (C.P.), CHU Rouen; Stroke Unit (S.R.), Department of Neurology, CHRU-Nancy, Université de Lorraine, France; Stroke Unit (M.R.), Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain; Department of Stroke and Diagnostic and Interventional Neuroradiology (B.L.), Foch Hospital, Suresnes, France; Department of Neuroradiology (P.P.), CHU Reims, France; Department of Neuroradiology (M.E.), University Medical Center Goettingen; Department of Neuroradiology (M.W.), University Hospital RWTH Aachen, Germany; Department of Neurology (M.B.), CHU Caen Normandie, University Caen Normandie, INSERM U1237, France; and Department of Neurology and Comprehensive Stroke Center (D.S.L.), David Geffen School of Medicine, University of California, Los Angeles
| | - Sebastien Richard
- From the Stroke Center and Department of Neurology (J.F., U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G.), and Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital and University of Bern; CTU Bern (L.B.), University of Bern, Switzerland; Department of Neurology (D.S.), Helsinki University Hospital, University of Helsinki, Finland; Department of Neuroradiology (O.F.E.), Hospices Civils de Lyon; Department of Diagnostic and Therapeutic Neuroradiology (J.-F.A.), Centre Hospitalier Universitaire de Toulouse; Department of Diagnostic and Interventional Neuroradiology (H.D.), Centre Hospitalier Universitaire de Nantes, Nantes Université; Interventional and Diagnostic Neuroradiology (G.M.), CHU Bordeaux, University of Bordeaux; Department of Radiology (C.P.), CHU Rouen; Stroke Unit (S.R.), Department of Neurology, CHRU-Nancy, Université de Lorraine, France; Stroke Unit (M.R.), Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain; Department of Stroke and Diagnostic and Interventional Neuroradiology (B.L.), Foch Hospital, Suresnes, France; Department of Neuroradiology (P.P.), CHU Reims, France; Department of Neuroradiology (M.E.), University Medical Center Goettingen; Department of Neuroradiology (M.W.), University Hospital RWTH Aachen, Germany; Department of Neurology (M.B.), CHU Caen Normandie, University Caen Normandie, INSERM U1237, France; and Department of Neurology and Comprehensive Stroke Center (D.S.L.), David Geffen School of Medicine, University of California, Los Angeles
| | - Manuel Requena
- From the Stroke Center and Department of Neurology (J.F., U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G.), and Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital and University of Bern; CTU Bern (L.B.), University of Bern, Switzerland; Department of Neurology (D.S.), Helsinki University Hospital, University of Helsinki, Finland; Department of Neuroradiology (O.F.E.), Hospices Civils de Lyon; Department of Diagnostic and Therapeutic Neuroradiology (J.-F.A.), Centre Hospitalier Universitaire de Toulouse; Department of Diagnostic and Interventional Neuroradiology (H.D.), Centre Hospitalier Universitaire de Nantes, Nantes Université; Interventional and Diagnostic Neuroradiology (G.M.), CHU Bordeaux, University of Bordeaux; Department of Radiology (C.P.), CHU Rouen; Stroke Unit (S.R.), Department of Neurology, CHRU-Nancy, Université de Lorraine, France; Stroke Unit (M.R.), Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain; Department of Stroke and Diagnostic and Interventional Neuroradiology (B.L.), Foch Hospital, Suresnes, France; Department of Neuroradiology (P.P.), CHU Reims, France; Department of Neuroradiology (M.E.), University Medical Center Goettingen; Department of Neuroradiology (M.W.), University Hospital RWTH Aachen, Germany; Department of Neurology (M.B.), CHU Caen Normandie, University Caen Normandie, INSERM U1237, France; and Department of Neurology and Comprehensive Stroke Center (D.S.L.), David Geffen School of Medicine, University of California, Los Angeles
| | - Bertrand Lapergue
- From the Stroke Center and Department of Neurology (J.F., U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G.), and Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital and University of Bern; CTU Bern (L.B.), University of Bern, Switzerland; Department of Neurology (D.S.), Helsinki University Hospital, University of Helsinki, Finland; Department of Neuroradiology (O.F.E.), Hospices Civils de Lyon; Department of Diagnostic and Therapeutic Neuroradiology (J.-F.A.), Centre Hospitalier Universitaire de Toulouse; Department of Diagnostic and Interventional Neuroradiology (H.D.), Centre Hospitalier Universitaire de Nantes, Nantes Université; Interventional and Diagnostic Neuroradiology (G.M.), CHU Bordeaux, University of Bordeaux; Department of Radiology (C.P.), CHU Rouen; Stroke Unit (S.R.), Department of Neurology, CHRU-Nancy, Université de Lorraine, France; Stroke Unit (M.R.), Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain; Department of Stroke and Diagnostic and Interventional Neuroradiology (B.L.), Foch Hospital, Suresnes, France; Department of Neuroradiology (P.P.), CHU Reims, France; Department of Neuroradiology (M.E.), University Medical Center Goettingen; Department of Neuroradiology (M.W.), University Hospital RWTH Aachen, Germany; Department of Neurology (M.B.), CHU Caen Normandie, University Caen Normandie, INSERM U1237, France; and Department of Neurology and Comprehensive Stroke Center (D.S.L.), David Geffen School of Medicine, University of California, Los Angeles
| | - Paolo Pagano
- From the Stroke Center and Department of Neurology (J.F., U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G.), and Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital and University of Bern; CTU Bern (L.B.), University of Bern, Switzerland; Department of Neurology (D.S.), Helsinki University Hospital, University of Helsinki, Finland; Department of Neuroradiology (O.F.E.), Hospices Civils de Lyon; Department of Diagnostic and Therapeutic Neuroradiology (J.-F.A.), Centre Hospitalier Universitaire de Toulouse; Department of Diagnostic and Interventional Neuroradiology (H.D.), Centre Hospitalier Universitaire de Nantes, Nantes Université; Interventional and Diagnostic Neuroradiology (G.M.), CHU Bordeaux, University of Bordeaux; Department of Radiology (C.P.), CHU Rouen; Stroke Unit (S.R.), Department of Neurology, CHRU-Nancy, Université de Lorraine, France; Stroke Unit (M.R.), Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain; Department of Stroke and Diagnostic and Interventional Neuroradiology (B.L.), Foch Hospital, Suresnes, France; Department of Neuroradiology (P.P.), CHU Reims, France; Department of Neuroradiology (M.E.), University Medical Center Goettingen; Department of Neuroradiology (M.W.), University Hospital RWTH Aachen, Germany; Department of Neurology (M.B.), CHU Caen Normandie, University Caen Normandie, INSERM U1237, France; and Department of Neurology and Comprehensive Stroke Center (D.S.L.), David Geffen School of Medicine, University of California, Los Angeles
| | - Marielle Ernst
- From the Stroke Center and Department of Neurology (J.F., U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G.), and Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital and University of Bern; CTU Bern (L.B.), University of Bern, Switzerland; Department of Neurology (D.S.), Helsinki University Hospital, University of Helsinki, Finland; Department of Neuroradiology (O.F.E.), Hospices Civils de Lyon; Department of Diagnostic and Therapeutic Neuroradiology (J.-F.A.), Centre Hospitalier Universitaire de Toulouse; Department of Diagnostic and Interventional Neuroradiology (H.D.), Centre Hospitalier Universitaire de Nantes, Nantes Université; Interventional and Diagnostic Neuroradiology (G.M.), CHU Bordeaux, University of Bordeaux; Department of Radiology (C.P.), CHU Rouen; Stroke Unit (S.R.), Department of Neurology, CHRU-Nancy, Université de Lorraine, France; Stroke Unit (M.R.), Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain; Department of Stroke and Diagnostic and Interventional Neuroradiology (B.L.), Foch Hospital, Suresnes, France; Department of Neuroradiology (P.P.), CHU Reims, France; Department of Neuroradiology (M.E.), University Medical Center Goettingen; Department of Neuroradiology (M.W.), University Hospital RWTH Aachen, Germany; Department of Neurology (M.B.), CHU Caen Normandie, University Caen Normandie, INSERM U1237, France; and Department of Neurology and Comprehensive Stroke Center (D.S.L.), David Geffen School of Medicine, University of California, Los Angeles
| | - Martin Wiesmann
- From the Stroke Center and Department of Neurology (J.F., U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G.), and Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital and University of Bern; CTU Bern (L.B.), University of Bern, Switzerland; Department of Neurology (D.S.), Helsinki University Hospital, University of Helsinki, Finland; Department of Neuroradiology (O.F.E.), Hospices Civils de Lyon; Department of Diagnostic and Therapeutic Neuroradiology (J.-F.A.), Centre Hospitalier Universitaire de Toulouse; Department of Diagnostic and Interventional Neuroradiology (H.D.), Centre Hospitalier Universitaire de Nantes, Nantes Université; Interventional and Diagnostic Neuroradiology (G.M.), CHU Bordeaux, University of Bordeaux; Department of Radiology (C.P.), CHU Rouen; Stroke Unit (S.R.), Department of Neurology, CHRU-Nancy, Université de Lorraine, France; Stroke Unit (M.R.), Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain; Department of Stroke and Diagnostic and Interventional Neuroradiology (B.L.), Foch Hospital, Suresnes, France; Department of Neuroradiology (P.P.), CHU Reims, France; Department of Neuroradiology (M.E.), University Medical Center Goettingen; Department of Neuroradiology (M.W.), University Hospital RWTH Aachen, Germany; Department of Neurology (M.B.), CHU Caen Normandie, University Caen Normandie, INSERM U1237, France; and Department of Neurology and Comprehensive Stroke Center (D.S.L.), David Geffen School of Medicine, University of California, Los Angeles
| | - Marion Boulanger
- From the Stroke Center and Department of Neurology (J.F., U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G.), and Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital and University of Bern; CTU Bern (L.B.), University of Bern, Switzerland; Department of Neurology (D.S.), Helsinki University Hospital, University of Helsinki, Finland; Department of Neuroradiology (O.F.E.), Hospices Civils de Lyon; Department of Diagnostic and Therapeutic Neuroradiology (J.-F.A.), Centre Hospitalier Universitaire de Toulouse; Department of Diagnostic and Interventional Neuroradiology (H.D.), Centre Hospitalier Universitaire de Nantes, Nantes Université; Interventional and Diagnostic Neuroradiology (G.M.), CHU Bordeaux, University of Bordeaux; Department of Radiology (C.P.), CHU Rouen; Stroke Unit (S.R.), Department of Neurology, CHRU-Nancy, Université de Lorraine, France; Stroke Unit (M.R.), Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain; Department of Stroke and Diagnostic and Interventional Neuroradiology (B.L.), Foch Hospital, Suresnes, France; Department of Neuroradiology (P.P.), CHU Reims, France; Department of Neuroradiology (M.E.), University Medical Center Goettingen; Department of Neuroradiology (M.W.), University Hospital RWTH Aachen, Germany; Department of Neurology (M.B.), CHU Caen Normandie, University Caen Normandie, INSERM U1237, France; and Department of Neurology and Comprehensive Stroke Center (D.S.L.), David Geffen School of Medicine, University of California, Los Angeles
| | - David S Liebeskind
- From the Stroke Center and Department of Neurology (J.F., U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G.), and Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital and University of Bern; CTU Bern (L.B.), University of Bern, Switzerland; Department of Neurology (D.S.), Helsinki University Hospital, University of Helsinki, Finland; Department of Neuroradiology (O.F.E.), Hospices Civils de Lyon; Department of Diagnostic and Therapeutic Neuroradiology (J.-F.A.), Centre Hospitalier Universitaire de Toulouse; Department of Diagnostic and Interventional Neuroradiology (H.D.), Centre Hospitalier Universitaire de Nantes, Nantes Université; Interventional and Diagnostic Neuroradiology (G.M.), CHU Bordeaux, University of Bordeaux; Department of Radiology (C.P.), CHU Rouen; Stroke Unit (S.R.), Department of Neurology, CHRU-Nancy, Université de Lorraine, France; Stroke Unit (M.R.), Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain; Department of Stroke and Diagnostic and Interventional Neuroradiology (B.L.), Foch Hospital, Suresnes, France; Department of Neuroradiology (P.P.), CHU Reims, France; Department of Neuroradiology (M.E.), University Medical Center Goettingen; Department of Neuroradiology (M.W.), University Hospital RWTH Aachen, Germany; Department of Neurology (M.B.), CHU Caen Normandie, University Caen Normandie, INSERM U1237, France; and Department of Neurology and Comprehensive Stroke Center (D.S.L.), David Geffen School of Medicine, University of California, Los Angeles
| | - Jan Gralla
- From the Stroke Center and Department of Neurology (J.F., U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G.), and Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital and University of Bern; CTU Bern (L.B.), University of Bern, Switzerland; Department of Neurology (D.S.), Helsinki University Hospital, University of Helsinki, Finland; Department of Neuroradiology (O.F.E.), Hospices Civils de Lyon; Department of Diagnostic and Therapeutic Neuroradiology (J.-F.A.), Centre Hospitalier Universitaire de Toulouse; Department of Diagnostic and Interventional Neuroradiology (H.D.), Centre Hospitalier Universitaire de Nantes, Nantes Université; Interventional and Diagnostic Neuroradiology (G.M.), CHU Bordeaux, University of Bordeaux; Department of Radiology (C.P.), CHU Rouen; Stroke Unit (S.R.), Department of Neurology, CHRU-Nancy, Université de Lorraine, France; Stroke Unit (M.R.), Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain; Department of Stroke and Diagnostic and Interventional Neuroradiology (B.L.), Foch Hospital, Suresnes, France; Department of Neuroradiology (P.P.), CHU Reims, France; Department of Neuroradiology (M.E.), University Medical Center Goettingen; Department of Neuroradiology (M.W.), University Hospital RWTH Aachen, Germany; Department of Neurology (M.B.), CHU Caen Normandie, University Caen Normandie, INSERM U1237, France; and Department of Neurology and Comprehensive Stroke Center (D.S.L.), David Geffen School of Medicine, University of California, Los Angeles
| | - Urs Fischer
- From the Stroke Center and Department of Neurology (J.F., U.F.), University Hospital Basel and University of Basel; University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G.), and Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital and University of Bern; CTU Bern (L.B.), University of Bern, Switzerland; Department of Neurology (D.S.), Helsinki University Hospital, University of Helsinki, Finland; Department of Neuroradiology (O.F.E.), Hospices Civils de Lyon; Department of Diagnostic and Therapeutic Neuroradiology (J.-F.A.), Centre Hospitalier Universitaire de Toulouse; Department of Diagnostic and Interventional Neuroradiology (H.D.), Centre Hospitalier Universitaire de Nantes, Nantes Université; Interventional and Diagnostic Neuroradiology (G.M.), CHU Bordeaux, University of Bordeaux; Department of Radiology (C.P.), CHU Rouen; Stroke Unit (S.R.), Department of Neurology, CHRU-Nancy, Université de Lorraine, France; Stroke Unit (M.R.), Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain; Department of Stroke and Diagnostic and Interventional Neuroradiology (B.L.), Foch Hospital, Suresnes, France; Department of Neuroradiology (P.P.), CHU Reims, France; Department of Neuroradiology (M.E.), University Medical Center Goettingen; Department of Neuroradiology (M.W.), University Hospital RWTH Aachen, Germany; Department of Neurology (M.B.), CHU Caen Normandie, University Caen Normandie, INSERM U1237, France; and Department of Neurology and Comprehensive Stroke Center (D.S.L.), David Geffen School of Medicine, University of California, Los Angeles
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Sun A, Cao Y, Jia Z, Zhao L, Shi H, Liu S. Prognostic value of CBV index in patients with acute ischemic stroke treated with endovascular thrombectomy in late therapeutic window. Front Neurol 2024; 14:1282159. [PMID: 38259642 PMCID: PMC10800525 DOI: 10.3389/fneur.2023.1282159] [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: 08/23/2023] [Accepted: 12/18/2023] [Indexed: 01/24/2024] Open
Abstract
Purpose To evaluate the prognostic value of the cerebral blood volume (CBV) index for 90-day functional outcomes in patients with acute ischemic stroke (AIS) treated within a late therapeutic window. Methods We retrospectively reviewed patients who underwent pre-treatment computed tomography perfusion (CTP) and endovascular thrombectomy (EVT) for large-vessel occlusion (LVO) of the anterior circulation within the late therapeutic window between January 2021 and February 2023. Clinical data, the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) based on unenhanced computed tomography (CT), and perfusion parameters, including ischemic core, hypoperfusion volume, mismatch volume between the core and penumbra, and CBV index, were assessed and compared between patients who achieved favorable outcomes (defined as a modified Rankin Scale score of 0-2). Results Of the 118 patients, 56 (47.5%) had favorable outcomes. In the univariate analysis, age, National Institutes of Health Stroke Scale (NIHSS) score at admission, ASPECTS score, CBV index, and ischemic core volume were significantly associated with functional outcomes (P < 0.05). In multivariate analyses, age (odds ratio [OR], 1.060; 95% confidence interval [CI] 1.013-1.110, P = 0.012), NIHSS score at admission (OR, 1.126; 95% CI 1.031-1.229, P = 0.009), and CBV index (OR, 0.001; 95% CI 0.000-0.240, P = 0.014) were independent predictors of a 90-day favorable outcome. Conclusion A high CBV index was independently associated with favorable outcomes in patients who underwent mechanical thrombectomy within the late therapeutic window. In addition, a higher CBV index reflects improved blood flow and favorable digital subtraction angiography collateral status.
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Affiliation(s)
| | | | | | | | | | - Sheng Liu
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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30
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Sun D, Guo X, Nguyen TN, Pan Y, Ma G, Tong X, Raynald, Wang M, Ma N, Gao F, Mo D, Huo X, Miao Z. Alberta Stroke Program Early Computed Tomography Score, Infarct Core Volume, and Endovascular Therapy Outcomes in Patients With Large Infarct: A Secondary Analysis of the ANGEL-ASPECT Trial. JAMA Neurol 2024; 81:30-38. [PMID: 38010691 PMCID: PMC10682939 DOI: 10.1001/jamaneurol.2023.4430] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/28/2023] [Indexed: 11/29/2023]
Abstract
Importance Endovascular therapy (EVT) demonstrated better outcomes compared with medical management in recent randomized clinical trials (RCTs) of patients with large infarct. Objective To compare outcomes of EVT vs medical management across different strata of the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) and infarct core volume in patients with large infarct. Design, Setting, and Participants This prespecified secondary analysis of subgroups of the Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients With a Large Infarct Core (ANGEL-ASPECT) RCT included patients from 46 stroke centers across China between October 2, 2020, and May 18, 2022. Participants were enrolled within 24 hours of symptom onset and had ASPECTS of 3 to 5 or 0 to 2 and infarct core volume of 70 to 100 mL. Patients were divided into 3 groups: ASPECTS of 3 to 5 with infarct core volume less than 70 mL, ASPECTS of 3 to 5 with infarct core volume of 70 mL or greater, and ASPECTS of 0 to 2. Interventions Endovascular therapy or medical management. Main Outcomes and Measures The primary outcome was the ordinal 90-day modified Rankin Scale (mRS) score. Results There were 455 patients in the trial; median age was 68 years (IQR, 60-73 years), and 279 (61.3%) were male. The treatment effect did not vary significantly across the 3 baseline imaging subgroups (P = .95 for interaction). The generalized odds ratio for the shift in the 90-day mRS distribution toward better outcomes with EVT vs medical management was 1.40 (95% CI, 1.06-1.85; P = .01) in patients with ASPECTS of 3 to 5 and infarct core volume less than 70 mL, 1.22 (95% CI, 0.81-1.83; P = .23) in patients with ASPECTS of 3 to 5 and infarct core volume of 70 mL or greater, and 1.59 (95% CI, 0.89-2.86; P = .09) in patients with ASPECTS of 0 to 2. Conclusions and Relevance In this study, no significant interaction was found between baseline imaging status and the benefit of EVT compared with medical management in patients with large infarct core volume. However, estimates within subgroups were underpowered. A pooled analysis of large core trials stratified by ASPECTS and infarct core volume strata is warranted. Trial Registration ClinicalTrials.gov Identifier: NCT04551664.
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Affiliation(s)
- Dapeng Sun
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Guo
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Thanh N. Nguyen
- Department of Neurology, Radiology, Boston Medical Center, Boston, Massachusetts
| | - Yuesong Pan
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gaoting Ma
- Department of Neurology, Beijing Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Raynald
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mengxing Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Radiology, Boston Medical Center, Boston, Massachusetts
| | - Dapeng Mo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Radiology, Boston Medical Center, Boston, Massachusetts
| | - Xiaochuan Huo
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Broocks G, Meyer L, Bechstein M, Elsayed S, Schön G, Kniep H, Kemmling A, Hanning U, Fiehler J, McDonough RV. Penumbra salvage in extensive stroke: exploring limits for reperfusion therapy. J Neurointerv Surg 2023; 15:e419-e425. [PMID: 36878689 DOI: 10.1136/jnis-2022-020025] [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: 12/22/2022] [Accepted: 02/17/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND The effect of thrombectomy in patients presenting with extensive ischemic stroke at baseline is currently being investigated; it remains uncertain to what extent brain tissue may be saved by reperfusion in such patients. Penumbra salvage volume (PSV) has been described as a tool to measure the volume of rescued penumbra. OBJECTIVE To assess whether the effect of recanalization on PSV is dependent on the extent of early ischemic changes. METHODS Observational study of patients with anterior circulation ischemic stroke triaged by multimodal-CT undergoing thrombectomy. PSV was defined as the difference between baseline penumbra volume and net infarct growth to follow-up. The effect of vessel recanalization on PSV depending on the extent of early ischemic changes (defined using Alberta Stroke Program Early CT Score (ASPECTS) and core volumes based on relative cerebral blood flow) was determined using multivariable linear regression analysis, and the association with functional outcome at day 90 was tested using multivariable logistic regression. RESULTS 384 patients were included, of whom 292 (76%) achieved successful recanalization (modified Thrombolysis in Cerebral Infarction ≥2b). Successful recanalization was independently associated with 59 mL PSV (95% CI 29.8 to 88.8 mL) and was linked to increased penumbra salvage up to an ASPECTS of 3 and core volume up to 110 mL. Recanalization was associated with a higher probability of a modified Rankin Scale score of ≤2 up to a core volume of 100 mL. CONCLUSIONS Recanalization was associated with significant penumbra salvage up to a lower ASPECTS margin of 3 and upper core volume margin of 110 mL. The clinical benefit of recanalization for patients with very large ischemic regions of >100 mL or ASPECTS <3 remains uncertain and requires prospective investigation.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Elsayed
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie V McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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Dong Z, Deng S, Zhang J, Chen S, Ye Z, Zhang L, Hu R, Zhong C, Liu X, Qin C. Simplified stroke imaging selection modality for endovascular thrombectomy in the extended time window: systematic review and meta-analysis. J Neurointerv Surg 2023; 16:101-106. [PMID: 36597953 PMCID: PMC10803987 DOI: 10.1136/jnis-2022-019556] [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: 08/20/2022] [Accepted: 11/16/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The impact of imaging selection modality on clinical outcomes of endovascular thrombectomy (EVT) in the 6-24-hour time window remains undetermined. We compared the clinical outcomes of a simplified stroke imaging selection modality using non-contrast computed tomography (NCCT)±CT angiography (CTA) with using advanced CT perfusion (CTP). METHODS PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials were searched from inception to 1 May 2022 to compare NCCT±CTA and CTP for patient selection for EVT in late-presenting stroke with large vessel occlusions (LVO). The primary outcome was the proportion of patients achieving functional independence (modified Rankin Scale score 0-2) within 180 days. The secondary outcomes included mortality within 90 days, successful recanalization, and any intracranial hemorrhage. RESULTS A total of 3419 patients in six articles were included in this meta-analysis. There was no significant difference between NCCT±CTA (no-CTP) and CTP in functional independence either in overall or subgroup analysis. However, the mortality in the no-CTP group was higher than in the CTP group. Furthermore, within the DAWN/DEFUSE 3-like subgroup, there were no significant differences in mortality, successful recanalization, and any intracranial hemorrhage between the two groups. CONCLUSION There was no significant difference between the simplified NCCT±CTA modality and the advanced CTP modality. The use of NCCT±CTA may represent a reasonable option for selecting patients for EVT in the extended time window, especially in the absence of CTP and acute phase MRI capabilities.
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Affiliation(s)
- Zimei Dong
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
- Department of Neurology, People's Hospital of Chuxiong Yi Autonomous Prefecture, Chuxiong, Yunnan, China
| | - Shan Deng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
- Department of Neurology, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi, China
| | - Jian Zhang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Shijian Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Ziming Ye
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Limei Zhang
- Department of Cardiology, People's Hospital of Chuxiong Yi Autonomous Prefecture, Chuxiong, Yunnan, China
| | - Ruiting Hu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Cai Zhong
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Xiuying Liu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Chao Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
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Lim GZ, Lai JY, Seet CYH, Tham CH, Venketasubramanian N, Tan BYQ, Jing M, Yeo JYP, Myint MZ, Sia CH, Teoh HL, Sharma VK, Chan BPL, Yang C, Makmur A, Ong SJ, Yeo LLL. Revolutionizing the Management of Large-Core Ischaemic Strokes: Decoding the Success of Endovascular Therapy in the Recent Stroke Trials. J Cardiovasc Dev Dis 2023; 10:499. [PMID: 38132666 PMCID: PMC10743836 DOI: 10.3390/jcdd10120499] [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: 11/10/2023] [Revised: 12/02/2023] [Accepted: 12/15/2023] [Indexed: 12/23/2023] Open
Abstract
Endovascular therapy (EVT) has revolutionized the management of acute ischaemic strokes with large vessel occlusion, with emerging evidence suggesting its benefit also in large infarct core volume strokes. In the last two years, four randomised controlled trials have been published on this topic-RESCUE-Japan LIMIT, ANGEL-ASPECT, SELECT2 and TENSION, with overall results showing that EVT improves functional and neurological outcomes compared to medical management alone. This review aims to summarise the recent evidence presented by these four trials and highlight some of the limitations in our current understanding of this topic.
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Affiliation(s)
- Gareth Zigui Lim
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Jonathan Yexian Lai
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Christopher Ying Hao Seet
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Carol Huilian Tham
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | | | - Benjamin Yong Qiang Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Mingxue Jing
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Joshua Yee Peng Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - May Zin Myint
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
- Department of Cardiology, National University Heart Center, Singapore 119228, Singapore
| | - Hock Luen Teoh
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Vijay Kumar Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Bernard Poon Lap Chan
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Cunli Yang
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Department of Diagnostic Imaging, National University Health System, Singapore 119228, Singapore
| | - Andrew Makmur
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Department of Diagnostic Imaging, National University Health System, Singapore 119228, Singapore
| | - Shao Jin Ong
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Department of Diagnostic Imaging, National University Health System, Singapore 119228, Singapore
| | - Leonard Leong Litt Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Department of Diagnostic Imaging, National University Health System, Singapore 119228, Singapore
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Fainardi E, Busto G, Morotti A. Automated advanced imaging in acute ischemic stroke. Certainties and uncertainties. Eur J Radiol Open 2023; 11:100524. [PMID: 37771657 PMCID: PMC10523426 DOI: 10.1016/j.ejro.2023.100524] [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: 05/30/2023] [Revised: 09/12/2023] [Accepted: 09/13/2023] [Indexed: 09/30/2023] Open
Abstract
The purpose of this is study was to review pearls and pitfalls of advanced imaging, such as computed tomography perfusion and diffusion-weighed imaging and perfusion-weighted imaging in the selection of acute ischemic stroke (AIS) patients suitable for endovascular treatment (EVT) in the late time window (6-24 h from symptom onset). Advanced imaging can quantify infarct core and ischemic penumbra using specific threshold values and provides optimal selection parameters, collectively called target mismatch. More precisely, target mismatch criteria consist of core volume and/or penumbra volume and mismatch ratio (the ratio between total hypoperfusion and core volumes) with precise cut-off values. The parameters of target mismatch are automatically calculated with dedicated software packages that allow a quick and standardized interpretation of advanced imaging. However, this approach has several limitations leading to a misclassification of core and penumbra volumes. In fact, automatic software platforms are affected by technical artifacts and are not interchangeable due to a remarkable vendor-dependent variability, resulting in different estimate of target mismatch parameters. In addition, advanced imaging is not completely accurate in detecting infarct core, that can be under- or overestimated. Finally, the selection of candidates for EVT remains currently suboptimal due to the high rates of futile reperfusion and overselection caused by the use of very stringent inclusion criteria. For these reasons, some investigators recently proposed to replace advanced with conventional imaging in the selection for EVT, after the demonstration that non-contrast CT ASPECTS and computed tomography angiography collateral evaluation are not inferior to advanced images in predicting outcome in AIS patients treated with EVT. However, other authors confirmed that CTP and PWI/DWI postprocessed images are superior to conventional imaging in establishing the eligibility of patients for EVT. Therefore, the routine application of automatic assessment of advanced imaging remains a matter of debate. Recent findings suggest that the combination of conventional and advanced imaging might improving our selection criteria.
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Affiliation(s)
- Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Italy
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Giorgio Busto
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Andrea Morotti
- Department of Neurological and Vision Sciences, Neurology Unit, ASST Spedali Civili, Brescia, Italy
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Capirossi C, Laiso A, Renieri L, Capasso F, Limbucci N. Epidemiology, organization, diagnosis and treatment of acute ischemic stroke. Eur J Radiol Open 2023; 11:100527. [PMID: 37860148 PMCID: PMC10582298 DOI: 10.1016/j.ejro.2023.100527] [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: 06/17/2023] [Revised: 09/25/2023] [Accepted: 09/30/2023] [Indexed: 10/21/2023] Open
Abstract
The management of acute ischemic stroke is changing. Over the period of 2010-2050, the number of incident strokes is expected to be more than double. Rapid access to mechanical thrombectomy for patients with large vessel occlusion is critically associated with their functional outcome. Moreover, patients with first pass effect had a better clinical outcome, lower mortality, and fewer procedural adverse events. We discuss some advances in acute ischemic stroke regarding the organization, the diagnosis and the treatment.
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Affiliation(s)
- Carolina Capirossi
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Antonio Laiso
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Leonardo Renieri
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Francesco Capasso
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Nicola Limbucci
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
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Michelard M, Detante O, Heck O, Marcel S, Vadot W, Gavazzi G, Papassin J. Thrombolysis and thrombectomy for stroke in octogenarians and nonagenarians: A regional observational study. Rev Neurol (Paris) 2023; 179:1068-1073. [PMID: 37596186 DOI: 10.1016/j.neurol.2023.03.023] [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: 10/12/2022] [Revised: 02/24/2023] [Accepted: 03/01/2023] [Indexed: 08/20/2023]
Abstract
INTRODUCTION Elderly patients are a growing population in stroke units, characterized by higher frailty, but underrepresented in clinical trials about acute care. We investigated efficacy of intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) in elderlies in current practice. METHODS We assessed consecutive patients with acute ischemic stroke (AIS) hospitalized in the four stroke units of the French Northern Alps Emergency Network between 2015 and 2020. We compared baseline characteristics, early neurological evolution and outcome of patients aged 80-89 and≥90years old (yo). RESULTS Among 8367 patients, 2744 (32.8%) were 80-89 yo and 541 (6.5%) were≥90 yo. IVT and/or MT were performed in 787 patients≥80 yo (632 patients aged 80-89, 155 patients aged>90). Early neurological improvement was more frequent in patients≥80 yo treated by IVT and/or MT compared to untreated patients (45.6% versus 38.4%, P=0.002). After adjustment, reperfusion treatments improved likelihood of good outcome at discharge (OR=2.0 [1.6-2.7]) and reduced in-hospital mortality (OR=0.5 [0.4-0.7]). Age and initial NIHSS score were independent factors of poor functional outcome at discharge and in-hospital mortality. The rate of successful recanalization was comparable between octogenarians and nonagenarians (87% versus 85.2%, P=0.8). Octogenarians had better functional outcome at discharge compared to nonagenarians [modified Rankin scale (mRS) 0-2: 36% versus 25.7%, P=0.02], whatever IVT or MT strategy. In-hospital mortality was lower for octogenarians compared to nonagenarians (19.5% versus 27.1%, P=0.04). DISCUSSION IVT and MT improve early neurological recovery and functional outcome at discharge of both octogenarians and nonagenarians in current practice. Despite a poorer outcome for nonagenarians than octogenarians, these reperfusion treatments should not be withheld on the basis of age only.
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Affiliation(s)
- M Michelard
- Medical intensive care unit, Grenoble Alpes University Hospital, Grenoble, France
| | - O Detante
- Stroke unit, Grenoble Alpes University Hospital, Grenoble, France; Université Grenoble Alpes, Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences, 38000 Grenoble, France
| | - O Heck
- Neuroradiology, Grenoble Alpes University Hospital, Grenoble, France
| | - S Marcel
- Stroke unit, Métropole Savoie Hospital, 73000 Chambéry, France
| | - W Vadot
- Stroke unit, Annecy-Genevois Hospital, Annecy, France
| | - G Gavazzi
- Geriatric department, Grenoble Alpes University Hospital, Grenoble, France
| | - J Papassin
- Stroke unit, Métropole Savoie Hospital, 73000 Chambéry, France.
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Wei W, Zhang J, Xie S, Fan D, Chen Y, Zhong C, Chen L, Zhang Y, Shi S. Endovascular therapy versus medical management for acute ischemic stroke with large infarct core: Systematic review and meta-analysis of randomized controlled trials. Clin Neurol Neurosurg 2023; 234:108007. [PMID: 37797364 DOI: 10.1016/j.clineuro.2023.108007] [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: 07/08/2023] [Accepted: 09/29/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE To compare the efficacy and safety of endovascular therapy (EVT) versus best medical management (BMM) in patients with acute ischemic stroke (AIS) with large infarct core. METHODS We searched Pubmed, Embase and Cochrane Central Register of Controlled Trials for published randomized clinical trials (RCTs) from inception to February 18, 2023. We defined patients with large core infarcts as having an Alberta Stroke Program early computed tomography score (ASPECTS) of 3-5. The primary outcome was functional independence, defined as a score of 0-2 on the modified Rankin scale (mRS) at 90 days. Secondary outcome was independent ambulation defined as mRS 0-3 at 90 days. Safety outcomes were mortality at 90 days, symptomatic intracranial hemorrhage (sICH) and any intracranial hemorrhage (ICH). RESULTS The overall treatment effect was more favourable to EVT group. EVT was significantly correlated with improvement of functional independence at 90 days (mRS 0-2) (RR = 2.40; 95 % CI, 1.82-3.16; P < 0.01; I2 = 0 %) and independent ambulation (mRS 0-3) (RR = 1,78; 95 % CI, 1.28-2.48; P < 0.01; I2 = 58 %) at 90 days. 90-day mortality was not significantly different between the two groups(RR = 0.95; 95 % CI, 0.78-1.16; P > 0.05; I2 = 0 %). The risk of sICH and any ICH was higher in EVT group than in BMM group. CONCLUSION Compared with BMM, EVT may improve functional outcomes in patients with ASPECTS 3-5, despite being associated with an increased risk of sICH and any ICH.
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Affiliation(s)
- Wenqian Wei
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, No. 166 Daxuedong Road, Nanning, Guangxi 530007, China
| | - Jian Zhang
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, No. 166 Daxuedong Road, Nanning, Guangxi 530007, China
| | - Shuyu Xie
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, No. 166 Daxuedong Road, Nanning, Guangxi 530007, China
| | - Dongmei Fan
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, No. 166 Daxuedong Road, Nanning, Guangxi 530007, China
| | - Yiyun Chen
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, No. 166 Daxuedong Road, Nanning, Guangxi 530007, China
| | - Chongxu Zhong
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, No. 166 Daxuedong Road, Nanning, Guangxi 530007, China
| | - Liufei Chen
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, No. 166 Daxuedong Road, Nanning, Guangxi 530007, China
| | - Yueling Zhang
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, No. 166 Daxuedong Road, Nanning, Guangxi 530007, China.
| | - Shengliang Shi
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, No. 166 Daxuedong Road, Nanning, Guangxi 530007, China.
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Bai X, Zhang Y, Sui Y. Noncontrast versus perfusion CT to select endovascular therapy in an extended time window: Systematic review/meta-analysis. J Neuroimaging 2023; 33:889-897. [PMID: 37676117 DOI: 10.1111/jon.13152] [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: 04/24/2023] [Revised: 08/06/2023] [Accepted: 08/25/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND AND PURPOSE The effect of noncontrast CT (NCCT) on the eligibility for endovascular therapy (EVT) in an extended time window remains to be elucidated. We sought to assess the efficacy and safety of NCCT in comparison with CT perfusion (CTP) in selecting patients with acute ischemic stroke (AIS) for EVT 6-24 hours after onset. METHODS PubMed, Embase, and Cochrane libraries were searched from inception to August 31, 2022, to identify all studies reporting 90-day outcomes of EVT in patients with AIS in an extended time window. A meta-analysis was performed for the pooled risk ratio (RR) with 95% confidence interval (CI) using a random-effects model. The primary outcome used to assess efficacy was good functional independence, defined as a modified Rankin Scale score of 0-2 at 90 days. Secondary outcomes included successful reperfusion, symptomatic intracranial hemorrhage (sICH), and mortality at 90 days. RESULTS We included four nonrandomized studies with a total of 2685 patients. The outcomes of good functional independence at 90 days (RR = 0.98; 95% CI: 0.88-1.07; I2 = 0%; p = .62), successful reperfusion (RR = 0.98; 95% CI: 0.93-1.03; I2 = 50.5%; p = .11), sICH (RR = 1.11; 95% CI: 0.55-2.21; I2 = 49.4%; p = .12), or mortality at 90 days (RR = 1.18; 95% CI: 0.99-1.40; I2 = 0%; p = .42) did not differ significantly between the two groups. CONCLUSIONS These findings suggest that NCCT is as effective as CTP in selecting patients for EVT in an extended time window.
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Affiliation(s)
- Xue Bai
- School of Public Health, China Medical University, Shenyang, China
| | - Yao Zhang
- Department of Neurology, Shenyang First People's Hospital, Shenyang Medical College Affiliated Brain Hospital, Shenyang, China
| | - Yi Sui
- School of Public Health, China Medical University, Shenyang, China
- Department of Neurology, Shenyang First People's Hospital, Shenyang Medical College Affiliated Brain Hospital, Shenyang, China
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
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Gao J, Jing Z, Huang S, Yang J, Guan M, Zhang S, Li H, Li Y, Lu K, Yang M, Huang L. Comparison of clinical outcomes in patients with acute ischemic stroke who underwent endovascular treatment using different perfusion modalities: a real-world multicenter study. Front Neurol 2023; 14:1275715. [PMID: 37954641 PMCID: PMC10634531 DOI: 10.3389/fneur.2023.1275715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 09/28/2023] [Indexed: 11/14/2023] Open
Abstract
Background Advanced perfusion modalities are increasingly popular for various diseases. However, few studies have focused on contrasting perfusion patterns. Objective This study aimed to compare the time efficiency and clinical outcomes of patients with acute ischemic stroke (AIS) who underwent endovascular treatment (EVT) before one-stop arterial spin labeling (ASL) and computed tomography perfusion (CTP) protocols. Methods This study retrospectively included 326 patients with AIS who had accepted EVT within 24 h of onset from four comprehensive stroke centers between October 2017 and September 2022. After 1:1 matching of the propensity scores, 202 patients were separated into two groups: the ASL group (n = 101) and the CTP group (n = 101). Results Functional independence at 90 days (modified Rankin Scale [mRS] 0-2; p = 0.574), onset-to-puncture time (p = 0.231), door-to-puncture time (p = 0.136), and door-to-perfusion time (p = 0.646) were not significantly different between the two groups. The proportion of EVT complications (31.7% in the ASL group vs. 14.9% in the CTP group, p = 0.005) and symptomatic intracranial hemorrhage (sICH) at 24 h (23.8% in the ASL group vs. 9.9% in the CTP group, p = 0.008) in the CTP group were lower than the ASL group. The ischemic core volume was a common predictor of favorable outcomes in both ASL (p < 0.001) and CTP (p < 0.001) groups. Conclusion There were no significant differences in time efficiency and efficacy outcomes between the two groups of patients receiving one-stop ASL and CTP. The proportion of sICH at 24 h and EVT complications of patients in the CTP group was lower than the ASL group. The ischemic core volume was an independent predictor for favorable outcomes.
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Affiliation(s)
- Jiali Gao
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Zhen Jing
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Shengming Huang
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jiajie Yang
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Min Guan
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Shijun Zhang
- Department of Neurology, The Fourth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Hao Li
- Department of Neurology, Maoming People’s Hospital, Maoming, China
| | - Yongxin Li
- Department of Neurology, Shunde Hospital of Southern Medical University, Foshan, China
| | - Kui Lu
- Department of Neurology, Zhongshan People’s Hospital, Zhongshan, China
| | - Ming Yang
- Neuroblem Limited Company, Shanghai, China
| | - Li’an Huang
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
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Thirugnanachandran T, Aitchison SG, Lim A, Ding C, Ma H, Phan T. Assessing the diagnostic accuracy of CT perfusion: a systematic review. Front Neurol 2023; 14:1255526. [PMID: 37885475 PMCID: PMC10598661 DOI: 10.3389/fneur.2023.1255526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 09/15/2023] [Indexed: 10/28/2023] Open
Abstract
Background and purpose Computed tomography perfusion (CTP) has successfully extended the time window for reperfusion therapies in ischemic stroke. However, the published perfusion parameters and thresholds vary between studies. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy Studies (PRISMA-DTA) guidelines, we conducted a systematic review to investigate the accuracy of parameters and thresholds for identifying core and penumbra in adult stroke patients. Methods We searched Medline, Embase, the Cochrane Library, and reference lists of manuscripts up to April 2022 using the following terms "computed tomography perfusion," "stroke," "infarct," and "penumbra." Studies were included if they reported perfusion thresholds and undertook co-registration of CTP to reference standards. The quality of studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool and Standards for Reporting of Diagnostic Accuracy (STARD) guidelines. Results A total of 24 studies were included. A meta-analysis could not be performed due to insufficient data and significant heterogeneity in the study design. When reported, the mean age was 70.2 years (SD+/-3.69), and the median NIHSS on admission was 15 (IQR 13-17). The perfusion parameter identified for the core was relative cerebral blood flow (rCBF), with a median threshold of <30% (IQR 30, 40%). However, later studies reported lower thresholds in the early time window with rapid reperfusion (median 25%, IQR 20, 30%). A total of 15 studies defined a single threshold for all brain regions irrespective of collaterals and the gray and white matter. Conclusion A single threshold and parameter may not always accurately differentiate penumbra from core and oligemia. Further refinement of parameters is needed in the current era of reperfusion therapy.
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Affiliation(s)
| | | | | | | | | | - Thanh Phan
- Stroke and Ageing Research (STAR), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
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Ballout AA. Endovascular thrombectomy of large ischemic strokes: Reimagining the boundaries of reperfusion. Interv Neuroradiol 2023; 29:493-497. [PMID: 37069819 PMCID: PMC10549720 DOI: 10.1177/15910199231170283] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/29/2023] [Indexed: 04/19/2023] Open
Abstract
The cumulative results of the SELECT-2, ANGEL-ASPECTS, and RESCUE-JAPAN LIMIT clinical trials suggest that endovascular thrombectomy performed within 24 h of symptom onset, in patients presenting with large ischemic strokes, defined by parenchymal and/or perfusion imaging, is safe and is associated with better functional outcomes with a treatment effect that persisted across all subgroups of patients. Our aim was to review these studies and to discuss the implications that these studies may have on patient selection, systems of care, and the utility of our imaging modalities.
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Affiliation(s)
- Ahmad A Ballout
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
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Choi S, Lee E, Lee SB, Won Y, Lee SB, Kim YW, Kim CI, Sheen JJ. Usefulness of additional diffusion MRI acquisition prior to mechanical thrombectomy for acute large vessel occlusion in the early time period at a CT-based stroke center. Clin Neurol Neurosurg 2023; 233:107901. [PMID: 37531750 DOI: 10.1016/j.clineuro.2023.107901] [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: 03/26/2023] [Revised: 06/19/2023] [Accepted: 07/15/2023] [Indexed: 08/04/2023]
Abstract
OBJECTIVE This study aimed to investigate whether evaluating the infarction core using additionally acquired diffusion magnetic resonance imaging (MRI) could help improve the assessment of prognosis including complication rates and modify the strategy for mechanical thrombectomy in endovascular procedures at a computed tomography (CT)-based stroke center. METHODS Single-center data from patients with acute large-vessel occlusion in the anterior circulation who underwent mechanical thrombectomy between May 2018 and January 2021 were analyzed. Diffusion MRI sequences were performed during the preparation period for mechanical thrombectomy after CT angiography. We set the infarction core reference volume on diffusion MRI to 60 cc and divided the patients into two groups: a small infarction core group (less than 60 cc) and a large infarction core group (more than 60 cc). The baseline characteristics, radiological and clinical outcomes of the patients were investigated and compared between the two groups. RESULTS The difference in numbers between the two groups was not significant in the Alberta Stroke Program Early Computed Tomography (ASPECT) score; however, the ASPECT score on diffusion MRI showed a remarkable difference between the two groups. The large infarction core volume group on diffusion MRI had a poor prognosis, with the modified Rankin score at 90 days showing a statistically significant difference (p = 0.011). Complications after the procedure, such as hemorrhagic transformation, that can occur after reperfusion, symptomatic intracerebral hemorrhage, decompressive craniectomy for increased intracranial pressure, and mortality, were significantly more frequent in the large infarction core volume group. CONCLUSION At a CT-based stroke center, additionally acquired diffusion MRI without a time delay for reperfusion would improve the assessment of prognosis including complication rate, and could help neurointerventionists determine the extent of recanalization of occluded vessels during mechanical thrombectomy.
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Affiliation(s)
- Sunghoon Choi
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eunhye Lee
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Si Baek Lee
- Department of Neurology, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yoodong Won
- Department of Radiology, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Bok Lee
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Woo Kim
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chong-In Kim
- Department of Neurosurgery, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Jae Jon Sheen
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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43
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Krawchuk LJ, Sharrock MF. Prognostic Neuroimaging Biomarkers in Acute Vascular Brain Injury and Traumatic Brain Injury. Semin Neurol 2023; 43:699-711. [PMID: 37802120 DOI: 10.1055/s-0043-1775790] [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: 10/08/2023]
Abstract
Prognostic imaging biomarkers after acute brain injury inform treatment decisions, track the progression of intracranial injury, and can be used in shared decision-making processes with families. Herein, key established biomarkers and prognostic scoring systems are surveyed in the literature, and their applications in clinical practice and clinical trials are discussed. Biomarkers in acute ischemic stroke include computed tomography (CT) hypodensity scoring, diffusion-weighted lesion volume, and core infarct size on perfusion imaging. Intracerebral hemorrhage biomarkers include hemorrhage volume, expansion, and location. Aneurysmal subarachnoid biomarkers include hemorrhage grading, presence of diffusion-restricting lesions, and acute hydrocephalus. Traumatic brain injury CT scoring systems, contusion expansion, and diffuse axonal injury grading are reviewed. Emerging biomarkers including white matter disease scoring, diffusion tensor imaging, and the automated calculation of scoring systems and volumetrics are discussed.
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Affiliation(s)
- Lindsey J Krawchuk
- Department of Neurology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Matthew F Sharrock
- Department of Neurology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Tan D, Liu J, Chen S, Yao R, Li Y, Zhu S, Li L. Automatic Evaluating of Multi-Phase Cranial CTA Collateral Circulation Based on Feature Fusion Attention Network Model. IEEE Trans Nanobioscience 2023; 22:789-799. [PMID: 37276106 DOI: 10.1109/tnb.2023.3283049] [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: 06/07/2023]
Abstract
Stroke is one of the main causes of disability and death, and it can be divided into hemorrhagic stroke and ischemic stroke. Ischemic stroke is more common, and about 8 out of 10 stroke patients suffer from ischemic stroke. In clinical practice, doctors diagnose stroke by using computed tomography angiography (CTA) image to accurately evaluate the collateral circulation in stroke patients. This imaging information is of great significance in assisting doctors to determine the patient's treatment plan and prognosis. Currently, great progress has been made in the field of computer-aided diagnosis technology in medicine by using artificial intelligence. However, in related research based on deep learning algorithms, researchers usually only use single-phase data for training, lacking the temporal dimension information of multi-phase image data. This makes it difficult for the model to learn more comprehensive and effective collateral circulation feature representation, thereby limiting its performance. Therefore, combining data for training is expected to improve the accuracy and reliability of collateral circulation evaluation. In this study, we propose an effective hybrid mechanism to assist the feature encoding network in evaluating the degree of collateral circulation in the brain. By using a hybrid attention mechanism, additional guidance and regularization are provided to enhance the collateral circulation feature representation across multiple stages. Time dimension information is added to the input, and multiple feature-level fusion modules are designed in the multi-branch network. The first fusion module in the single-stage feature extraction network completes the fusion of deep and shallow vessel features in the single-branch network, followed by the multi-stage network feature fusion module, which achieves feature fusion for four stages. Tested on a dataset of multi-phase cranial CTA images, the accuracy rate exceeding 90.43%. The experimental results demonstrate that the addition of these modules can fully explore collateral vessel features, improve feature expression capabilities, and optimize the performance of deep learning network model.
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Subramaniam JC, Cheung A, Manning N, Whitley J, Cordato D, Zagami A, Cappelen-Smith C, Tian H, Levi C, Parsons M, Butcher KS. Most endovascular thrombectomy patients have Target Mismatch despite absence of formal CT perfusion selection criteria. PLoS One 2023; 18:e0285679. [PMID: 37708105 PMCID: PMC10501580 DOI: 10.1371/journal.pone.0285679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 04/27/2023] [Indexed: 09/16/2023] Open
Abstract
Endovascular thrombectomy (EVT) is the standard of care for large vessel occlusion stroke. Use of Computed Tomographic Perfusion (CTP) to select EVT candidates is variable. The frequency of treatment and outcome in patients with unfavourable CTP patterns is unknown. A retrospective analysis of CTP utilisation prior to EVT was conducted. All CTP data were analysed centrally and a Target Mismatch was defined as an infarct core ≤70 ml, penumbral volume ≥15ml, and a total hypoperfused volume:core volume ratio >1.8. The primary outcome was good functional outcome at 90 days, defined as a modified Rankin Scale (mRS) score 0-2. follow-up infarct volume, core expansion and penumbral salvage volumes were secondary outcomes. Of 572 anterior circulation EVT patients, CTP source image data required to generate objective maps were available in 170, and a Target Mismatch was present in 151 (89%). The rate of 90-day good functional outcome was similar between Target Mismatch (53%) and Large Core Non-Mismatch groups (46%, p = 0.629). Median follow-up infarct volume in the Large Core Non-Mismatch group (104ml [IQR 25ml-189ml]) was larger than that in the Target Mismatch patients (16ml [8ml-47ml], p<0.001). Despite a lack of formal CTP selection criteria, the majority of patients treated at our centres had a Target Mismatch. Patients without Target Mismatch had larger follow-up infarct volumes, but the functional recovery rate was similar to that in Target Mismatch patients. Infarct volumes should be included as objective assessment criteria in the evaluation of the efficacy of EVT in non-Target Mismatch patients.
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Affiliation(s)
| | - Andrew Cheung
- Department of Interventional Neuroradiology, The Prince of Wales Hospital, Sydney, Australia
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, Australia
| | - Nathan Manning
- Department of Interventional Neuroradiology, The Prince of Wales Hospital, Sydney, Australia
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, Australia
| | - Justin Whitley
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, Australia
| | - Dennis Cordato
- Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, Australia
- Ingham Institute of Applied Medical Research, Sydney, Australia
| | - Alessandro Zagami
- Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia
| | - Cecilia Cappelen-Smith
- Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, Australia
- Ingham Institute of Applied Medical Research, Sydney, Australia
| | - Huiqiao Tian
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Chris Levi
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - Mark Parsons
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Ingham Institute of Applied Medical Research, Sydney, Australia
| | - Ken S. Butcher
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia
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46
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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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Mangiardi M, Bonura A, Iaccarino G, Alessiani M, Bravi MC, Crupi D, Pezzella FR, Fabiano S, Pampana E, Stilo F, Alfano G, Anticoli S. The Pathophysiology of Collateral Circulation in Acute Ischemic Stroke. Diagnostics (Basel) 2023; 13:2425. [PMID: 37510169 PMCID: PMC10378392 DOI: 10.3390/diagnostics13142425] [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: 06/22/2023] [Revised: 07/08/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Cerebral collateral circulation is a network of blood vessels which stabilizes blood flow and maintains cerebral perfusion whenever the main arteries fail to provide an adequate blood supply, as happens in ischemic stroke. These arterial networks are able to divert blood flow to hypoperfused cerebral areas. The extent of the collateral circulation determines the volume of the salvageable tissue, the so-called "penumbra". Clinically, this is associated with greater efficacy of reperfusion therapies (thrombolysis and thrombectomy) in terms of better short- and long-term functional outcomes, lower incidence of hemorrhagic transformation and of malignant oedema, and smaller cerebral infarctions. Recent advancements in brain imaging techniques (CT and MRI) allow us to study these anastomotic networks in detail and increase the likelihood of making effective therapeutic choices. In this narrative review we will investigate the pathophysiology, the clinical aspects, and the possible diagnostic and therapeutic role of collateral circulation in acute ischemic stroke.
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Affiliation(s)
- Marilena Mangiardi
- Department of Stroke Unit, San Camillo-Forlanini Hospital, 00152 Rome, Italy
| | - Adriano Bonura
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University, 00128 Rome, Italy
| | - Gianmarco Iaccarino
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University, 00128 Rome, Italy
| | - Michele Alessiani
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University, 00128 Rome, Italy
| | - Maria Cristina Bravi
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University, 00128 Rome, Italy
| | - Domenica Crupi
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University, 00128 Rome, Italy
| | - Francesca Romana Pezzella
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University, 00128 Rome, Italy
| | - Sebastiano Fabiano
- Department of Neuroradiology and Interventional Neuroradiology, San Camillo-Forlanini Hospital, 00152 Rome, Italy
| | - Enrico Pampana
- Department of Neuroradiology and Interventional Neuroradiology, San Camillo-Forlanini Hospital, 00152 Rome, Italy
| | - Francesco Stilo
- Unit of Vascular Surgery, Campus Bio-Medico University, 00128 Rome, Italy
| | - Guido Alfano
- Department of Radiology and Interventional Radiology, M.G. Vannini Hospital, 00177 Rome, Italy
| | - Sabrina Anticoli
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University, 00128 Rome, Italy
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Liu W, Zhao J, Liu H, Li T, Zhou T, He Y, Zhu L, Ding Y, Hui FK, He Y. Safety and Efficacy of Direct Thrombectomy Versus Bridging Therapy in Patients with Acute Ischemic Stroke Eligible for Intravenous Thrombolysis: A Meta-Analysis of Randomized Controlled Trials. World Neurosurg 2023; 175:113-121.e3. [PMID: 37040841 DOI: 10.1016/j.wneu.2023.04.018] [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: 03/04/2023] [Accepted: 04/05/2023] [Indexed: 04/13/2023]
Abstract
OBJECTIVE In the present study, we conducted a meta-analysis of reported randomized controlled trials (RCTs) comparing the safety and efficacy of direct thrombectomy (DT) and bridging therapy (BT) for patients eligible for intravenous thrombolysis (IVT). METHODS A comprehensive search of PubMed, Cochrane Library, EMBASE, and Web of Science up to July 11, 2022 was performed. RCTs comparing DT and BT were included. The relative risk or rate difference and their 95% confidence intervals in a Mantel-Haenszel fixed effects model were used as the effect index of each outcome. The noninferior margin was specified as 80% for the relative risk or -10% for the rate difference. The primary outcome was the proportion of patients with a favorable functional outcome, defined as a modified Rankin scale (mRS) score of 0-2 or a return to baseline at 90 days. Additional efficacy and safety outcomes included successful recanalization at the end of thrombectomy, excellent clinical outcomes (defined as an mRS score of 0-1), death within 90 ± 14 days, symptomatic intracerebral hemorrhage, any type of intracerebral hemorrhage, and clot migration. RESULTS Six RCTs with 2334 patients were pooled for the meta-analysis. The results showed the noninferiority of DT for favorable functional outcomes, higher successful recanalization rates, and any intracerebral hemorrhage in the BT group, with no statistically significant differences for other outcomes. The risk of bias for all RCTs in our analysis was low. CONCLUSIONS DT achieved noninferiority to BT for favorable functional outcomes. Patient-level pooled analysis and subgroup analysis are needed to provide more information to distinguish which patients will benefit more from which therapy.
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Affiliation(s)
- Wenbo Liu
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Jingge Zhao
- Clinical Research Center, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Huan Liu
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Tianxiao Li
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Tengfei Zhou
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Yanyan He
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Liangfu Zhu
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Yonghong Ding
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ferdinand K Hui
- University of Hawaii, Queen's Medical Center, Honolulu, Hawaii, USA
| | - Yingkun He
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China.
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49
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Ni H, Hang Y, Wang CD, Jia ZY, Shi HB, Liu S, Zhao LB. Subcortical infarcts on admission CTP predict poor outcome despite excellent reperfusion in delayed time windows. Neuroradiology 2023:10.1007/s00234-023-03172-3. [PMID: 37237038 DOI: 10.1007/s00234-023-03172-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 05/21/2023] [Indexed: 05/28/2023]
Abstract
PURPOSE The effect of pretreatment infarct location on clinical outcome after successful mechanical thrombectomy is not understood. Our aim was to evaluate the association between computed tomography perfusion (CTP)-based ischemic core location and clinical outcome following excellent reperfusion in late time windows. METHODS We retrospectively reviewed patients who underwent thrombectomy for acute anterior circulation large vessel occlusion in late time windows from October 2019 to June 2021 and enrolled 65 patients with visible ischemic core on admission CTP who had received excellent reperfusion (modified thrombolysis in cerebral infarction grade 2c/3). Poor outcome was defined as a modified Rankin scale score of 3-6 at 90 days. The ischemic core infarct territories were classified into the cortical and subcortical areas. Multivariate logistic regression and receiver operating characteristic (ROC) curve analyses were used in this study. RESULTS Of the 65 patients analyzed, 38 (58.5%) had a poor outcome. Multivariable logistic analysis showed that the subcortical infarcts (OR 11.75; 95% CI 1.79-77.32; P = 0.010) and their volume (OR 1.17; 95% CI 1.04-1.32; P = 0.011) were independently associated with poor outcome. The ROC curve indicated the capacity of the subcortical infarct involvement (areas under the curve (AUC) = 0.65; 95% CI, 0.53-0.77, P < 0.001) and subcortical infarct volume (AUC = 0.72; 95% CI, 0.60-0.83, P < 0.001) in predicting poor outcome accurately. CONCLUSION Subcortical infarcts and their volume on admission CTP are associated with poor outcome after excellent reperfusion in late time windows, rather than cortical infarcts.
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Affiliation(s)
- Heng Ni
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Rd, Nanjing, 210029, China
| | - Yu Hang
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Rd, Nanjing, 210029, China
| | - Chen-Dong Wang
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Rd, Nanjing, 210029, China
| | - Zhen-Yu Jia
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Rd, Nanjing, 210029, China
| | - Hai-Bin Shi
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Rd, Nanjing, 210029, China
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Rd, Nanjing, 210029, China
| | - Lin-Bo Zhao
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Rd, Nanjing, 210029, China.
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50
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Regenhardt RW, Potter CA, Huang SS, Lev MH. Advanced Imaging for Acute Stroke Treatment Selection: CT, CTA, CT Perfusion, and MR Imaging. Radiol Clin North Am 2023; 61:445-456. [PMID: 36931761 DOI: 10.1016/j.rcl.2023.01.003] [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: 03/17/2023]
Abstract
There is constant evolution in the diagnosis and treatment of acute ischemic stroke due to advances in treatments, imaging, and outreach. Two major revolutions were the advent of intravenous thrombolysis in the 1990s and endovascular thrombectomy in 2010s. Neuroimaging approaches have also evolved with key goals-detect hemorrhage, augment thrombolysis treatment selection, detect arterial occlusion, estimate infarct core, estimate viable penumbra, and augment thrombectomy treatment selection. The ideal approach to diagnosis and treatment may differ depending on the system of care and available resources. Future directions include expanding indications for these treatments, including a shift from time-based to tissue-based selection.
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Affiliation(s)
- Robert W Regenhardt
- Massachusetts General Hospital, 55 Fruit Street, WAC 7-745, Boston, MA 02114, USA. https://twitter.com/rwregen
| | | | - Samuel S Huang
- Albany Medical College, 438 Waltham Street, Lexington, MA 02421, USA
| | - Michael H Lev
- Massachusetts General Hospital, 55 Fruit Street, WAC 7-745, Boston, MA 02114, USA
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