1
|
Bani-Sadr A, Trintignac M, Mechtouff L, Hermier M, Cappucci M, Ameli R, de Bourguignon C, Derex L, Cho TH, Nighoghossian N, Eker OF, Berthezene Y. Is the optimal Tmax threshold identifying perfusion deficit volumes variable across MR perfusion software packages? A pilot study. MAGMA (NEW YORK, N.Y.) 2023; 36:815-822. [PMID: 36811716 DOI: 10.1007/s10334-023-01068-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE Accurate quantification of ischemic core and ischemic penumbra is mandatory for late-presenting acute ischemic stroke. Substantial differences between MR perfusion software packages have been reported, suggesting that the optimal Time-to-Maximum (Tmax) threshold may be variable. We performed a pilot study to assess the optimal Tmax threshold of two MR perfusion software packages (A: RAPID®; B: OleaSphere®) by comparing perfusion deficit volumes to final infarct volumes as ground truth. METHODS The HIBISCUS-STROKE cohort includes acute ischemic stroke patients treated by mechanical thrombectomy after MRI triage. Mechanical thrombectomy failure was defined as a modified thrombolysis in cerebral infarction score of 0. Admission MR perfusion were post-processed using two packages with increasing Tmax thresholds (≥ 6 s, ≥ 8 s and ≥ 10 s) and compared to final infarct volume evaluated with day-6 MRI. RESULTS Eighteen patients were included. Lengthening the threshold from ≥ 6 s to ≥ 10 s led to significantly smaller perfusion deficit volumes for both packages. For package A, Tmax ≥ 6 s and ≥ 8 s moderately overestimated final infarct volume (median absolute difference: - 9.5 mL, interquartile range (IQR) [- 17.5; 0.9] and 0.2 mL, IQR [- 8.1; 4.8], respectively). Bland-Altman analysis indicated that they were closer to final infarct volume and had narrower ranges of agreement compared with Tmax ≥ 10 s. For package B, Tmax ≥ 10 s was closer to final infarct volume (median absolute difference: - 10.1 mL, IQR: [- 17.7; - 2.9]) versus - 21.8 mL (IQR: [- 36.7; - 9.5]) for Tmax ≥ 6 s. Bland-Altman plots confirmed these findings (mean absolute difference: 2.2 mL versus 31.5 mL, respectively). CONCLUSIONS The optimal Tmax threshold for defining the ischemic penumbra appeared to be most accurate at ≥ 6 s for package A and ≥ 10 s for package B. This implies that the widely recommended Tmax threshold ≥ 6 s may not be optimal for all available MRP software package. Future validation studies are required to define the optimal Tmax threshold to use for each package.
Collapse
Affiliation(s)
- Alexandre Bani-Sadr
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France.
- CREATIS Laboratory, CNRS UMR 5220, INSERM U 5220, Claude Bernard Lyon I University, 7 Avenue Jean Capelle O, 69100, Villeurbanne, France.
| | - Mathilde Trintignac
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
| | - Laura Mechtouff
- Stroke Department, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
- CarMeN Laboratory, INSERM U1060, Claude Bernard Lyon I University, 59 Bd Pinel, 69500, Bron, France
| | - Marc Hermier
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
| | - Matteo Cappucci
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
| | - Roxana Ameli
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
| | | | - Laurent Derex
- Stroke Department, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
| | - Tae-Hee Cho
- Stroke Department, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
- CarMeN Laboratory, INSERM U1060, Claude Bernard Lyon I University, 59 Bd Pinel, 69500, Bron, France
| | - Norbert Nighoghossian
- Stroke Department, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
- CarMeN Laboratory, INSERM U1060, Claude Bernard Lyon I University, 59 Bd Pinel, 69500, Bron, France
| | - Omer Faruk Eker
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
- CREATIS Laboratory, CNRS UMR 5220, INSERM U 5220, Claude Bernard Lyon I University, 7 Avenue Jean Capelle O, 69100, Villeurbanne, France
| | - Yves Berthezene
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
- CREATIS Laboratory, CNRS UMR 5220, INSERM U 5220, Claude Bernard Lyon I University, 7 Avenue Jean Capelle O, 69100, Villeurbanne, France
| |
Collapse
|
2
|
Elsaid N, Bigliardi G, Dell'Acqua ML, Vandelli L, Ciolli L, Picchetto L, Borzì G, Ricceri R, Pentore R, Vallone S, Meletti S, Saied A. Evaluation of stroke prognostication using age and NIH Stroke Scale index (SPAN-100 index) in delayed intravenous thrombolysis patients (beyond 4.5 hours). J Stroke Cerebrovasc Dis 2022; 31:106384. [PMID: 35182948 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 01/05/2022] [Accepted: 01/30/2022] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES the efficacy of delayed intravenous tissue plasminogen activator (tPA), beyond the 4.5 h window, is evolving. Advanced age and high admission National Institutes of Health Stroke Scale (NIHSS) score are proposed to adversely affect the outcome of delayed thrombolysis and limit the inclusion criteria. The summation of patient age and admission NIHSS score was introduced as the SPAN-100 index as a tool of prediction of the clinical outcome after acute ischemic stroke (AIS). We aimed to assess the SPAN-100 index in AIS thrombolysed patients after 4.5 h. MATERIALS AND METHODS The SPAN-100 index was applied to AIS patients receiving delayed IV thrombolysis (IVT) after 4.5 h. Patients demographics, risk factors, clinical, laboratory and radiological data, mismatch evidence, treatment onset and modality, NIHSS score at baseline and at discharge, and 3 months follow-up modified Rankin Scale (mRS) were reviewed. SPAN-100 score ≥ 100 is classified as SPAN-100 positive while score < 100 is SPAN-100 negative. Clinical outcomes, death and intracerebral hemorrhage (ICH) incidences were compared between SPAN-100 positive and negative groups. RESULTS SPAN-100-positive delayed IVT-patients (11/136) had a 6-fold increased risk for unfavorable outcome compared to SPAN-negative patients (OR 6.34; 95% CI 1.59-25.24 p=0.004), however there was no relation between the SPAN-100 positivity and mortality or ICH. CONCLUSION SPAN-100-positive patients are more likely to achieve non-favorable outcome with delayed IVT in comparison to the SPAN-100-negative patients. SPAN-100 index may influence the eligibility criteria of delayed thrombolysis.
Collapse
Affiliation(s)
- Nada Elsaid
- Stroke Unit - Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy; Department of Neurology, Faculty of Medicine, Mansoura University, Mansoura 35511, Egypt.
| | - Guido Bigliardi
- Stroke Unit - Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy.
| | - Maria Luisa Dell'Acqua
- Stroke Unit - Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy.
| | - Laura Vandelli
- Stroke Unit - Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy.
| | - Ludovico Ciolli
- Stroke Unit - Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy.
| | - Livio Picchetto
- Stroke Unit - Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy.
| | - Giuseppe Borzì
- Stroke Unit - Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy.
| | - Riccardo Ricceri
- Stroke Unit - Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy.
| | - Roberta Pentore
- Stroke Unit - Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy.
| | - Stefano Vallone
- Neuroradiology, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy.
| | - Stefano Meletti
- Stroke Unit - Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy.
| | - Ahmed Saied
- Stroke Unit - Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy; Department of Neurology, Faculty of Medicine, Mansoura University, Mansoura 35511, Egypt.
| |
Collapse
|
3
|
Hong L, Ling Y, Su Y, Yang L, Lin L, Parsons M, Cheng X, Dong Q. Hemispheric cerebral blood flow predicts outcome in acute small subcortical infarcts. J Cereb Blood Flow Metab 2021; 41:2534-2545. [PMID: 34435912 PMCID: PMC8504947 DOI: 10.1177/0271678x211029884] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The association between baseline perfusion measures and clinical outcomes in patients with acute small subcortical infarcts (SSIs) has not been studied in detail. Post-processed acute perfusion CT and follow-up diffusion-weighted imaging of 71 patients with SSIs were accurately co-registered. Relative perfusion values were calculated from the perfusion values of the infarct lesion divided by those of the mirrored contralateral area. The association between perfusion measures with clinical outcomes and the interaction with intravenous thrombolysis were studied. Additionally, the perfusion measures for patients having perfusion CT before and after thrombolysis were compared. Higher contralateral hemispheric cerebral blood flow (CBF) was the only independent predictor of an excellent clinical outcome (modified Rankin Scale of 0-1) at 3 months (OR = 1.3, 95% CI 1.1-1.4, P = 0.001) amongst all the perfusion parameters, and had a significant interaction with thrombolysis (P = 0.04). Patients who had perfusion CT after thrombolysis demonstrated a better perfusion profile (relative CBF ≥1) than those who had perfusion CT before thrombolysis (After:45.5%, Before:21.1%, P = 0.03). This study implies that for patients with SSIs, hemispheric CBF is a predictor of clinical outcome and has an influence on the effect of intravenous thrombolysis.
Collapse
Affiliation(s)
- Lan Hong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Yifeng Ling
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Ya Su
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Lumeng Yang
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Longting Lin
- Department of Neurology, Liverpool Hospital, University of New South Wales South Western Sydney Clinical School, The Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - Mark Parsons
- Department of Neurology, Liverpool Hospital, University of New South Wales South Western Sydney Clinical School, The Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - Xin Cheng
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Qiang Dong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| |
Collapse
|
4
|
Lu J, Mei Q, Hou X, Manaenko A, Zhou L, Liebeskind DS, Zhang JH, Li Y, Hu Q. Imaging Acute Stroke: From One-Size-Fit-All to Biomarkers. Front Neurol 2021; 12:697779. [PMID: 34630278 PMCID: PMC8497192 DOI: 10.3389/fneur.2021.697779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/30/2021] [Indexed: 12/27/2022] Open
Abstract
In acute stroke management, time window has been rigidly used as a guide for decades and the reperfusion treatment is only available in the first few limited hours. Recently, imaging-based selection of patients has successfully expanded the treatment window out to 16 and even 24 h in the DEFUSE 3 and DAWN trials, respectively. Recent guidelines recommend the use of imaging techniques to guide therapeutic decision-making and expanded eligibility in acute ischemic stroke. A tissue window is proposed to replace the time window and serve as the surrogate marker for potentially salvageable tissue. This article reviews the evolution of time window, addresses the advantage of a tissue window in precision medicine for ischemic stroke, and discusses both the established and emerging techniques of neuroimaging and their roles in defining a tissue window. We also emphasize the metabolic imaging and molecular imaging of brain pathophysiology, and highlight its potential in patient selection and treatment response prediction in ischemic stroke.
Collapse
Affiliation(s)
- Jianfei Lu
- Central Laboratory, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qiyong Mei
- Department of Neurosurgery, Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Xianhua Hou
- Department of Neurology, Southwest Hospital, Army Medical University, Chongqing, China
| | - Anatol Manaenko
- National Health Commission Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lili Zhou
- Department of Neurology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - David S. Liebeskind
- Neurovascular Imaging Research Core and University of California Los Angeles Stroke Center, University of California, Los Angeles, Los Angeles, CA, United States
| | - John H. Zhang
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Yao Li
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Qin Hu
- Central Laboratory, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| |
Collapse
|
5
|
Elsaid N, Bigliardi G, Dell'Acqua ML, Vandelli L, Ciolli L, Picchetto L, Borzì G, Ricceri R, Pentore R, Vallone S, Meletti S, Saied A. Factors affecting the outcome of delayed intravenous thrombolysis (>4.5hours). Rev Neurol (Paris) 2021; 177:1266-1275. [PMID: 34384630 DOI: 10.1016/j.neurol.2021.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 03/31/2021] [Accepted: 04/19/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Evidence of the intravenous tissue plasminogen activator (tPA) efficacy beyond the 4.5hours window is emerging. We aim to study the factors affecting the outcome of delayed thrombolysis in patients of clear onset acute ischemic stroke (AIS). METHODS Data of patients with AIS who received intravenous thrombolytic after 4.5hours were reviewed including: demographics, risk factors, clinical, laboratory, investigational and radiological data, evidence of mismatch, treatment type and onset, National Institutes of Health Stroke Scale (NIHSS) score at baseline, 24hours, 7days after thrombolysis and before discharge, and 3 months follow-up modified Rankin Scale (mRS). RESULTS We report 136 patients treated by intravenous tPA between 4.53 and 19.75hours with average duration of 5.7h. The ASPECT score of our patients was≥7. Sixty-four cases showed intracranial arterial occlusion. Perfusion mismatch was detected in 117 (84.6%) patients, while clinical imaging mismatch was detected in 19 (15.4%). Early neurological improvement after 24hours occurred in 114 (83.8%) patients. At 90days, 91 patients (67%) achieved good outcome (mRS 0-2), while 45 (33%) had bad outcome (mRS 3-6). Age, endovascular treatment, NIHSS, AF, and HT were significantly higher in the bad outcome group. Age (P=0.001, OR: 1.099, 95% CI: 1.042-1.160) and baseline NIHSS were predictive of the poor outcome (P=0.002, OR: 1.151, 95% CI: 1.055-1.256). The best cutoff value of age was 72.5 with AUC of 0.76, sensitivity 73.3% and specificity 60.4%. While for NIHSS at admission, the cutoff value of 7 showed the best results with AUC of 0.73, sensitivity 71.1% and specificity 63.7%. Combination of age and admission NIHSS raised the sensitivity and specificity to 84.4% and 63.7%, respectively. CONCLUSION Increased age and admission NIHSS may adversely affect the outcome of delayed thrombolysis and narrow the eligibility criteria. Age and baseline NIHSS based stratification of the patients may provide further evidence as regards the efficacy of the delayed thrombolysis.
Collapse
Affiliation(s)
- N Elsaid
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy; Department of Neurology, Mansoura University, Mansoura, Egypt.
| | - G Bigliardi
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - M L Dell'Acqua
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - L Vandelli
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - L Ciolli
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - L Picchetto
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - G Borzì
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - R Ricceri
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - R Pentore
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - S Vallone
- Neuroradiology, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - S Meletti
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - A Saied
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy; Department of Neurology, Mansoura University, Mansoura, Egypt
| |
Collapse
|
6
|
Potreck A, Seker F, Mutke MA, Weyland CS, Herweh C, Heiland S, Bendszus M, Möhlenbruch M. What is the impact of head movement on automated CT perfusion mismatch evaluation in acute ischemic stroke? J Neurointerv Surg 2021; 14:628-633. [PMID: 34301804 DOI: 10.1136/neurintsurg-2021-017510] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 07/04/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Automated CT perfusion mismatch assessment is an established treatment decision tool in acute ischemic stroke. However, the reliability of this method in patients with head motion is unclear. We therefore sought to evaluate the influence of head movement on automated CT perfusion mismatch evaluation. METHODS Using a realistic CT brain-perfusion-phantom, 7 perfusion mismatch scenarios were simulated within the left middle cerebral artery territory. Real CT noise and artificial head movement were added. Thereafter, ischemic core, penumbra volumes and mismatch ratios were evaluated using an automated mismatch analysis software (RAPID, iSchemaView) and compared with ground truth simulated values. RESULTS While CT scanner noise alone had only a minor impact on mismatch evaluation, a tendency towards smaller infarct core estimates (mean difference of -5.3 (-14 to 3.5) mL for subtle head movement and -7.0 (-14.7 to 0.7) mL for strong head movement), larger penumbral estimates (+9.9 (-25 to 44) mL and +35 (-14 to 85) mL, respectively) and consequently larger mismatch ratios (+0.8 (-1.5 to 3.0) for subtle head movement and +1.9 (-1.3 to 5.1) for strong head movement) were noted in dependence of patient head movement. CONCLUSIONS Motion during CT perfusion acquisition influences automated mismatch evaluation. Potentially treatment-relevant changes in mismatch classifications in dependence of head movement were observed and occurred in favor of mechanical thrombectomy.
Collapse
Affiliation(s)
- Arne Potreck
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Fatih Seker
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | | | | | - Christian Herweh
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Sabine Heiland
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| |
Collapse
|
7
|
Four Decades of Ischemic Penumbra and Its Implication for Ischemic Stroke. Transl Stroke Res 2021; 12:937-945. [PMID: 34224106 DOI: 10.1007/s12975-021-00916-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/10/2021] [Accepted: 05/12/2021] [Indexed: 12/15/2022]
Abstract
The ischemic penumbra defined four decades ago has been the main battleground of ischemic stroke. The evolving ischemic penumbra concept has been providing insight for the development of vascular and cellular approaches as well as diagnostic tools for the treatment of ischemic stroke. rt-PA thrombolytic therapy to prevent the transition of ischemic penumbra to core has been approved for acute ischemic stroke within 3 h and was later recommended to extend to 4.5 h after symptom onset. Mechanical thrombectomy was introduced for the treatment of acute ischemic stroke with a therapeutic window of up to 24 h after stroke onset. Multiple modalities brain imaging techniques have been developed that provide guidance to define ischemic penumbra for reperfusion therapy in clinical practice. Cellular and molecular dissection of ischemic penumbra has been providing targets for the development of neuroprotective therapy for ischemic stroke. However, the dynamic nature of ischemic penumbra implicates that infarct core eventually expands into penumbra over time without reperfusion, dictating relative short therapeutic windows and limiting the impact of current reperfusion intervention. Entering the 5th decade since the introduction, ischemic penumbra remains the main focus of ischemic stroke research and clinical practice. In this review, we summarized the evolving ischemic penumbra concept and its implication in the development of vascular and cellular interventions as well as diagnostic tools for acute ischemic stroke. In addition, we discussed future perspectives on expansion of the campaign beyond ischemic penumbra to develop treatment for ischemic stroke.
Collapse
|
8
|
Frey D, Livne M, Leppin H, Akay EM, Aydin OU, Behland J, Sobesky J, Vajkoczy P, Madai VI. A precision medicine framework for personalized simulation of hemodynamics in cerebrovascular disease. Biomed Eng Online 2021; 20:44. [PMID: 33933080 PMCID: PMC8088619 DOI: 10.1186/s12938-021-00880-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/20/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Cerebrovascular disease, in particular stroke, is a major public health challenge. An important biomarker is cerebral hemodynamics. To measure and quantify cerebral hemodynamics, however, only invasive, potentially harmful or time-to-treatment prolonging methods are available. RESULTS We present a simulation-based approach which allows calculation of cerebral hemodynamics based on the patient-individual vessel configuration derived from structural vessel imaging. For this, we implemented a framework allowing segmentation and annotation of brain vessels from structural imaging followed by 0-dimensional lumped simulation modeling of cerebral hemodynamics. For annotation, a 3D-graphical user interface was implemented. For 0D-simulation, we used a modified nodal analysis, which was adapted for easy implementation by code. The simulation enables identification of areas vulnerable to stroke and simulation of changes due to different systemic blood pressures. Moreover, sensitivity analysis was implemented allowing the live simulation of changes to simulate procedures and disease progression. Beyond presentation of the framework, we demonstrated in an exploratory analysis in 67 patients that the simulation has a high specificity and low-to-moderate sensitivity to detect perfusion changes in classic perfusion imaging. CONCLUSIONS The presented precision medicine approach using novel biomarkers has the potential to make the application of harmful and complex perfusion methods obsolete.
Collapse
Affiliation(s)
- Dietmar Frey
- Charite Lab for Artificial Intelligence in Medicine, Department of Neurosurgery, Charité University Medicine Berlin, Chariteplatz 1, 10115, Berlin, Germany.
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany.
| | - Michelle Livne
- Charite Lab for Artificial Intelligence in Medicine, Department of Neurosurgery, Charité University Medicine Berlin, Chariteplatz 1, 10115, Berlin, Germany
| | - Heiko Leppin
- Charite Lab for Artificial Intelligence in Medicine, Department of Neurosurgery, Charité University Medicine Berlin, Chariteplatz 1, 10115, Berlin, Germany
| | - Ela M Akay
- Charite Lab for Artificial Intelligence in Medicine, Department of Neurosurgery, Charité University Medicine Berlin, Chariteplatz 1, 10115, Berlin, Germany
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
| | - Orhun U Aydin
- Charite Lab for Artificial Intelligence in Medicine, Department of Neurosurgery, Charité University Medicine Berlin, Chariteplatz 1, 10115, Berlin, Germany
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
| | - Jonas Behland
- Charite Lab for Artificial Intelligence in Medicine, Department of Neurosurgery, Charité University Medicine Berlin, Chariteplatz 1, 10115, Berlin, Germany
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
| | - Jan Sobesky
- Johanna Etienne Hospital Neuss, Berlin, Germany
- Centre for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
| | - Vince I Madai
- Charite Lab for Artificial Intelligence in Medicine, Department of Neurosurgery, Charité University Medicine Berlin, Chariteplatz 1, 10115, Berlin, Germany
- School of Computing and Digital Technology, Faculty of Computing, Engineering and the Built Environment, Birmingham City University, Birmingham, UK
| |
Collapse
|
9
|
Kuo DP, Kuo PC, Chen YC, Kao YCJ, Lee CY, Chung HW, Chen CY. Machine learning-based segmentation of ischemic penumbra by using diffusion tensor metrics in a rat model. J Biomed Sci 2020; 27:80. [PMID: 32664906 PMCID: PMC7362663 DOI: 10.1186/s12929-020-00672-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/09/2020] [Indexed: 01/01/2023] Open
Abstract
Background Recent trials have shown promise in intra-arterial thrombectomy after the first 6–24 h of stroke onset. Quick and precise identification of the salvageable tissue is essential for successful stroke management. In this study, we examined the feasibility of machine learning (ML) approaches for differentiating the ischemic penumbra (IP) from the infarct core (IC) by using diffusion tensor imaging (DTI)-derived metrics. Methods Fourteen male rats subjected to permanent middle cerebral artery occlusion (pMCAO) were included in this study. Using a 7 T magnetic resonance imaging, DTI metrics such as fractional anisotropy, pure anisotropy, diffusion magnitude, mean diffusivity (MD), axial diffusivity, and radial diffusivity were derived. The MD and relative cerebral blood flow maps were coregistered to define the IP and IC at 0.5 h after pMCAO. A 2-level classifier was proposed based on DTI-derived metrics to classify stroke hemispheres into the IP, IC, and normal tissue (NT). The classification performance was evaluated using leave-one-out cross validation. Results The IC and non-IC can be accurately segmented by the proposed 2-level classifier with an area under the receiver operating characteristic curve (AUC) between 0.99 and 1.00, and with accuracies between 96.3 and 96.7%. For the training dataset, the non-IC can be further classified into the IP and NT with an AUC between 0.96 and 0.98, and with accuracies between 95.0 and 95.9%. For the testing dataset, the classification accuracy for IC and non-IC was 96.0 ± 2.3% whereas for IP and NT, it was 80.1 ± 8.0%. Overall, we achieved the accuracy of 88.1 ± 6.7% for classifying three tissue subtypes (IP, IC, and NT) in the stroke hemisphere and the estimated lesion volumes were not significantly different from those of the ground truth (p = .56, .94, and .78, respectively). Conclusions Our method achieved comparable results to the conventional approach using perfusion–diffusion mismatch. We suggest that a single DTI sequence along with ML algorithms is capable of dichotomizing ischemic tissue into the IC and IP.
Collapse
Affiliation(s)
- Duen-Pang Kuo
- Department of Medical Imaging, Taipei Medical University Hospital, No.250, Wu-Hsing St, Taipei, 11031, Taiwan.,Department of Radiology, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
| | - Po-Chih Kuo
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Yung-Chieh Chen
- Department of Medical Imaging, Taipei Medical University Hospital, No.250, Wu-Hsing St, Taipei, 11031, Taiwan
| | - Yu-Chieh Jill Kao
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, No.155, Sec.2, Linong St, Taipei, 11221, Taiwan
| | - Ching-Yen Lee
- TMU Center for Big Data and Artificial Intelligence in Medical Imaging, Taipei Medical University Hospital, Taipei, Taiwan.,TMU Research Center for Artificial Intelligence in Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Hsiao-Wen Chung
- Graduate Institute of Biomedical Electrics and Bioinformatics, National Taiwan University, Taipei, Taiwan
| | - Cheng-Yu Chen
- Department of Medical Imaging, Taipei Medical University Hospital, No.250, Wu-Hsing St, Taipei, 11031, Taiwan. .,Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, No.155, Sec.2, Linong St, Taipei, 11221, Taiwan. .,Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, No.250, Wu-Hsing St, Taipei, 11031, Taiwan. .,Radiogenomic Research Center, Taipei Medical University Hospital, No.250, Wu-Hsing St, Taipei, 11031, Taiwan. .,Center for Artificial Intelligence in Medicine, Taipei Medical University, No.250, Wu-Hsing St, Taipei, 11031, Taiwan. .,Department of Radiology, National Defense Medical Center, No.250, Wu-Hsing St, Taipei, 11031, Taiwan.
| |
Collapse
|
10
|
Alambyan V, Pace J, Sukpornchairak P, Yu X, Alnimir H, Tatton R, Chitturu G, Yarlagadda A, Ramos-Estebanez C. Imaging Guidance for Therapeutic Delivery: The Dawn of Neuroenergetics. Neurotherapeutics 2020; 17:522-538. [PMID: 32240530 PMCID: PMC7283376 DOI: 10.1007/s13311-020-00843-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Modern neurocritical care relies on ancillary diagnostic testing in the form of multimodal monitoring to address acute changes in the neurological homeostasis. Much of our armamentarium rests upon physiological and biochemical surrogates of organ or regional level metabolic activity, of which a great deal is invested at the metabolic-hemodynamic-hydrodynamic interface to rectify the traditional intermediaries of glucose consumption. Despite best efforts to detect cellular neuroenergetics, current modalities cannot appreciate the intricate coupling between astrocytes and neurons. Invasive monitoring is not without surgical complication, and noninvasive strategies do not provide an adequate spatial or temporal resolution. Without knowledge of the brain's versatile behavior in specific metabolic states (glycolytic vs oxidative), clinical practice would lag behind laboratory empiricism. Noninvasive metabolic imaging represents a new hope in delineating cellular, nigh molecular level energy exchange to guide targeted management in a diverse array of neuropathology.
Collapse
Affiliation(s)
- Vilakshan Alambyan
- Department of Neurology, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA
| | - Jonathan Pace
- Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Persen Sukpornchairak
- Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Xin Yu
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Radiology, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, Ohio, USA
| | - Hamza Alnimir
- Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ryan Tatton
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
| | - Gautham Chitturu
- Department of Arts and Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Anisha Yarlagadda
- Department of Arts and Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ciro Ramos-Estebanez
- Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA.
| |
Collapse
|
11
|
Zaro-Weber O, Fleischer H, Reiblich L, Schuster A, Moeller-Hartmann W, Heiss WD. Penumbra detection in acute stroke with perfusion magnetic resonance imaging: Validation with 15 O-positron emission tomography. Ann Neurol 2019; 85:875-886. [PMID: 30937950 PMCID: PMC6593670 DOI: 10.1002/ana.25479] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 03/20/2019] [Accepted: 03/31/2019] [Indexed: 12/17/2022]
Abstract
Objective Accurate identification of the ischemic penumbra, the therapeutic target in acute clinical stroke, is of critical importance to identify patients who might benefit from reperfusion therapies beyond the established time windows. Therefore, we aimed to validate magnetic resonance imaging (MRI) mismatch–based penumbra detection against full quantitative positron emission tomography (15O‐PET), the gold standard for penumbra detection in acute ischemic stroke. Methods Ten patients (group A) with acute and subacute ischemic stroke underwent perfusion‐weighted (PW)/diffusion‐weighted MRI and consecutive full quantitative 15O‐PET within 48 hours of stroke onset. Penumbra as defined by 15O‐PET cerebral blood flow (CBF), oxygen extraction fraction, and oxygen metabolism was used to validate a wide range of established PW measures (eg, time‐to‐maximum [Tmax]) to optimize penumbral tissue detection. Validation was carried out using a voxel‐based receiver‐operating‐characteristic curve analysis. The same validation based on penumbra as defined by quantitative 15O‐PET CBF was performed for comparative reasons in 23 patients measured within 48 hours of stroke onset (group B). Results The PW map Tmax (area‐under‐the‐curve = 0.88) performed best in detecting penumbral tissue up to 48 hours after stroke onset. The optimal threshold to discriminate penumbra from oligemia was Tmax >5.6 seconds with a sensitivity and specificity of >80%. Interpretation The performance of the best PW measure Tmax to detect the upper penumbral flow threshold in ischemic stroke is excellent. Tmax >5.6 seconds–based penumbra detection is reliable to guide treatment decisions up to 48 hours after stroke onset and might help to expand reperfusion treatment beyond the current time windows. ANN NEUROL 2019;85:875–886.
Collapse
Affiliation(s)
- Olivier Zaro-Weber
- Max Planck Institute for Neurological Research, Cologne, Germany.,Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Hermann Fleischer
- Max Planck Institute for Neurological Research, Cologne, Germany.,Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Lucas Reiblich
- Max Planck Institute for Neurological Research, Cologne, Germany.,Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | | | | |
Collapse
|
12
|
Seiler A, Blockley NP, Deichmann R, Nöth U, Singer OC, Chappell MA, Klein JC, Wagner M. The relationship between blood flow impairment and oxygen depletion in acute ischemic stroke imaged with magnetic resonance imaging. J Cereb Blood Flow Metab 2019; 39:454-465. [PMID: 28929836 PMCID: PMC6421246 DOI: 10.1177/0271678x17732448] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Oxygenation-sensitive spin relaxation time T2' and relaxation rate R2' (1/T2') are presumed to be markers of the cerebral oxygen extraction fraction (OEF) in acute ischemic stroke. In this study, we investigate the relationship of T2'/R2' with dynamic susceptibility contrast-based relative cerebral blood flow (rCBF) in acute ischemic stroke to assess their plausibility as surrogate markers of the ischemic penumbra. Twenty-one consecutive patients with internal carotid artery and/or middle cerebral artery occlusion were studied at 3.0 T. A physiological model of the cerebral vasculature (VM) was used to process PWI raw data in addition to a conventional deconvolution technique. T2', R2', and rCBF values were extracted from the ischemic core and hypoperfused areas. Within hypoperfused tissue, no correlation was found between deconvolved rCBF and T2' ( r = -0.05, p = 0.788), or R2' ( r = 0.039, p = 0.836). In contrast, we found a strong positive correlation with T2' ( r = 0.444, p = 0.006) and negative correlation with R2' ( r = -0.494, p = 0.0025) for rCBFVM, indicating increasing OEF with decreasing CBF and that rCBF based on the vascular model may be more closely related to metabolic disturbances. Further research to refine and validate these techniques may enable their use as MRI-based surrogate markers of the ischemic penumbra for selecting stroke patients for interventional treatment strategies.
Collapse
Affiliation(s)
- Alexander Seiler
- 1 Department of Neurology, Goethe University Frankfurt, Frankfurt, Germany
| | - Nicholas P Blockley
- 2 Nuffield Department of Clinical Neurosciences, Oxford Center for Functional MRI of the Brain, University of Oxford, Oxford, UK
| | - Ralf Deichmann
- 3 Brain Imaging Center, Goethe University Frankfurt, Frankfurt, Germany
| | - Ulrike Nöth
- 3 Brain Imaging Center, Goethe University Frankfurt, Frankfurt, Germany
| | - Oliver C Singer
- 1 Department of Neurology, Goethe University Frankfurt, Frankfurt, Germany
| | - Michael A Chappell
- 2 Nuffield Department of Clinical Neurosciences, Oxford Center for Functional MRI of the Brain, University of Oxford, Oxford, UK.,4 Department of Engineering Science, Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| | - Johannes C Klein
- 5 Nuffield Department of Clinical Neurosciences, Oxford University, and Department of Neurology, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Marlies Wagner
- 6 Institute of Neuroradiology, Goethe University Frankfurt, Frankfurt, Germany
| |
Collapse
|
13
|
|
14
|
Livne M, Boldsen JK, Mikkelsen IK, Fiebach JB, Sobesky J, Mouridsen K. Boosted Tree Model Reforms Multimodal Magnetic Resonance Imaging Infarct Prediction in Acute Stroke. Stroke 2018. [PMID: 29540608 DOI: 10.1161/strokeaha.117.019440] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Stroke imaging is pivotal for diagnosis and stratification of patients with acute ischemic stroke to treatment. The potential of combining multimodal information into reliable estimates of outcome learning calls for robust machine learning techniques with high flexibility and accuracy. We applied the novel extreme gradient boosting algorithm for multimodal magnetic resonance imaging-based infarct prediction. METHODS In a retrospective analysis of 195 patients with acute ischemic stroke, fluid-attenuated inversion recovery, diffusion-weighted imaging, and 10 perfusion parameters were derived from acute magnetic resonance imaging scans. They were integrated to predict final infarct as seen on follow-up T2-fluid-attenuated inversion recovery using the extreme gradient boosting and compared with a standard generalized linear model approach using cross-validation. Submodels for recanalization and persistent occlusion were calculated and were used to identify the important imaging markers. Performance in infarct prediction was analyzed with receiver operating characteristics. Resulting areas under the curve and accuracy rates were compared using Wilcoxon signed-rank test. RESULTS The extreme gradient boosting model demonstrated significantly higher performance in infarct prediction compared with generalized linear model in both cross-validation approaches: 5-folds (P<10e-16) and leave-one-out (P<0.015). The imaging parameters time-to-peak, mean transit time, time-to-maximum, and diffusion-weighted imaging were indicated as most valuable for infarct prediction by the systematic algorithm rating. Notably, the performance improvement was higher with 5-folds cross-validation approach than leave-one-out. CONCLUSIONS We demonstrate extreme gradient boosting as a state-of-the-art method for clinically applicable multimodal magnetic resonance imaging infarct prediction in acute ischemic stroke. Our findings emphasize the role of perfusion parameters as important biomarkers for infarct prediction. The effect of cross-validation techniques on performance indicates that the intrapatient variability is expressed in nonlinear dynamics of the imaging modalities.
Collapse
Affiliation(s)
- Michelle Livne
- From the Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany (M.L., J.B.F., J.S.); and Center of Functionally Integrative Neuroscience, Aarhus University, Denmark (J.K.B., I.K.M., K.M.).
| | - Jens K Boldsen
- From the Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany (M.L., J.B.F., J.S.); and Center of Functionally Integrative Neuroscience, Aarhus University, Denmark (J.K.B., I.K.M., K.M.)
| | - Irene K Mikkelsen
- From the Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany (M.L., J.B.F., J.S.); and Center of Functionally Integrative Neuroscience, Aarhus University, Denmark (J.K.B., I.K.M., K.M.)
| | - Jochen B Fiebach
- From the Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany (M.L., J.B.F., J.S.); and Center of Functionally Integrative Neuroscience, Aarhus University, Denmark (J.K.B., I.K.M., K.M.)
| | - Jan Sobesky
- From the Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany (M.L., J.B.F., J.S.); and Center of Functionally Integrative Neuroscience, Aarhus University, Denmark (J.K.B., I.K.M., K.M.)
| | - Kim Mouridsen
- From the Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany (M.L., J.B.F., J.S.); and Center of Functionally Integrative Neuroscience, Aarhus University, Denmark (J.K.B., I.K.M., K.M.)
| |
Collapse
|
15
|
|
16
|
Livne M, Madai VI, Brunecker P, Zaro-Weber O, Moeller-Hartmann W, Heiss WD, Mouridsen K, Sobesky J. A PET-Guided Framework Supports a Multiple Arterial Input Functions Approach in DSC-MRI in Acute Stroke. J Neuroimaging 2017; 27:486-492. [PMID: 28207200 DOI: 10.1111/jon.12428] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 01/02/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE In acute stroke, arterial-input-function (AIF) determination is essential for obtaining perfusion estimates with dynamic susceptibility-weighted contrast-enhanced magnetic resonance imaging (DSC-MRI). Standard DSC-MRI postprocessing applies single AIF selection, ie, global AIF. Physiological considerations, however, suggest that a multiple AIFs selection method would improve perfusion estimates to detect penumbral flow. In this study, we developed a framework based on comparable DSC-MRI and positron emission tomography (PET) images to compare the two AIF selection approaches and assess their performance in penumbral flow detection in acute stroke. METHODS In a retrospective analysis of 17 sub(acute) stroke patients with consecutive MRI and PET scans, voxel-wise optimized AIFs were calculated based on the kinetic model as derived from both imaging modalities. Perfusion maps were calculated based on the optimized-AIF using two methodologies: (1) Global AIF and (2) multiple AIFs as identified by cluster analysis. Performance of penumbral-flow detection was tested by receiver-operating characteristics (ROC) curve analysis, ie, the area under the curve (AUC). RESULTS Large variation of optimized AIFs across brain voxels demonstrated that there is no optimal single AIF. Subsequently, the multiple-AIF method (AUC range over all maps: .82-.90) outperformed the global AIF methodology (AUC .72-.85) significantly. CONCLUSIONS We provide PET imaging-based evidence that a multiple AIF methodology is beneficial for penumbral flow detection in comparison with the standard global AIF methodology in acute stroke.
Collapse
Affiliation(s)
- Michelle Livne
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Vince I Madai
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Brunecker
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | | | | | - Kim Mouridsen
- Center of Functionally Integrative Neuroscience, Aarhus University, Denmark
| | - Jan Sobesky
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
17
|
Zhou IY, Guo Y, Igarashi T, Wang Y, Mandeville E, Chan ST, Wen L, Vangel M, Lo EH, Ji X, Sun PZ. Fast diffusion kurtosis imaging (DKI) with Inherent COrrelation-based Normalization (ICON) enhances automatic segmentation of heterogeneous diffusion MRI lesion in acute stroke. NMR IN BIOMEDICINE 2016; 29:1670-1677. [PMID: 27696558 PMCID: PMC5123902 DOI: 10.1002/nbm.3617] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 08/03/2016] [Accepted: 08/09/2016] [Indexed: 05/05/2023]
Affiliation(s)
- Iris Yuwen Zhou
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology; Massachusetts General Hospital and Harvard Medical School; Charlestown Massachusetts USA
| | - Yingkun Guo
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology; Massachusetts General Hospital and Harvard Medical School; Charlestown Massachusetts USA
- Department of Radiology; West China Second University Hospital, Sichuan University; Chengdu Sichuan China
| | - Takahiro Igarashi
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology; Massachusetts General Hospital and Harvard Medical School; Charlestown Massachusetts USA
| | - Yu Wang
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology; Massachusetts General Hospital and Harvard Medical School; Charlestown Massachusetts USA
- China-America Joint Neuroscience Institute, Xuanwu Hospital; Capital Medical University; Beijing China
| | - Emiri Mandeville
- Neuroprotection Research Laboratory, Department of Radiology and Neurology; Massachusetts General Hospital and Harvard Medical School; Charlestown Massachusetts USA
| | - Suk-Tak Chan
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology; Massachusetts General Hospital and Harvard Medical School; Charlestown Massachusetts USA
| | - Lingyi Wen
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology; Massachusetts General Hospital and Harvard Medical School; Charlestown Massachusetts USA
- Department of Radiology; West China Second University Hospital, Sichuan University; Chengdu Sichuan China
| | - Mark Vangel
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology; Massachusetts General Hospital and Harvard Medical School; Charlestown Massachusetts USA
| | - Eng H. Lo
- Neuroprotection Research Laboratory, Department of Radiology and Neurology; Massachusetts General Hospital and Harvard Medical School; Charlestown Massachusetts USA
| | - Xunming Ji
- China-America Joint Neuroscience Institute, Xuanwu Hospital; Capital Medical University; Beijing China
| | | |
Collapse
|
18
|
Jendelová P, Kubinová Š, Sandvig I, Erceg S, Sandvig A, Syková E. Current developments in cell- and biomaterial-based approaches for stroke repair. Expert Opin Biol Ther 2015; 16:43-56. [DOI: 10.1517/14712598.2016.1094457] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
19
|
Moretti A, Ferrari F, Villa RF. Pharmacological therapy of acute ischaemic stroke: Achievements and problems. Pharmacol Ther 2015; 153:79-89. [DOI: 10.1016/j.pharmthera.2015.06.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 06/03/2015] [Indexed: 01/04/2023]
|
20
|
Leaving the black box approach: individualized prediction of recanalization benefit by advanced imaging in acute stroke. J Cereb Blood Flow Metab 2015; 35:1396. [PMID: 26154868 PMCID: PMC4640331 DOI: 10.1038/jcbfm.2015.146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 05/28/2015] [Indexed: 12/22/2022]
|
21
|
Werner P, Saur D, Zeisig V, Ettrich B, Patt M, Sattler B, Jochimsen T, Lobsien D, Meyer PM, Bergh FT, Dreyer A, Boltze J, Classen J, Fritzsch D, Hoffmann KT, Sabri O, Barthel H. Simultaneous PET/MRI in stroke: a case series. J Cereb Blood Flow Metab 2015; 35:1421-5. [PMID: 26174332 PMCID: PMC4640332 DOI: 10.1038/jcbfm.2015.158] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 05/15/2015] [Accepted: 05/19/2015] [Indexed: 11/09/2022]
Abstract
Prospective studies on magnetic resonance imaging (MRI)-guided systemic thrombolysis >4.5 hours after stroke onset did not reach their primary end points. It was discussed and observed in post hoc data re-assessment that this was partly because of limited MRI accuracy to measure critical hypoperfusion. We report the first cases of simultaneous [(15)O]H2O-positron emission tomography (PET)/MRI in stroke patients and an ovine model. Discrepancies between simultaneously obtained PET and MRI readouts were observed that might explain the above current limitations of stroke MRI. By offering highly complementary information, [(15)O]H2O-PET/MRI might help to identify critically hypoperfused tissue resulting in an improved patient stratification in thrombolysis trials.
Collapse
Affiliation(s)
- Peter Werner
- Department of Nuclear Medicine, University of Leipzig, Leipzig, Germany
| | - Dorothee Saur
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | - Vilia Zeisig
- Department of Nuclear Medicine, University of Leipzig, Leipzig, Germany
| | - Barbara Ettrich
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | - Marianne Patt
- Department of Nuclear Medicine, University of Leipzig, Leipzig, Germany
| | - Bernhard Sattler
- Department of Nuclear Medicine, University of Leipzig, Leipzig, Germany
| | - Thies Jochimsen
- Department of Nuclear Medicine, University of Leipzig, Leipzig, Germany
| | - Donald Lobsien
- Department of Neuroradiology, University of Leipzig, Leipzig, Germany
| | - Philipp M Meyer
- Department of Nuclear Medicine, University of Leipzig, Leipzig, Germany
| | - Florian Then Bergh
- Department of Neurology, University of Leipzig, Leipzig, Germany.,Translational Centre for Regenerative Medicine, University Hospital Leipzig, University of Leipzig, Leipzig, Germany
| | - Antje Dreyer
- Translational Centre for Regenerative Medicine, University Hospital Leipzig, University of Leipzig, Leipzig, Germany.,Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Johannes Boltze
- Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany.,Massachusetts General Hospital and Harvard Medical School, Stroke and Neurovascular Regulation Laboratory, Charlestown, Massachusetts, USA
| | - Joseph Classen
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | - Dominik Fritzsch
- Department of Neuroradiology, University of Leipzig, Leipzig, Germany
| | | | - Osama Sabri
- Department of Nuclear Medicine, University of Leipzig, Leipzig, Germany
| | - Henryk Barthel
- Department of Nuclear Medicine, University of Leipzig, Leipzig, Germany
| |
Collapse
|
22
|
Zaro-Weber O, Livne M, Martin SZ, von Samson-Himmelstjerna FC, Moeller-Hartmann W, Schuster A, Brunecker P, Heiss WD, Sobesky J, Madai VI. Comparison of the 2 Most Popular Deconvolution Techniques for the Detection of Penumbral Flow in Acute Stroke. Stroke 2015; 46:2795-9. [PMID: 26306755 DOI: 10.1161/strokeaha.115.010246] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 07/15/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Dynamic susceptibility-weighted contrast-enhanced (DSC) magnetic resonance imaging (MRI) is used to identify the tissue-at-risk in acute stroke, but the choice of optimal DSC postprocessing in the clinical setting remains a matter of debate. Using 15O-water positron emission tomography (PET), we validated the performance of 2 common deconvolution methods for DSC-MRI. METHODS In (sub)acute stroke patients with consecutive MRI and PET imaging, DSC maps were calculated applying 2 deconvolution methods, standard and block-circulant single value decomposition. We used 2 standardized analysis methods, a region of interest-based and a voxel-based analysis, where PET cerebral blood flow masks of <20 mL/100 g per minute (penumbral flow) and gray matter masks were overlaid on DSC parameter maps. For both methods, receiver operating characteristic curve analysis was performed to identify the accuracy of each DSC-MR map for the detection of PET penumbral flow. RESULTS In 18 data sets (median time after stroke onset: 18 hours; median time PET to MRI: 101 minutes), block-circulant single value decomposition showed significantly better performance to detect PET penumbral flow only for mean transit time maps. Time-to-maximum (Tmax) had the highest performance independent of the deconvolution method. CONCLUSIONS Block-circulant single value decomposition seems only significantly beneficial for mean transit time maps in (sub)acute stroke. Tmax is likely the most stable deconvolved parameter for the detection of tissue-at-risk using DSC-MRI.
Collapse
Affiliation(s)
- Olivier Zaro-Weber
- From the Max-Planck-Institute for Metabolism Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.); Center for Stroke Research Berlin (CSB) (M.L., S.Z.M., F.C.v.S.-H., P.B., J.S., V.I.M.) and Department of Neurology (J.S., V.I.M.), Charité-Universitätsmedizin, Berlin, Germany; Fraunhofer MEVIS, Bremen, Germany (F.C.v.S.-H.); Department of Radiology, Ludmillenstift, Meppen, Germany (W.M.-H.); and Max-Planck-Institute for Neurological Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.).
| | - Michelle Livne
- From the Max-Planck-Institute for Metabolism Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.); Center for Stroke Research Berlin (CSB) (M.L., S.Z.M., F.C.v.S.-H., P.B., J.S., V.I.M.) and Department of Neurology (J.S., V.I.M.), Charité-Universitätsmedizin, Berlin, Germany; Fraunhofer MEVIS, Bremen, Germany (F.C.v.S.-H.); Department of Radiology, Ludmillenstift, Meppen, Germany (W.M.-H.); and Max-Planck-Institute for Neurological Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.)
| | - Steve Z Martin
- From the Max-Planck-Institute for Metabolism Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.); Center for Stroke Research Berlin (CSB) (M.L., S.Z.M., F.C.v.S.-H., P.B., J.S., V.I.M.) and Department of Neurology (J.S., V.I.M.), Charité-Universitätsmedizin, Berlin, Germany; Fraunhofer MEVIS, Bremen, Germany (F.C.v.S.-H.); Department of Radiology, Ludmillenstift, Meppen, Germany (W.M.-H.); and Max-Planck-Institute for Neurological Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.)
| | - Federico C von Samson-Himmelstjerna
- From the Max-Planck-Institute for Metabolism Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.); Center for Stroke Research Berlin (CSB) (M.L., S.Z.M., F.C.v.S.-H., P.B., J.S., V.I.M.) and Department of Neurology (J.S., V.I.M.), Charité-Universitätsmedizin, Berlin, Germany; Fraunhofer MEVIS, Bremen, Germany (F.C.v.S.-H.); Department of Radiology, Ludmillenstift, Meppen, Germany (W.M.-H.); and Max-Planck-Institute for Neurological Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.)
| | - Walter Moeller-Hartmann
- From the Max-Planck-Institute for Metabolism Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.); Center for Stroke Research Berlin (CSB) (M.L., S.Z.M., F.C.v.S.-H., P.B., J.S., V.I.M.) and Department of Neurology (J.S., V.I.M.), Charité-Universitätsmedizin, Berlin, Germany; Fraunhofer MEVIS, Bremen, Germany (F.C.v.S.-H.); Department of Radiology, Ludmillenstift, Meppen, Germany (W.M.-H.); and Max-Planck-Institute for Neurological Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.)
| | - Alexander Schuster
- From the Max-Planck-Institute for Metabolism Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.); Center for Stroke Research Berlin (CSB) (M.L., S.Z.M., F.C.v.S.-H., P.B., J.S., V.I.M.) and Department of Neurology (J.S., V.I.M.), Charité-Universitätsmedizin, Berlin, Germany; Fraunhofer MEVIS, Bremen, Germany (F.C.v.S.-H.); Department of Radiology, Ludmillenstift, Meppen, Germany (W.M.-H.); and Max-Planck-Institute for Neurological Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.)
| | - Peter Brunecker
- From the Max-Planck-Institute for Metabolism Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.); Center for Stroke Research Berlin (CSB) (M.L., S.Z.M., F.C.v.S.-H., P.B., J.S., V.I.M.) and Department of Neurology (J.S., V.I.M.), Charité-Universitätsmedizin, Berlin, Germany; Fraunhofer MEVIS, Bremen, Germany (F.C.v.S.-H.); Department of Radiology, Ludmillenstift, Meppen, Germany (W.M.-H.); and Max-Planck-Institute for Neurological Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.)
| | - Wolf-Dieter Heiss
- From the Max-Planck-Institute for Metabolism Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.); Center for Stroke Research Berlin (CSB) (M.L., S.Z.M., F.C.v.S.-H., P.B., J.S., V.I.M.) and Department of Neurology (J.S., V.I.M.), Charité-Universitätsmedizin, Berlin, Germany; Fraunhofer MEVIS, Bremen, Germany (F.C.v.S.-H.); Department of Radiology, Ludmillenstift, Meppen, Germany (W.M.-H.); and Max-Planck-Institute for Neurological Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.)
| | - Jan Sobesky
- From the Max-Planck-Institute for Metabolism Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.); Center for Stroke Research Berlin (CSB) (M.L., S.Z.M., F.C.v.S.-H., P.B., J.S., V.I.M.) and Department of Neurology (J.S., V.I.M.), Charité-Universitätsmedizin, Berlin, Germany; Fraunhofer MEVIS, Bremen, Germany (F.C.v.S.-H.); Department of Radiology, Ludmillenstift, Meppen, Germany (W.M.-H.); and Max-Planck-Institute for Neurological Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.)
| | - Vince I Madai
- From the Max-Planck-Institute for Metabolism Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.); Center for Stroke Research Berlin (CSB) (M.L., S.Z.M., F.C.v.S.-H., P.B., J.S., V.I.M.) and Department of Neurology (J.S., V.I.M.), Charité-Universitätsmedizin, Berlin, Germany; Fraunhofer MEVIS, Bremen, Germany (F.C.v.S.-H.); Department of Radiology, Ludmillenstift, Meppen, Germany (W.M.-H.); and Max-Planck-Institute for Neurological Research, Cologne, Germany (O.Z.-W., A.S., W.-D.H.).
| |
Collapse
|
23
|
Hotter B, Ostwaldt AC, Levichev-Connolly A, Rozanski M, Audebert HJ, Fiebach JB. Natural course of total mismatch and predictors for tissue infarction. Neurology 2015; 85:770-5. [PMID: 26231256 DOI: 10.1212/wnl.0000000000001889] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 05/05/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We longitudinally assessed patients presenting with total mismatch and hypothesized that hypoperfusion intensity ratio (HIR), severity of stroke, and occlusion of blood vessel are predictors of tissue fate. METHODS Patients with suspected stroke or TIA admitted to our emergency department between September 2008 and October 2012 with suspected stroke or TIA were eligible to participate in the ongoing stroke imaging study 1000Plus. Patients received acute and follow-up stroke MRI, basic demographics were collected, and stroke severity was rated according to the NIH Stroke Scale (NIHSS). Inclusion criteria for the substudy were total mismatch on admission examination and available follow-up. RESULTS We identified 23 patients with total mismatch: median age 70 years (interquartile range 66-78), 10 female (43.5%). Infarction was found on follow-up diffusion-weighted imaging (median lesion size 1.3 mL) in 9 patients (39.1%). Infarction was correlated with NIHSS at admission (p = 0.026) and HIR (p = 0.015) but not with vessel occlusion. Clinical outcome as measured by last recorded NIHSS score and modified Rankin Scale score at discharge was significantly worse in patients with infarction on follow-up. CONCLUSION Final infarction is frequently seen in patients with total mismatch. Clinical presentation at admission and severity of hypoperfusion measured by HIR, but not occlusion of the supplying vessel, predict tissue fate.
Collapse
Affiliation(s)
- Benjamin Hotter
- From the Center for Stroke Research Berlin, Charité University Hospital Berlin, Germany.
| | - Ann-Christin Ostwaldt
- From the Center for Stroke Research Berlin, Charité University Hospital Berlin, Germany
| | | | - Michal Rozanski
- From the Center for Stroke Research Berlin, Charité University Hospital Berlin, Germany
| | - Heinrich J Audebert
- From the Center for Stroke Research Berlin, Charité University Hospital Berlin, Germany
| | - Jochen B Fiebach
- From the Center for Stroke Research Berlin, Charité University Hospital Berlin, Germany
| |
Collapse
|
24
|
Baran U, Li Y, Wang RK. In vivo tissue injury mapping using optical coherence tomography based methods. APPLIED OPTICS 2015; 54:6448-53. [PMID: 26367827 PMCID: PMC4570269 DOI: 10.1364/ao.54.006448] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
An injury causes changes in the optical attenuation coefficient (OAC) of a light beam traveling inside a tissue. We report a method called tissue injury mapping (TIM), which utilizes a noninvasive in vivo optical coherence tomography approach to generate an OAC and microvascular map of the injured tissue. Using TIM, the infarct region development in a mouse cerebral cortex during a stroke is visualized. Moreover, we demonstrate the changes in human facial skin structure and microvasculature during an acne lesion development from initiation to scarring. The results indicate that TIM may be used to aid in the characterization and the treatment of various diseases by enabling a high-resolution detection of tissue structural and microvascular changes.
Collapse
Affiliation(s)
- Utku Baran
- Dept. of Bioengineering, University of Washington, 3720 15th Ave. NE, Seattle WA 98195, USA
- Dept. of Electrical Engineering, University of Washington, 185 Stevens Way, Seattle WA 98195, USA
| | - Yuandong Li
- Dept. of Bioengineering, University of Washington, 3720 15th Ave. NE, Seattle WA 98195, USA
| | - Ruikang K. Wang
- Dept. of Bioengineering, University of Washington, 3720 15th Ave. NE, Seattle WA 98195, USA
- Corresponding author:
| |
Collapse
|
25
|
Lestro Henriques I, Gutiérrez-Fernández M, Rodríguez-Frutos B, Ramos-Cejudo J, Otero-Ortega L, Navarro Hernanz T, Cerdán S, Ferro JM, Díez-Tejedor E. Intralesional Patterns of MRI ADC Maps Predict Outcome in Experimental Stroke. Cerebrovasc Dis 2015; 39:293-301. [PMID: 25895451 DOI: 10.1159/000381727] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 03/16/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND After acute ischemia, the tissue that is at risk of infarction can be detected by perfusion-weighted imaging/diffusion-weighted imaging (PWI/DWI) mismatch but the time that is needed to process PWI limits its use. As DWI is highly sensitive to acute ischemic tissue damage, we hypothesized that different ADC patterns represent areas with a different potential for recovery. METHODS In a model of permanent middle cerebral artery occlusion (pMCAO), Sprague-Dawley rats were randomly distributed to sham surgery and pMCAO. We further separated the pMCAO group according to intralesional ADC pattern (homogeneous or heterogeneous). At 24 h after ischemia induction, we analyzed lesion size, functional outcome, cell death expression, and brain protection markers including ROS enzyme NOX-4. MRI included DWI (ADC maps), DTI (tractography), and PWI (CBF, CBV and MTT). RESULTS The lesion size was similar in pMCAO rats. Animals with a heterogeneous pattern in ADC maps showed better functional outcome in Rotarod test (p = 0.032), less expression of cell death (p = 0.014) and NOX-4 (p = 0.0063), higher intralesional CBF (p = 0.0026) and larger PWI/DWI mismatch (p = 0.007). CONCLUSIONS In a rodent model for ischemic stroke, intralesional heterogeneity in ADC maps was related to better functional outcome in lesions of similar size and interval after pMCAO. DWI ADC maps may assist in the early identification of ischemic tissue with an increased potential for recovery as higher expression of acute protection markers, lower expression of cell death, increased PWI/DWI mismatch, and higher intralesional CBF were present in animals with a heterogeneous ADC pattern.
Collapse
Affiliation(s)
- Isabel Lestro Henriques
- Department of Neurology and Stroke Centre, Neuroscience and Cerebrovascular Research Laboratory, La Paz University Hospital, Neuroscience Area of IdiPAZ (Health Research Institute), Autónoma University of Madrid, Madrid, Spain
| | | | | | | | | | | | | | | | | |
Collapse
|
26
|
González-Duarte A, Venzor-Castellanos JP, Treviño-Frenk I, Cano-García F, Barrios-Ordoñez A. Acute hydrocephalus and stroke in a 20 year-old man. Brain Pathol 2014; 24:675-8. [PMID: 25345899 DOI: 10.1111/bpa.12206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Alejandra González-Duarte
- Department of Neurology, Insitituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City
| | | | | | | | | |
Collapse
|
27
|
Rapacchi S, Natsuaki Y, Plotnik A, Gabriel S, Laub G, Finn JP, Hu P. Reducing view-sharing using compressed sensing in time-resolved contrast-enhanced magnetic resonance angiography. Magn Reson Med 2014; 74:474-81. [PMID: 25157749 DOI: 10.1002/mrm.25414] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 07/23/2014] [Accepted: 07/25/2014] [Indexed: 11/11/2022]
Abstract
PURPOSE To study temporal and spatial blurring artifacts from k-space view-sharing in time-resolved MR angiography (MRA) and to propose a technique for reducing these artifacts. METHODS We acquired k-space data sets using a three-dimensional time-resolved MRA view-sharing sequence and retrospectively reformatted them into two reconstruction frameworks: full view-sharing via time-resolved imaging with stochastic trajectories (TWIST) and minimal k-space view-sharing and compressed sensing (CS-TWIST). The two imaging series differed in temporal footprint but not in temporal frame rate. The artifacts from view-sharing were compared qualitatively and quantitatively in nine patients in addition to a phantom experiment. RESULTS CS-TWIST was able to reduce the imaging temporal footprint by two- to three-fold compared with TWIST, and the overall subjective image quality of CS-TWIST was higher than that for TWIST (P < 0.05). View sharing caused a delay in the visualization of small blood vessels, and the mean transit time of the carotid artery calculated based on TWIST reconstruction was 0.6 s longer than that for CS-TWIST (P < 0.01). In thoracic MRA, the shorter temporal footprint decreased the sensitivity to physiological motion blurring, and vessel sharpness was improved by 8.8% ± 6.0% using CS-TWIST (P < 0.05). CONCLUSION In time-resolved MRA, the longer temporal footprint due to view-sharing causes spatial and temporal artifacts. CS-TWIST is a promising method for reducing these artifacts.
Collapse
Affiliation(s)
- Stanislas Rapacchi
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | - Adam Plotnik
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Simon Gabriel
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Gerhard Laub
- Siemens Healthcare, Los Angeles, California, USA
| | - J Paul Finn
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Peng Hu
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| |
Collapse
|
28
|
De Los Rios F, Kleindorfer DO, Guzik A, Ortega-Gutierrez S, Sangha N, Kumar G, Grotta JC, Lee JM, Meyer BC, Schwamm LH, Khatri P. Intravenous fibrinolysis eligibility: a survey of stroke clinicians' practice patterns and review of the literature. J Stroke Cerebrovasc Dis 2014; 23:2130-2138. [PMID: 25113084 DOI: 10.1016/j.jstrokecerebrovasdis.2014.03.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 03/29/2014] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The indications and contraindications for intravenous (IV) recombinant tissue plasminogen activator (rtPA) use in ischemic stroke can be confusing to the practicing neurologist. Here we seek to describe practice patterns regarding decision-making among US stroke clinicians. METHODS Stroke clinicians (attending and fellow) from the 8 National Institutes of Health SPOTRIAS (Specialized Programs of Translational Research in Acute Stroke) centers were asked to complete a survey ahead of the 2012 SPOTRIAS Investigators' meeting. RESULTS A total of 51 surveys were collected (71% response rate). Most of the responders were attending physicians (68%). Only 18% of clinicians reported strictly adhering to current American Heart Association guidelines for treatment within 3 hours from symptom onset; this increased to 51% for the European Cooperative Acute Stroke Study (ECASS) III criteria in the 3 to 4.5 hours time frame. All clinicians treat eligible patients in the 3 to 4.5 hours time frame. The great majority will recommend rtPA in the following scenarios: (1) elderly individuals irrespective of age (97%); (2) severe stroke irrespective of National Institutes of Health Stroke Scale (NIHSS) (95%); or (3) suspected stroke with seizures at symptom onset (91%). None recommended rtPA in the setting of an international normalized ratio >1.7. Most clinicians defined mild strokes as an exclusion based on the perceived disability of the deficit (80%) rather than on a specific NIHSS threshold. CONCLUSIONS Most surveyed stroke clinicians seem to find that the current IV rtPA eligibility criteria for the 3-hour time frame too restrictive. All would recommend rtPA to eligible patients in the 3 to 4.5 hours time frame despite the absence of an U.S. Food and Drug Administration (FDA)-approved indication.
Collapse
Affiliation(s)
- Felipe De Los Rios
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; Department of Neurology, Sanna Healthcare Network, Lima, Peru.
| | - Dawn O Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Amy Guzik
- Department of Neuroscience, University of California San Diego, San Diego, California
| | | | - Navdeep Sangha
- Department of Neurology, University of Texas, Houston, Texas
| | - Gyanendra Kumar
- Department of Neurology, Washington University, St. Louis, Missouri
| | - James C Grotta
- Department of Neurology, University of Texas, Houston, Texas
| | - Jin-Moo Lee
- Department of Neurology, Washington University, St. Louis, Missouri
| | - Brett C Meyer
- Department of Neuroscience, University of California San Diego, San Diego, California
| | - Lee H Schwamm
- Department of Neurology, Harvard Medical School, Boston, Massachussets
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | |
Collapse
|
29
|
Lou M, Chen Z, Wan J, Hu H, Cai X, Shi Z, Sun J. Susceptibility-diffusion mismatch predicts thrombolytic outcomes: a retrospective cohort study. AJNR Am J Neuroradiol 2014; 35:2061-7. [PMID: 25012670 DOI: 10.3174/ajnr.a4017] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND PURPOSE Asymmetric hypointensity of cerebral veins on susceptibility-weighted imaging has been shown to indirectly reflect tissue hypoxia after cerebral ischemia. We therefore investigated whether patients with prominent asymmetry of the cerebral veins on SWI and a relatively small diffusion-weighted imaging lesion (SWI-DWI mismatch), representing the presence of salvageable tissue, were more likely to benefit from thrombolytic therapy. MATERIALS AND METHODS We conducted a retrospective study of the anterior circulation of patients with ischemic stroke with SWI/DWI acquired before thrombolysis. The asymmetry index was defined as the ratio of cerebral vein voxel count between the ischemic and normal hemisphere on the SWI phase map. We defined SWI-DWI mismatch as an asymmetry index score of ≥1.75 with a DWI lesion volume of ≤25 mL. Favorable outcome was defined as modified Rankin Scale 0-2 at 3 months. Univariate and multivariate logistic regression analyses were used to examine the association between the mismatch profile and favorable outcome. RESULTS Fifty-four patients undergoing thrombolytic treatment were enrolled in this study. The rate of favorable outcome was significantly higher among patients with baseline SWI-DWI mismatch compared with those without (78% versus 44%; adjusted odds ratio, 6.317; 95% CI, 1.12-35.80; P = .037). Patients with SWI-DWI mismatch were also more likely to have a favorable outcome from reperfusion (91% versus 43%, P = .033) or recanalization (100% versus 40%, P = .013). The accuracy of SWI-DWI mismatch for predicting favorable outcome was higher than that of perfusion-diffusion mismatch (63% versus 48.1%). CONCLUSIONS The presence of SWI-DWI mismatch may identify patients with ischemia who would benefit from early reperfusion therapy.
Collapse
Affiliation(s)
- M Lou
- From the Departments of Neurology (M.L., Z.C., J.W., H.H., X.C., Z.S.)
| | - Z Chen
- From the Departments of Neurology (M.L., Z.C., J.W., H.H., X.C., Z.S.)
| | - J Wan
- From the Departments of Neurology (M.L., Z.C., J.W., H.H., X.C., Z.S.)
| | - H Hu
- From the Departments of Neurology (M.L., Z.C., J.W., H.H., X.C., Z.S.)
| | - X Cai
- From the Departments of Neurology (M.L., Z.C., J.W., H.H., X.C., Z.S.)
| | - Z Shi
- From the Departments of Neurology (M.L., Z.C., J.W., H.H., X.C., Z.S.)
| | - J Sun
- Radiology (J.S.), the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China.
| |
Collapse
|
30
|
Madai VI, Galinovic I, Grittner U, Zaro-Weber O, Schneider A, Martin SZ, Samson-Himmelstjerna FCV, Stengl KL, Mutke MA, Moeller-Hartmann W, Ebinger M, Fiebach JB, Sobesky J. DWI intensity values predict FLAIR lesions in acute ischemic stroke. PLoS One 2014; 9:e92295. [PMID: 24658092 PMCID: PMC3962388 DOI: 10.1371/journal.pone.0092295] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 02/21/2014] [Indexed: 12/03/2022] Open
Abstract
Background and Purpose In acute stroke, the DWI-FLAIR mismatch allows for the allocation of patients to the thrombolysis window (<4.5 hours). FLAIR-lesions, however, may be challenging to assess. In comparison, DWI may be a useful bio-marker owing to high lesion contrast. We investigated the performance of a relative DWI signal intensity (rSI) threshold to predict the presence of FLAIR-lesions in acute stroke and analyzed its association with time-from-stroke-onset. Methods In a retrospective, dual-center MR-imaging study we included patients with acute stroke and time-from-stroke-onset ≤12 hours (group A: n = 49, 1.5T; group B: n = 48, 3T). DW- and FLAIR-images were coregistered. The largest lesion extent in DWI defined the slice for further analysis. FLAIR-lesions were identified by 3 raters, delineated as regions-of-interest (ROIs) and copied on the DW-images. Circular ROIs were placed within the DWI-lesion and labeled according to the FLAIR-pattern (FLAIR+ or FLAIR−). ROI-values were normalized to the unaffected hemisphere. Adjusted and nonadjusted receiver-operating-characteristics (ROC) curve analysis on patient level was performed to analyze the ability of a DWI- and ADC-rSI threshold to predict the presence of FLAIR-lesions. Spearman correlation and adjusted linear regression analysis was performed to assess the relationship between DWI-intensity and time-from-stroke-onset. Results DWI-rSI performed well in predicting lesions in FLAIR-imaging (mean area under the curve (AUC): group A: 0.84; group B: 0.85). An optimal mean DWI-rSI threshold was identified (A: 162%; B: 161%). ADC-maps performed worse (mean AUC: A: 0.58; B: 0.77). Adjusted regression models confirmed the superior performance of DWI-rSI. Correlation coefficents and linear regression showed a good association with time-from-stroke-onset for DWI-rSI, but not for ADC-rSI. Conclusion An easily assessable DWI-rSI threshold identifies the presence of lesions in FLAIR-imaging with good accuracy and is associated with time-from-stroke-onset in acute stroke. This finding underlines the potential of a DWI-rSI threshold as a marker of lesion age.
Collapse
Affiliation(s)
- Vince I. Madai
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
- Department of Neurology, Charité-Universtitätsmedizin, Berlin, Germany
| | - Ivana Galinovic
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
| | - Ulrike Grittner
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
- Department for Biostatistics and Clinical Epidemiology, Charité-Universitätsmedizin, Berlin, Germany
| | - Olivier Zaro-Weber
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
- Max-Planck-Institute for Neurological Research, Cologne, Germany
| | - Alice Schneider
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
- Department for Biostatistics and Clinical Epidemiology, Charité-Universitätsmedizin, Berlin, Germany
| | - Steve Z. Martin
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
| | | | - Katharina L. Stengl
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
- Department of Neurology, Charité-Universtitätsmedizin, Berlin, Germany
| | - Matthias A. Mutke
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
- Department of Neurology, Charité-Universtitätsmedizin, Berlin, Germany
| | | | - Martin Ebinger
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
- Department of Neurology, Charité-Universtitätsmedizin, Berlin, Germany
| | - Jochen B. Fiebach
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
| | - Jan Sobesky
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany
- Department of Neurology, Charité-Universtitätsmedizin, Berlin, Germany
- * E-mail:
| |
Collapse
|
31
|
Dirnagl U, Endres M. Found in translation: preclinical stroke research predicts human pathophysiology, clinical phenotypes, and therapeutic outcomes. Stroke 2014; 45:1510-8. [PMID: 24652307 DOI: 10.1161/strokeaha.113.004075] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Ulrich Dirnagl
- From the Departments of Neurology and Experimental Neurology, Center for Stroke Research Berlin, and Excellence Cluster NeuroCure, Charité-Universitätsmedizin Berlin, Berlin, Germany (U.D., M.E.); German Center for Neurodegeneration Research (DZNE), Partner Site, Berlin, Germany (U.D.); and German Center for Cardiovascular Diseases (DZHK), Partner Site, Berlin, Germany (U.D., M.E.)
| | | |
Collapse
|
32
|
Dieringer MA, Deimling M, Santoro D, Wuerfel J, Madai VI, Sobesky J, von Knobelsdorff-Brenkenhoff F, Schulz-Menger J, Niendorf T. Rapid parametric mapping of the longitudinal relaxation time T1 using two-dimensional variable flip angle magnetic resonance imaging at 1.5 Tesla, 3 Tesla, and 7 Tesla. PLoS One 2014; 9:e91318. [PMID: 24621588 PMCID: PMC3951399 DOI: 10.1371/journal.pone.0091318] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 02/08/2014] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Visual but subjective reading of longitudinal relaxation time (T1) weighted magnetic resonance images is commonly used for the detection of brain pathologies. For this non-quantitative measure, diagnostic quality depends on hardware configuration, imaging parameters, radio frequency transmission field (B1+) uniformity, as well as observer experience. Parametric quantification of the tissue T1 relaxation parameter offsets the propensity for these effects, but is typically time consuming. For this reason, this study examines the feasibility of rapid 2D T1 quantification using a variable flip angles (VFA) approach at magnetic field strengths of 1.5 Tesla, 3 Tesla, and 7 Tesla. These efforts include validation in phantom experiments and application for brain T1 mapping. METHODS T1 quantification included simulations of the Bloch equations to correct for slice profile imperfections, and a correction for B1+. Fast gradient echo acquisitions were conducted using three adjusted flip angles for the proposed T1 quantification approach that was benchmarked against slice profile uncorrected 2D VFA and an inversion-recovery spin-echo based reference method. Brain T1 mapping was performed in six healthy subjects, one multiple sclerosis patient, and one stroke patient. RESULTS Phantom experiments showed a mean T1 estimation error of (-63±1.5)% for slice profile uncorrected 2D VFA and (0.2±1.4)% for the proposed approach compared to the reference method. Scan time for single slice T1 mapping including B1+ mapping could be reduced to 5 seconds using an in-plane resolution of (2×2) mm2, which equals a scan time reduction of more than 99% compared to the reference method. CONCLUSION Our results demonstrate that rapid 2D T1 quantification using a variable flip angle approach is feasible at 1.5T/3T/7T. It represents a valuable alternative for rapid T1 mapping due to the gain in speed versus conventional approaches. This progress may serve to enhance the capabilities of parametric MR based lesion detection and brain tissue characterization.
Collapse
Affiliation(s)
- Matthias A. Dieringer
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max-Delbrueck Center for Molecular Medicine, Berlin, Germany
- Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center, a joint cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, HELIOS Clinics Berlin Buch, Department of Cardiology and Nephrology, Berlin, Germany
- * E-mail:
| | - Michael Deimling
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max-Delbrueck Center for Molecular Medicine, Berlin, Germany
- Siemens Healthcare, Erlangen, Germany
| | - Davide Santoro
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max-Delbrueck Center for Molecular Medicine, Berlin, Germany
| | - Jens Wuerfel
- Institute of Neuroradiology, University Medicine Göttingen, Göttingen, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Berlin, Germany
| | - Vince I. Madai
- Clinic for Neurology & Center for Stroke Research Berlin, Charité Medical Faculty Berlin, Berlin, Germany
| | - Jan Sobesky
- Clinic for Neurology & Center for Stroke Research Berlin, Charité Medical Faculty Berlin, Berlin, Germany
| | - Florian von Knobelsdorff-Brenkenhoff
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max-Delbrueck Center for Molecular Medicine, Berlin, Germany
- Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center, a joint cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, HELIOS Clinics Berlin Buch, Department of Cardiology and Nephrology, Berlin, Germany
| | - Jeanette Schulz-Menger
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max-Delbrueck Center for Molecular Medicine, Berlin, Germany
- Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center, a joint cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, HELIOS Clinics Berlin Buch, Department of Cardiology and Nephrology, Berlin, Germany
| | - Thoralf Niendorf
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max-Delbrueck Center for Molecular Medicine, Berlin, Germany
- Experimental and Clinical Research Center, a joint cooperation between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany
| |
Collapse
|
33
|
Canazza A, Minati L, Boffano C, Parati E, Binks S. Experimental models of brain ischemia: a review of techniques, magnetic resonance imaging, and investigational cell-based therapies. Front Neurol 2014; 5:19. [PMID: 24600434 PMCID: PMC3928567 DOI: 10.3389/fneur.2014.00019] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 02/06/2014] [Indexed: 01/17/2023] Open
Abstract
Stroke continues to be a significant cause of death and disability worldwide. Although major advances have been made in the past decades in prevention, treatment, and rehabilitation, enormous challenges remain in the way of translating new therapeutic approaches from bench to bedside. Thrombolysis, while routinely used for ischemic stroke, is only a viable option within a narrow time window. Recently, progress in stem cell biology has opened up avenues to therapeutic strategies aimed at supporting and replacing neural cells in infarcted areas. Realistic experimental animal models are crucial to understand the mechanisms of neuronal survival following ischemic brain injury and to develop therapeutic interventions. Current studies on experimental stroke therapies evaluate the efficiency of neuroprotective agents and cell-based approaches using primarily rodent models of permanent or transient focal cerebral ischemia. In parallel, advancements in imaging techniques permit better mapping of the spatial-temporal evolution of the lesioned cortex and its functional responses. This review provides a condensed conceptual review of the state of the art of this field, from models and magnetic resonance imaging techniques through to stem cell therapies.
Collapse
Affiliation(s)
- Alessandra Canazza
- Cerebrovascular Diseases Unit, Fondazione IRCCS Istituto Neurologico "Carlo Besta" , Milan , Italy
| | - Ludovico Minati
- Scientific Department, Fondazione IRCCS Istituto Neurologico "Carlo Besta" , Milan , Italy ; Brighton and Sussex Medical School , Brighton , UK
| | - Carlo Boffano
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico "Carlo Besta" , Milan , Italy
| | - Eugenio Parati
- Cerebrovascular Diseases Unit, Fondazione IRCCS Istituto Neurologico "Carlo Besta" , Milan , Italy
| | - Sophie Binks
- Brighton and Sussex Medical School , Brighton , UK ; Brighton and Sussex University Hospitals NHS Trust , Brighton , UK
| |
Collapse
|
34
|
Clinical evaluation of an arterial-spin-labeling product sequence in steno-occlusive disease of the brain. PLoS One 2014; 9:e87143. [PMID: 24516546 PMCID: PMC3916330 DOI: 10.1371/journal.pone.0087143] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 12/18/2013] [Indexed: 11/28/2022] Open
Abstract
Introduction In brain perfusion imaging, arterial spin labeling (ASL) is a noninvasive alternative to dynamic susceptibility contrast-magnetic resonance imaging (DSC-MRI). For clinical imaging, only product sequences can be used. We therefore analyzed the performance of a product sequence (PICORE-PASL) included in an MRI software-package compared with DSC-MRI in patients with steno-occlusion of the MCA or ICA >70%. Methods Images were acquired on a 3T MRI system and qualitatively analyzed by 3 raters. For a quantitative analysis, cortical ROIs were placed in co-registered ASL and DSC images. Pooled data for ASL-cerebral blood flow (CBF) and DSC-CBF were analyzed by Spearman’s correlation and the Bland-Altman (BA)-plot. Results In 28 patients, 11 ASL studies were uninterpretable due to patient motion. Of the remaining patients, 71% showed signs of delayed tracer arrival. A weak correlation for DSC-relCBF vs ASL-relCBF (r = 0.24) and a large spread of values in the BA-plot owing to unreliable CBF-measurement was found. Conclusion The PICORE ASL product sequence is sensitive for estimation of delayed tracer arrival, but cannot be recommended to measure CBF in steno-occlusive disease. ASL-sequences that are less sensitive to patient motion and correcting for delayed blood flow should be available in the clinical setting.
Collapse
|
35
|
Bouts MJRJ, Tiebosch IACW, van der Toorn A, Hendrikse J, Dijkhuizen RM. Lesion development and reperfusion benefit in relation to vascular occlusion patterns after embolic stroke in rats. J Cereb Blood Flow Metab 2014; 34:332-8. [PMID: 24301289 PMCID: PMC3915211 DOI: 10.1038/jcbfm.2013.202] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 10/08/2013] [Accepted: 10/25/2013] [Indexed: 11/09/2022]
Abstract
Vascular occlusion sites largely determine the pattern of cerebral tissue damage and likelihood of subsequent reperfusion after acute ischemic stroke. We aimed to elucidate relationships between flow obstruction in segments of the internal carotid artery (ICA) and middle cerebral artery (MCA), and (1) profiles of acute ischemic lesions and (2) probability of subsequent beneficial reperfusion. Embolic stroke was induced by unilateral intracarotid blood clot injection in normotensive (n=53) or spontaneously hypertensive (n=20) rats, followed within 2 hours by magnetic resonance (MR) angiography (MRA), diffusion- (DWI) and perfusion-weighted magnetic resonance imaging (MRI) (PWI). In a subset of animals (n=9), MRI was repeated after 24 and 168 hours to determine the predictive value of the occlusion pattern on benefit of reperfusion. The extent of cerebral perfusion and diffusion abnormality was related to the pattern of flow obstruction in ICA and MCA segments. Hypertensive animals displayed significantly larger cortical perfusion lesions. Acute perfusion-diffusion lesion mismatches were detected in all animals that subsequently benefitted from reperfusion. Yet, the presence of an angiography-diffusion mismatch was more specific in predicting reperfusion benefit. Combination of DWI, PWI, and MRA exclusively informs on the impact of arterial occlusion profiles after acute ischemic stroke, which may improve prognostication and subsequent treatment decisions.
Collapse
Affiliation(s)
- Mark J R J Bouts
- 1] Biomedical MR Imaging and Spectroscopy Group, Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands [2] Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Ivo A C W Tiebosch
- Biomedical MR Imaging and Spectroscopy Group, Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Annette van der Toorn
- Biomedical MR Imaging and Spectroscopy Group, Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rick M Dijkhuizen
- Biomedical MR Imaging and Spectroscopy Group, Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| |
Collapse
|
36
|
Alawneh JA, Moustafa RR, Marrapu ST, Jensen-Kondering U, Morris RS, Jones PS, Aigbirhio FI, Fryer TD, Carpenter TA, Warburton EA, Baron JC. Diffusion and perfusion correlates of the 18F-MISO PET lesion in acute stroke: pilot study. Eur J Nucl Med Mol Imaging 2013; 41:736-44. [PMID: 24126468 DOI: 10.1007/s00259-013-2581-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 09/12/2013] [Indexed: 12/22/2022]
Abstract
PURPOSE Mapping the ischaemic penumbra in acute stroke is of considerable clinical interest. For this purpose, mapping tissue hypoxia with (18)F-misonidazole (FMISO) PET is attractive, and is straightforward compared to (15)O PET. Given the current emphasis on penumbra imaging using diffusion/perfusion MR or CT perfusion, investigating the relationships between FMISO uptake and abnormalities with these modalities is important. METHODS According to a prospective design, three patients (age 54-81 years; admission NIH stroke scale scores 16-22) with an anterior circulation stroke and extensive penumbra on CT- or MR-based perfusion imaging successfully completed FMISO PET, diffusion-weighted imaging and MR angiography 6-26 h after stroke onset, and follow-up FLAIR to map the final infarction. All had persistent proximal occlusion and a poor outcome despite thrombolysis. Significant FMISO trapping was defined voxel-wise relative to ten age-matched controls and mapped onto coregistered maps of the penumbra and irreversibly damaged ischaemic core. RESULTS FMISO trapping was present in all patients (volume range 18-119 ml) and overlapped mainly with the penumbra but also with the core in each patient. There was a significant (p ≤ 0.001) correlation in the expected direction between FMISO uptake and perfusion, with a sharp FMISO uptake bend around the expected penumbra threshold. CONCLUSION FMISO uptake had the expected overlap with the penumbra and relationship with local perfusion. However, consistent with recent animal data, our study suggests FMISO trapping may not be specific to the penumbra. If confirmed in larger samples, this preliminary finding would have potential implications for the clinical application of FMISO PET in acute ischaemic stroke.
Collapse
Affiliation(s)
- Josef A Alawneh
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Bouts MJRJ, Tiebosch IACW, van der Toorn A, Viergever MA, Wu O, Dijkhuizen RM. Early identification of potentially salvageable tissue with MRI-based predictive algorithms after experimental ischemic stroke. J Cereb Blood Flow Metab 2013; 33:1075-82. [PMID: 23571283 PMCID: PMC3705436 DOI: 10.1038/jcbfm.2013.51] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Revised: 03/04/2013] [Accepted: 03/05/2013] [Indexed: 01/13/2023]
Abstract
Individualized stroke treatment decisions can be improved by accurate identification of the extent of salvageable tissue. Magnetic resonance imaging (MRI)-based approaches, including measurement of a 'perfusion-diffusion mismatch' and calculation of infarction probability, allow assessment of tissue-at-risk; however, the ability to explicitly depict potentially salvageable tissue remains uncertain. In this study, five predictive algorithms (generalized linear model (GLM), generalized additive model, support vector machine, adaptive boosting, and random forest) were tested in their potency to depict acute cerebral ischemic tissue that can recover after reperfusion. Acute T2-, diffusion-, and perfusion-weighted MRI, and follow-up T2 maps were collected from rats subjected to right-sided middle cerebral artery occlusion without subsequent reperfusion, for training of algorithms (Group I), and with spontaneous (Group II) or thrombolysis-induced reperfusion (Group III), to determine infarction probability-based viability thresholds and prediction accuracies. The infarction probability difference between irreversible-i.e., infarcted after reperfusion-and salvageable tissue injury-i.e., noninfarcted after reperfusion-was largest for GLM (20±7%) with highest accuracy of risk-based identification of acutely ischemic tissue that could recover on subsequent reperfusion (Dice's similarity index=0.79±0.14). Our study shows that assessment of the heterogeneity of infarction probability with MRI-based algorithms enables estimation of the extent of potentially salvageable tissue after acute ischemic stroke.
Collapse
Affiliation(s)
- Mark J R J Bouts
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | | | | | | | | |
Collapse
|
38
|
Barber PA. Magnetic resonance imaging of ischemia viability thresholds and the neurovascular unit. SENSORS 2013; 13:6981-7003. [PMID: 23711462 PMCID: PMC3715273 DOI: 10.3390/s130606981] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Revised: 05/02/2013] [Accepted: 05/06/2013] [Indexed: 01/24/2023]
Abstract
Neuroimaging has improved our understanding of the evolution of stroke at discreet time points helping to identify irreversibly damaged and potentially reversible ischemic brain. Neuroimaging has also contributed considerably to the basic premise of acute stroke therapy which is to salvage some portion of the ischemic region from evolving into infarction, and by doing so, maintaining brain function and improving outcome. The term neurovascular unit (NVU) broadens the concept of the ischemic penumbra by linking the microcirculation with neuronal-glial interactions during ischemia reperfusion. Strategies that attempt to preserve the individual components (endothelium, glia and neurons) of the NVU are unlikely to be helpful if blood flow is not fully restored to the microcirculation. Magnetic resonance imaging (MRI) is the foremost imaging technology able to bridge both basic science and the clinic via non-invasive real time high-resolution anatomical delineation of disease manifestations at the molecular and ionic level. Current MRI based technologies have focused on the mismatch between perfusion-weighted imaging (PWI) and diffusion weighted imaging (DWI) signals to estimate the tissue that could be saved if reperfusion was achieved. Future directions of MRI may focus on the discordance of recanalization and reperfusion, providing complimentary pathophysiological information to current compartmental paradigms of infarct core (DWI) and penumbra (PWI) with imaging information related to cerebral blood flow, BBB permeability, inflammation, and oedema formation in the early acute phase. In this review we outline advances in our understanding of stroke pathophysiology with imaging, transcending animal stroke models to human stroke, and describing the potential translation of MRI to image important interactions relevant to acute stroke at the interface of the neurovascular unit.
Collapse
Affiliation(s)
- Philip A Barber
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.
| |
Collapse
|
39
|
The potential roles of 18F-FDG-PET in management of acute stroke patients. BIOMED RESEARCH INTERNATIONAL 2013; 2013:634598. [PMID: 23762852 PMCID: PMC3671294 DOI: 10.1155/2013/634598] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Accepted: 04/14/2013] [Indexed: 01/17/2023]
Abstract
Extensive efforts have recently been devoted to developing noninvasive imaging tools capable of delineating brain tissue viability (penumbra) during acute ischemic stroke. These efforts could have profound clinical implications for identifying patients who may benefit from tPA beyond the currently approved therapeutic time window and/or patients undergoing neuroendovascular treatments. To date, the DWI/PWI MRI and perfusion CT have received the most attention for identifying ischemic penumbra. However, their routine use in clinical settings remains limited. Preclinical and clinical PET studies with [18F]-fluoro-2-deoxy-D-glucose (18F-FDG) have consistently revealed a decreased 18F-FDG uptake in regions of presumed ischemic core. More importantly, an elevated 18F-FDG uptake in the peri-ischemic regions has been reported, potentially reflecting viable tissues. To this end, this paper provides a comprehensive review of the literature on the utilization of 14C-2-DG and 18F-FDG-PET in experimental as well as human stroke studies. Possible cellular mechanisms and physiological underpinnings attributed to the reported temporal and spatial uptake patterns of 18F-FDG are addressed. Given the wide availability of 18F-FDG in routine clinical settings, 18F-FDG PET may serve as an alternative, non-invasive tool to MRI and CT for the management of acute stroke patients.
Collapse
|