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Zhou X, Cui M, Liu Y, Wu Y, Hu D, Zhai D, Qin M, Shen J, Ju S, Fan G, Cai W. Low Dose Iodinated Contrast Material and Radiation for Virtual Monochromatic Imaging in Craniocervical Dual-Layer Spectral Detector Computed Tomography Angiography: A Prospective and Randomized Study. Acad Radiol 2023:S1076-6332(23)00681-5. [PMID: 38135625 DOI: 10.1016/j.acra.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 12/01/2023] [Accepted: 12/01/2023] [Indexed: 12/24/2023]
Abstract
RATIONALE AND OBJECTIVES To investigate the feasibility of virtual monochromatic imaging (VMI) of dual-layer spectral detector computed tomography (SDCT) to reduce iodinated contrast material (CM) and radiation dose in craniocervical computed tomography angiography (CTA). MATERIALS AND METHODS A total of 280 consecutively selected patients performed craniocervical CTA with SDCT were prospectively selected and randomly divided into four groups (A, DoseRight index (DRI) 31, iopromide 370mgI/mL, volume 0.8 mL/kg; B, DRI 26, iopromide 370mgI/mL, volume 0.4 mL/kg; C, DRI 26, ioversol 320mgI/mL, volume 0.4 mL/kg; D, DRI 26, iohexol 300mgI/mL, volume 0.4 mL/kg). 50-70 kiloelectron volts (keV) VMIs in group B were reconstructed and compared to group A to select the optimal keV. Then, the optimal keV in groups B, C and D was reconstructed and compared. Objective image quality, including vascular attenuation, image noise, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR), was evaluated. Subjective image quality was assessed using a 5-point Likert scale. In addition, the effective dose (ED), iodine load and iodine delivery rate (IDR) were compared between groups A and D. RESULTS 55 keV VMI was the optimal VMI in group B. The objective and subjective image quality of 55 keV VMI in group B were equal to or better than those of the CI in group A. The SNR, CNR and subjective image quality in group D were similar to those in group B (P > 0.05). The ED, iodine load and IDR of group D were reduced by 44%, 59% and 19%, respectively, when compared to those of group A. CONCLUSION Low dose iodinated CM and radiation for 55 keV VMI in craniocervical CTA using SDCT could still provide equivalent or better image quality than the conventional scanning protocol.
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Affiliation(s)
- Xiuzhi Zhou
- Department of Radiology, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Gusu, Suzhou, 215004, Jiangsu, China (X.Z., M.C., Y.L., Y.W., D.H., D.Z., J.S., G.F., W.C.)
| | - Manman Cui
- Department of Radiology, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Gusu, Suzhou, 215004, Jiangsu, China (X.Z., M.C., Y.L., Y.W., D.H., D.Z., J.S., G.F., W.C.)
| | - Yan Liu
- Department of Radiology, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Gusu, Suzhou, 215004, Jiangsu, China (X.Z., M.C., Y.L., Y.W., D.H., D.Z., J.S., G.F., W.C.)
| | - Yuanyuan Wu
- Department of Radiology, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Gusu, Suzhou, 215004, Jiangsu, China (X.Z., M.C., Y.L., Y.W., D.H., D.Z., J.S., G.F., W.C.)
| | - Dongliang Hu
- Department of Radiology, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Gusu, Suzhou, 215004, Jiangsu, China (X.Z., M.C., Y.L., Y.W., D.H., D.Z., J.S., G.F., W.C.)
| | - Duchang Zhai
- Department of Radiology, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Gusu, Suzhou, 215004, Jiangsu, China (X.Z., M.C., Y.L., Y.W., D.H., D.Z., J.S., G.F., W.C.)
| | - Mingyu Qin
- Suzhou Medical College of Soochow University, Suzhou, 215026, Jiangsu, China (M.Q.)
| | - Junkang Shen
- Department of Radiology, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Gusu, Suzhou, 215004, Jiangsu, China (X.Z., M.C., Y.L., Y.W., D.H., D.Z., J.S., G.F., W.C.)
| | - Shenghong Ju
- Department of Radiology, Zhongda Hospital, Medical School of Southeast University, Nanjing, 210009, Jiangsu, China (S.J.)
| | - Guohua Fan
- Department of Radiology, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Gusu, Suzhou, 215004, Jiangsu, China (X.Z., M.C., Y.L., Y.W., D.H., D.Z., J.S., G.F., W.C.)
| | - Wu Cai
- Department of Radiology, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Gusu, Suzhou, 215004, Jiangsu, China (X.Z., M.C., Y.L., Y.W., D.H., D.Z., J.S., G.F., W.C.).
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Piscopo A, Zanaty M, Dlouhy K. Contemporary Methods for Detection and Intervention of Distal Medium and Small Vessel Occlusions. J Clin Med 2023; 12:6071. [PMID: 37763011 PMCID: PMC10531921 DOI: 10.3390/jcm12186071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/10/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
The efficacy of using mechanical thrombectomy for proximal large vessel occlusions has been demonstrated in multiple large-scale trials and has further raised the question of its potential utility for distal medium and small vessel occlusions (DMSVOs). Their longer, more tortuous course and smaller corresponding vascular territories render a significant challenge for detection and intervention. The aim of this study is to provide a comprehensive overview of the current imaging and endovascular intervention options for DMSVOs and review the current works in the literature. Compared with traditional computed tomography angiography (CTA) and CT perfusion, recent advances such as multiphase CTA and maps derived from the time-to-maximum parameter coupled with artificial intelligence have demonstrated increased sensitivity for the detection of DMSVOs. Furthermore, newer generations of mini stent retrievers and thromboaspiration devices have allowed for the access and navigation of smaller and more fragile distal arteries. Preliminary studies have suggested that mechanical thrombectomy using this newer generation of devices is both safe and feasible in distal medium-sized vessels, such as M2. However, endovascular intervention utilizing such contemporary methods and devices must be balanced at the discretion of operator experience and favorable vascular anatomy. Further large-scale multicenter clinical trials are warranted to elucidate the indications for as well as to strengthen the safety and efficacy of this approach.
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Affiliation(s)
| | - Mario Zanaty
- Department of Neurosurgery, University of Iowa Hospital and Clinics, Iowa City, IA 52242, USA; (A.P.); (K.D.)
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3
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Schneider AM, Neuhaus AA, Hadley G, Balami JS, Harston GW, DeLuca GC, Buchan AM. Posterior circulation ischaemic stroke diagnosis and management. Clin Med (Lond) 2023; 23:219-227. [PMID: 37236792 PMCID: PMC11046504 DOI: 10.7861/clinmed.2022-0499] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
This narrative review provides an overview of the posterior circulation and the clinical features of common posterior circulation stroke (PCS) syndromes in the posterior arterial territories and how to distinguish them from mimics. We outline the hyperacute management of patients with suspected PCS with emphasis on how to identify those who are likely to benefit from intervention based on imaging findings. Finally, we review advances in treatment options, including developments in endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT), and the principles of medical management and indications for neurosurgery. Observational and randomised clinical trial data have been equivocal regarding EVT in PCS, but more recent studies strongly support its efficacy. There have been concomitant advances in imaging of posterior stroke to guide optimal patient selection for thrombectomy. Recent evidence suggests that clinicians should have a heightened suspicion of posterior circulation events with the resultant implementation of timely, evidence-based management.
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Affiliation(s)
| | | | | | - Joyce S Balami
- University of Oxford, Oxford, UK, and consultant stroke physician, Norfolk and Norwich University Teaching Hospital NHS Trust, Norwich, UK
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4
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Shulman JG, Abdalkader M. Imaging of Central Nervous System Ischemia. Continuum (Minneap Minn) 2023; 29:54-72. [PMID: 36795873 DOI: 10.1212/con.0000000000001185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
OBJECTIVE This article describes imaging modalities used in the evaluation of patients presenting with symptoms of acute ischemic stroke. LATEST DEVELOPMENTS The year 2015 marked the beginning of a new era in acute stroke care with the widespread adoption of mechanical thrombectomy. Subsequent randomized controlled trials in 2017 and 2018 brought the stroke community even further into this new territory with the expansion of the eligibility window for thrombectomy using imaging-based patient selection, which led to an increase in the use of perfusion imaging. Now, after several years of routine use, the debate is ongoing as to when this additional imaging is truly required and when it results in unnecessary delays in time-sensitive stroke care. At this time, more than ever, a robust understanding of neuroimaging techniques, applications, and interpretation is essential for the practicing neurologist. ESSENTIAL POINTS CT-based imaging is the first step in most centers for the evaluation of patients presenting with symptoms of acute stroke because of its wide availability, speed, and safety. Noncontrast head CT alone is sufficient for IV thrombolysis decision making. CT angiography is very sensitive for the detection of large-vessel occlusion and can be used reliably to make this determination. Advanced imaging including multiphase CT angiography, CT perfusion, MRI, and MR perfusion can provide additional information useful for therapeutic decision making in specific clinical scenarios. In all cases, it is essential that neuroimaging be performed and interpreted rapidly to allow for timely reperfusion therapy.
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5
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Duvekot MHC, van Es ACGM, Venema E, Wolff L, Rozeman AD, Moudrous W, Vermeij FH, Lingsma HF, Bakker J, Plaisier AS, Hensen JHJ, Lycklama À Nijeholt GJ, Jan van Doormaal P, Dippel DWJ, Kerkhoff H, Roozenbeek B, van der Lugt A. Accuracy of CTA evaluations in daily clinical practice for large and medium vessel occlusion detection in suspected stroke patients. Eur Stroke J 2022; 6:357-366. [PMID: 35342807 DOI: 10.1177/23969873211058576] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Early detection of large vessel occlusion (LVO) is essential to facilitate fast endovascular treatment. CT angiography (CTA) is used to detect LVO in suspected stroke patients. We aimed to assess the accuracy of CTA evaluations in daily clinical practice in a large cohort of suspected stroke patients. PATIENTS AND METHODS We used data from the PRESTO study, a multicenter prospective observational cohort study that included suspected stroke patients between August 2018 and September 2019. Baseline CTAs were re-evaluated by an imaging core laboratory and compared to the local assessment. LVO was defined as an occlusion of the intracranial internal carotid artery, M1 segment, or basilar artery. Medium vessel occlusion (MeVO) was defined as an A1, A2, or M2 occlusion. We calculated the accuracy, sensitivity, and specificity to detect LVO and LVO+MeVO, using the core laboratory evaluation as reference standard. RESULTS We included 656 patients. The core laboratory detected 89 LVOs and 74 MeVOs in 155 patients. Local observers missed 6 LVOs (7%) and 28 MeVOs (38%), of which 23 M2 occlusions. Accuracy of LVO detection was 99% (95% CI: 98-100%), sensitivity 93% (95% CI: 86-97%), and specificity 100% (95% CI: 99-100%). Accuracy of LVO+MeVO detection was 95% (95% CI: 93-96%), sensitivity 79% (95% CI: 72-85%), and specificity 99% (95% CI: 98-100%). DISCUSSION AND CONCLUSION CTA evaluations in daily clinical practice are highly accurate and LVOs are adequately recognized. The detection of MeVOs seems more challenging. The evolving EVT possibilities emphasize the need to improve CTA evaluations in the acute setting.
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Affiliation(s)
- Martijne H C Duvekot
- Department of Neurology, Albert Schweitzer hospital, Dordrecht, the Netherlands.,Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Adriaan C G M van Es
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Esmee Venema
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Lennard Wolff
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Anouk D Rozeman
- Department of Neurology, Albert Schweitzer hospital, Dordrecht, the Netherlands
| | - Walid Moudrous
- Department of Neurology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Frédérique H Vermeij
- Department of Neurology, Franciscus Gasthuis and Vlietland, Rotterdam, the Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jeannette Bakker
- Department of Radiology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Aarnout S Plaisier
- Department of Radiology, IJsselland Hospital, Capelle a/d IJssel, the Netherlands
| | - Jan-Hein J Hensen
- Department of Radiology, Maasstad Hospital, Rotterdam, the Netherlands
| | | | - Pieter Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer hospital, Dordrecht, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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6
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Prodi E, Danieli L, Manno C, Pagnamenta A, Pravatà E, Roccatagliata L, Städler C, Cereda CW, Cianfoni A. Stroke Mimics in the Acute Setting: Role of Multimodal CT Protocol. AJNR Am J Neuroradiol 2022; 43:216-222. [PMID: 34969667 PMCID: PMC8985681 DOI: 10.3174/ajnr.a7379] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 10/06/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE Ischemic stroke can be mimicked by nonischemic conditions. Due to emphasis on the rapid treatment of acute ischemic stroke, it is crucial to identify these conditions to avoid unnecessary therapies and potential complications. We investigated the performance of the multimodal CT protocol (unenhanced brain CT, CTA, and CTP) to discriminate stroke mimics from acute ischemic stroke. MATERIALS AND METHODS We retrospectively selected multimodal CT studies performed for clinical suspicion of acute ischemic stroke in our center in a 24-month period, including patients with at least 1 follow-up imaging study (brain CT or MR imaging). Hemorrhagic strokes were excluded. We measured the performance of multimodal CT, comparing the original diagnostic results with the final clinical diagnosis at discharge. RESULTS Among 401 patients, a stroke mimic condition was diagnosed in 89 (22%), including seizures (34.8%), migraine with aura attack (12.4%), conversion disorder (12.4%), infection (7.9%), brain tumor (7.9%), acute metabolic condition (6.7%), peripheral vertigo (5.6%), syncope (5.6%), transient global amnesia (3.4%), subdural hematoma (1.1%), cervical epidural hematoma (1.1%), and dural AVF (1.1%). Multimodal CT sensitivity, specificity, and accuracy were 24.7%, 99.7%, and 83%. Multimodal CT revealed peri-ictal changes in 13/31 seizures and diagnosed 7/7 brain tumors, 1/1 dural AVF, and 1/1 subdural hematoma. CT perfusion played a pivotal diagnostic role. CONCLUSIONS Multimodal CT demonstrated low sensitivity but high specificity in the diagnosis of stroke mimics in the acute setting. The high specificity of multimodal CT allows ruling out stroke and thereby avoiding unnecessary revascularization treatment in patients with diagnosis of a stroke mimic.
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Affiliation(s)
- E Prodi
- From the Departments of Neuroradiology (E.Prodi, L.D., E.Pravatà, A.C.)
| | - L Danieli
- From the Departments of Neuroradiology (E.Prodi, L.D., E.Pravatà, A.C.)
| | - C Manno
- Neurology (C.M., C.S., C.W.C.), Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
| | - A Pagnamenta
- Unit of Clinical Epidemiology (A.P.), Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Department of Intensive Care Medicine (A.P.), Ente Ospedaliero Cantonale, Mendrisio, Switzerland
- Division of Pneumology (A.P.), University Hospital of Geneva, Geneva, Switzerland
| | - E Pravatà
- From the Departments of Neuroradiology (E.Prodi, L.D., E.Pravatà, A.C.)
- Faculty of Biomedical Sciences (E. Pravatà), Università della Svizzera Italiana, Lugano, Switzerland
| | - L Roccatagliata
- Department of Health Science (DISSAL) (L.R.), University of Genova, Genova, Italy
| | - C Städler
- Neurology (C.M., C.S., C.W.C.), Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
| | - C W Cereda
- Neurology (C.M., C.S., C.W.C.), Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
| | - A Cianfoni
- Department of Neuroradiology (A.C.), Inselspital Bern, University of Bern, Bern, Switzerland
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Lim J, Goh I, Gwini S, Stringer F, Ng ZN, Dohrmann S, Smith H, Clissold B. Long‐term renal outcome post‐multimodal computed tomography in stroke evaluation. Intern Med J 2022; 52:134-138. [DOI: 10.1111/imj.15643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 07/13/2021] [Accepted: 07/19/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Julia Lim
- Department of Medicine Barwon Health Geelong Victoria Australia
| | - Ian Goh
- Department of Medicine Barwon Health Geelong Victoria Australia
| | | | | | - Zun Niang Ng
- Department of Medicine Barwon Health Geelong Victoria Australia
| | - Sara Dohrmann
- Department of Medicine Barwon Health Geelong Victoria Australia
| | - Heather Smith
- Department of Neurology Barwon Health Geelong Victoria Australia
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8
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Dzialowski I, Puetz V, Parsons M, Bivard A, von Kummer R. Computed Tomography-Based Evaluation of Cerebrovascular Disease. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00047-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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9
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Shlobin NA, Baig AA, Waqas M, Patel TR, Dossani RH, Wilson No Degree M, Cappuzzo JM, Siddiqui AH, Tutino VM, Levy EI. Artificial Intelligence for Large Vessel Occlusion Stroke: A Systematic Review. World Neurosurg 2021; 159:207-220.e1. [PMID: 34896351 DOI: 10.1016/j.wneu.2021.12.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 12/17/2022]
Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ammad A Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Tatsat R Patel
- Department of Mechanical and Aerospace Engineering, University at Buffalo, Buffalo NY USA
| | - Rimal H Dossani
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | | | - Justin M Cappuzzo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Vincent M Tutino
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Mechanical and Aerospace Engineering, University at Buffalo, Buffalo NY USA; Department of Pathology and Anatomical Sciences, University at Buffalo, Buffalo NY USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.
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Katyal A, Bhaskar SMM. Value of pre-intervention CT perfusion imaging in acute ischemic stroke prognosis. DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY (ANKARA, TURKEY) 2021; 27:774-785. [PMID: 34792033 DOI: 10.5152/dir.2021.20805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Noninvasive imaging plays an important role in acute stroke towards diagnosis and ongoing management of patients. Systemic thrombolysis and endovascular thrombectomy (EVT) are proven treatments currently used in standards of care in acute stroke settings. The role of computed tomography angiography (CTA) in selecting patients with large vessel occlusion for EVT is well established. However, the value of CT perfusion (CTP) imaging in predicting outcomes after stroke remains ambiguous. This article critically evaluates the value of multimodal CT imaging in early diagnosis and prognosis of acute ischemic stroke with a focus on the role of CTP in delineating tissue characteristics, patient selection, and outcomes after reperfusion therapy. Insights on various technical and clinical considerations relevant to CTP applications in acute ischemic stroke, recommendations for existing workflow, and future areas of research are discussed.
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Affiliation(s)
- Anubhav Katyal
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, Australia; University of New South Wales (UNSW), South Western Sydney Clinical School, NSW, Australia
| | - Sonu Menachem Maimonides Bhaskar
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, Australia; Department of Neurology - Neurophysiology, Liverpool Hospital - South West Sydney Local Health District (SWSLHD), Sydney, Australia;University of New South Wales (UNSW), South Western Sydney Clinical School, NSW, Australia; Ingham Institute for Applied Medical Research, Stroke - Neurology Research Group, Sydney, Australia; NSW Brain Clot Bank, NSW Health Statewide Biobank and NSW Health Pathology, Sydney, NSW, Australia;Thrombolysis and Endovascular WorkFLOw Network (TEFLON), Sydney, Australia
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11
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Baykal T, Unal Akoglu E, Akoglu T, Cimilli Ozturk T, Akoglu H. The middle cerebral artery density and ratio for the diagnosis of acute ischaemic stroke in the Emergency Department. Int J Clin Pract 2021; 75:e14799. [PMID: 34482600 DOI: 10.1111/ijcp.14799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/31/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Non-contrast computed tomography (ncCT) is the first-line imaging modality for acute ischaemic stroke diagnosis. Recognition of the early diagnostic signs of a stroke on computed tomography (CT) is crucial. The hyperdense middle cerebral artery (MCA) sign is one of these findings. We investigated the diagnostic utility of absolute MCA density (MCAD) in patients with acute MCA stroke confirmed with diffusion-weighted magnetic resonance imaging (dwMRI). METHODS We retrospectively included all patients who presented to the Emergency Department with symptoms related to an acute stroke and confirmed with a dwMRI and ncCT to this diagnostic case-control study. An expert radiologist with more than four years of experience in neuroradiology re-evaluated all ncCT images. The evaluation of MCAD and ratio were measured on axial images in Hounsfield units (HU). RESULTS We included 407 patients in our study (MCA infarction: 55%, n = 225; Control: 45%, n = 182). We calculated the threshold for the highest sensitivity (20%) and specificity (94%) as 49 HU with the Youden J index test for MCAD and as 1.1 for MCAD ratio (sensitivity 20% and specificity 95%). MCAD >49 HU or MCAD ratio >1.1 alone or joint use of MCAD >47 HU and MCAD ratio >1.1 are useful markers to confirm the diagnosis of MCA AIS with a specificity of at least 94%. Higher MCAD values are associated with larger infarction volumes. CONCLUSION MCAD and MCAD ratio can be used to identify patients who need early treatment, especially in situations where computed tomography angiogram or dwMRI are not readily available.
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Affiliation(s)
- Taygun Baykal
- Emergency Service, Bursa Karacabey State Hospital, Bursa, Turkey
| | - Ebru Unal Akoglu
- Department of Emergency Medicine, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Tayfun Akoglu
- Department of Radiology, MEDAR Hospital, Kocaeli, Turkey
| | | | - Haldun Akoglu
- Department of Emergency Medicine, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
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12
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Watanabe S, Sakaguchi K, Murata D, Ishii K. Deep learning-based Hounsfield unit value measurement method for bolus tracking images in cerebral computed tomography angiography. Comput Biol Med 2021; 137:104824. [PMID: 34488029 DOI: 10.1016/j.compbiomed.2021.104824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 08/28/2021] [Accepted: 08/28/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Patient movement during bolus tracking (BT) impairs the accuracy of Hounsfield unit (HU) measurements. This study assesses the accuracy of measuring HU values in the internal carotid artery (ICA) using an original deep learning (DL)-based method as compared with using the conventional region of interest (ROI) setting method. METHOD A total of 722 BT images of 127 patients who underwent cerebral computed tomography angiography were selected retrospectively and divided into groups for training data, validation data, and test data. To segment the ICA using our proposed method, DL was performed using a convolutional neural network. The HU values in the ICA were obtained using our DL-based method and the ROI setting method. The ROI setting was performed with and without correcting for patient body movement (corrected ROI and settled ROI). We compared the proposed DL-based method with settled ROI to evaluate HU value differences from the corrected ROI, based on whether or not patients experienced involuntary movement during BT image acquisition. RESULTS Differences in HU values from the corrected ROI in the settled ROI and the proposed method were 23.8 ± 12.7 HU and 9.0 ± 6.4 HU in patients with body movement and 1.1 ± 1.6 HU and 3.9 ± 4.7 HU in patients without body movement, respectively. There were significant differences in both comparisons (P < 0.01). CONCLUSION DL-based method can improve the accuracy of HU value measurements for ICA in BT images with patient involuntary movement.
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Affiliation(s)
- Shota Watanabe
- Division of Positron Emission Tomography, Institute of Advanced Clinical Medicine, Kindai University Hospital, 377-2 Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan; Radiology Center, Kindai University Hospital, 377-2 Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan.
| | - Kenta Sakaguchi
- Radiology Center, Kindai University Hospital, 377-2 Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan.
| | - Daisuke Murata
- Radiology Center, Kindai University Hospital, 377-2 Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan.
| | - Kazunari Ishii
- Department of Radiology, Kindai University Faculty of Medicine, 377-2 Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan.
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Bando T, Ueno Y, Kuroyama T, Shimo D, Mikami K, Hori S, Tanaka Y, Hirai O. Histopathological diagnosis of clot tissues collected by mechanical thrombectomy provides understanding of cerebral infarction pathology in cancer associated thrombosis: A case report. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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14
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Zopfs D, Lennartz S, Abdullayev N, Lichtenstein T, Laukamp KR, Reimer RP, Kabbasch C, Borggrefe J, Schlamann M, Neuhaus V, Große Hokamp N. Generally applicable window settings of low-keV virtual monoenergetic reconstructions in dual-layer CT-angiography of the head and neck. Quant Imaging Med Surg 2021; 11:3408-3417. [PMID: 34341719 DOI: 10.21037/qims-20-1140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/25/2021] [Indexed: 11/06/2022]
Abstract
Background Increased vessel contrast in low-keV virtual monoenergetic images (VMI) in spectral detector CT angiography of the head and neck requires adaption of window settings. Aim of this study was to define generally applicable window settings of low-keV VMI. Methods Two radiologists determined ideal subjective window settings for VMI40-70 keV in 54 patients. To obtain generally applicable window settings, center and width values were modeled against the attenuation of the internal carotid artery (HUICA). This modeling was performed with and without respect to keV. Subsequently, image quality of VMI40-70 keV was assessed using the model-based determined window settings. Results With decreasing keV values, HUICA increased significantly in comparison to conventional images (CI) (P<0.05 for 40-60 keV). No significant differences between modelled and individually recorded window settings were found confirming validity of the obtained models (P values: 0.2-1.0). However, modelling with respect to keV was marginally less precise. Conclusions Window settings of low-keV VMI can be semi-automatically determined in dependency of the ICA attenuation in spectral detector CTA of the head and neck. The reported models are a promising tool to leverage the improved image quality of these images in clinical routine.
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Affiliation(s)
- David Zopfs
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University Cologne, Cologne, Germany
| | - Simon Lennartz
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University Cologne, Cologne, Germany.,Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Nuran Abdullayev
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University Cologne, Cologne, Germany
| | - Thorsten Lichtenstein
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University Cologne, Cologne, Germany
| | - Kai Roman Laukamp
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University Cologne, Cologne, Germany
| | - Robert Peter Reimer
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University Cologne, Cologne, Germany
| | - Christoph Kabbasch
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University Cologne, Cologne, Germany
| | - Jan Borggrefe
- Department of Radiology, Neuroradiology and Nuclear Medicine, Johannes Wesling University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Marc Schlamann
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University Cologne, Cologne, Germany
| | - Victor Neuhaus
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University Cologne, Cologne, Germany
| | - Nils Große Hokamp
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University Cologne, Cologne, Germany
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Amukotuwa SA, Wu A, Zhou K, Page I, Brotchie P, Bammer R. Time-to-Maximum of the Tissue Residue Function Improves Diagnostic Performance for Detecting Distal Vessel Occlusions on CT Angiography. AJNR Am J Neuroradiol 2021; 42:65-72. [PMID: 33431503 DOI: 10.3174/ajnr.a6891] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 08/28/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Detecting intracranial distal arterial occlusions on CTA is challenging but increasingly relevant to clinical decision-making. Our purpose was to determine whether the use of CTP-derived time-to-maximum of the tissue residue function maps improves diagnostic performance for detecting these occlusions. MATERIALS AND METHODS Seventy consecutive patients with a distal arterial occlusion and 70 randomly selected controls who underwent multimodal CT with CTA and CTP for a suspected acute ischemic stroke were included in this retrospective study. Four readers with different levels of experience independently read the CTAs in 2 separate sessions, with and without time-to-maximum of the tissue residue function maps, recording the presence or absence of an occlusion, diagnostic confidence, and interpretation time. Accuracy for detecting distal occlusions was assessed using receiver operating characteristic analysis, and areas under curves were compared to assess whether accuracy improved with use of time-to-maximum of the tissue residue function. Changes in diagnostic confidence and interpretation time were assessed using the Wilcoxon signed rank test. RESULTS Mean sensitivity for detecting occlusions on CTA increased from 70.7% to 90.4% with use of time-to-maximum of the tissue residue function maps. Diagnostic accuracy improved significantly for the 4 readers (P < .001), with areas under the receiver operating characteristic curves increasing by 0.186, 0.136, 0.114, and 0.121, respectively. Diagnostic confidence and speed also significantly increased. CONCLUSIONS All assessed metrics of diagnostic performance for detecting distal arterial occlusions improved with the use of time-to-maximum of the tissue residue function maps, encouraging their use to aid in interpretation of CTA by both experienced and inexperienced readers. These findings show the added diagnostic value of including CTP in the acute stroke imaging protocol.
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Affiliation(s)
- S A Amukotuwa
- From the Department of Diagnostic Imaging (S.A.A., A.W., K.Z.), Monash Health, Clayton, Australia .,Department of Radiology (S.A.A., P.B.), Barwon Health, Geelong, Australia
| | - A Wu
- From the Department of Diagnostic Imaging (S.A.A., A.W., K.Z.), Monash Health, Clayton, Australia
| | - K Zhou
- From the Department of Diagnostic Imaging (S.A.A., A.W., K.Z.), Monash Health, Clayton, Australia
| | - I Page
- Department of Radiology (I.P., R.B.), The Royal Melbourne Hospital, Parkville, Australia
| | - P Brotchie
- Department of Radiology (S.A.A., P.B.), Barwon Health, Geelong, Australia
| | - R Bammer
- Department of Radiology (I.P., R.B.), The Royal Melbourne Hospital, Parkville, Australia
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Dehkharghani S, Lansberg M, Venkatsubramanian C, Cereda C, Lima F, Coelho H, Rocha F, Qureshi A, Haerian H, Mont'Alverne F, Copeland K, Heit J. High-Performance Automated Anterior Circulation CT Angiographic Clot Detection in Acute Stroke: A Multireader Comparison. Radiology 2021; 298:665-670. [PMID: 33434110 DOI: 10.1148/radiol.2021202734] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Identification of large vessel occlusion (LVO) is critical to the management of acute ischemic stroke and prerequisite to endovascular therapy in recent trials. Increasing volumes and data complexity compel the development of fast, reliable, and automated tools for LVO detection to facilitate acute imaging triage. Purpose To investigate the performance of an anterior circulation LVO detection platform in a large mixed sample of individuals with and without LVO at cerebrovascular CT angiography (CTA). Materials and Methods In this retrospective analysis, CTA data from recent cerebrovascular trials (CRISP [ClinicalTrials.gov NCT01622517] and DASH) were enriched with local repositories from 11 worldwide sites to balance demographic and technical variables in LVO-positive and LVO-negative examinations. CTA findings were reviewed independently by two neuroradiologists from different institutions for intracranial internal carotid artery (ICA) or middle cerebral artery (MCA) M1 LVO; these observers were blinded to all clinical variables and outcomes. An automated analysis platform was developed and tested for prediction of LVO presence and location relative to reader consensus. Discordance between readers with respect to LVO presence or location was adjudicated by a blinded tertiary reader at a third institution. Sensitivity, specificity, and receiver operating characteristics were assessed by an independent statistician, and subgroup analyses were conducted. Prespecified performance thresholds were set at a lower bound of the 95% CI of sensitivity and specificity of 0.8 or greater at mean times to notification of less than 3.5 minutes. Results A total of 217 study participants (mean age, 64 years ± 16 [standard deviation]; 116 men; 109 with positive findings of LVO) were evaluated. Prespecified performance thresholds were exceeded (sensitivity, 105 of 109 [96%; 95% CI: 91, 99]; specificity, 106 of 108 [98%; 95% CI: 94, 100]). Sensitivity and specificity estimates across age, sex, location, and vendor subgroups exceeded 90%. The area under the receiver operating characteristic curve was 99% (95% CI: 97, 100). Mean processing and notification time was 3 minutes 18 seconds. Conclusion The results confirm the feasibility of fast automated high-performance detection of intracranial internal carotid artery and middle cerebral artery M1 occlusions. © RSNA, 2021 See also the editorial by Kloska in this issue.
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Affiliation(s)
- Seena Dehkharghani
- From the Department of Radiology, New York University Langone Medical Center, 660 First Ave, 2nd Floor, New York, NY 10016 (S.D.); Department of Neurology, Stanford University Hospital, Stanford, Calif (M.L., C.V., J.H.); Department of Neurology, Ente Ospedaliero Cantonale, Lugano, Switzerland (C.C.); Departments of Neurology (F.L., H.C., F.R.) and Radiology (F.M.), Hospital Geral de Fortaleza, Fortaleza, Brazil; Department of Neurology, Kansas University Medical Center, Kansas City, Kan (A.Q.); LifeBridge, Baltimore, Md (H.H.); and Boulder Statistics, Boulder, Colo (K.C.)
| | - Maarten Lansberg
- From the Department of Radiology, New York University Langone Medical Center, 660 First Ave, 2nd Floor, New York, NY 10016 (S.D.); Department of Neurology, Stanford University Hospital, Stanford, Calif (M.L., C.V., J.H.); Department of Neurology, Ente Ospedaliero Cantonale, Lugano, Switzerland (C.C.); Departments of Neurology (F.L., H.C., F.R.) and Radiology (F.M.), Hospital Geral de Fortaleza, Fortaleza, Brazil; Department of Neurology, Kansas University Medical Center, Kansas City, Kan (A.Q.); LifeBridge, Baltimore, Md (H.H.); and Boulder Statistics, Boulder, Colo (K.C.)
| | - Chitra Venkatsubramanian
- From the Department of Radiology, New York University Langone Medical Center, 660 First Ave, 2nd Floor, New York, NY 10016 (S.D.); Department of Neurology, Stanford University Hospital, Stanford, Calif (M.L., C.V., J.H.); Department of Neurology, Ente Ospedaliero Cantonale, Lugano, Switzerland (C.C.); Departments of Neurology (F.L., H.C., F.R.) and Radiology (F.M.), Hospital Geral de Fortaleza, Fortaleza, Brazil; Department of Neurology, Kansas University Medical Center, Kansas City, Kan (A.Q.); LifeBridge, Baltimore, Md (H.H.); and Boulder Statistics, Boulder, Colo (K.C.)
| | - Carlo Cereda
- From the Department of Radiology, New York University Langone Medical Center, 660 First Ave, 2nd Floor, New York, NY 10016 (S.D.); Department of Neurology, Stanford University Hospital, Stanford, Calif (M.L., C.V., J.H.); Department of Neurology, Ente Ospedaliero Cantonale, Lugano, Switzerland (C.C.); Departments of Neurology (F.L., H.C., F.R.) and Radiology (F.M.), Hospital Geral de Fortaleza, Fortaleza, Brazil; Department of Neurology, Kansas University Medical Center, Kansas City, Kan (A.Q.); LifeBridge, Baltimore, Md (H.H.); and Boulder Statistics, Boulder, Colo (K.C.)
| | - Fabricio Lima
- From the Department of Radiology, New York University Langone Medical Center, 660 First Ave, 2nd Floor, New York, NY 10016 (S.D.); Department of Neurology, Stanford University Hospital, Stanford, Calif (M.L., C.V., J.H.); Department of Neurology, Ente Ospedaliero Cantonale, Lugano, Switzerland (C.C.); Departments of Neurology (F.L., H.C., F.R.) and Radiology (F.M.), Hospital Geral de Fortaleza, Fortaleza, Brazil; Department of Neurology, Kansas University Medical Center, Kansas City, Kan (A.Q.); LifeBridge, Baltimore, Md (H.H.); and Boulder Statistics, Boulder, Colo (K.C.)
| | - Henrique Coelho
- From the Department of Radiology, New York University Langone Medical Center, 660 First Ave, 2nd Floor, New York, NY 10016 (S.D.); Department of Neurology, Stanford University Hospital, Stanford, Calif (M.L., C.V., J.H.); Department of Neurology, Ente Ospedaliero Cantonale, Lugano, Switzerland (C.C.); Departments of Neurology (F.L., H.C., F.R.) and Radiology (F.M.), Hospital Geral de Fortaleza, Fortaleza, Brazil; Department of Neurology, Kansas University Medical Center, Kansas City, Kan (A.Q.); LifeBridge, Baltimore, Md (H.H.); and Boulder Statistics, Boulder, Colo (K.C.)
| | - Felipe Rocha
- From the Department of Radiology, New York University Langone Medical Center, 660 First Ave, 2nd Floor, New York, NY 10016 (S.D.); Department of Neurology, Stanford University Hospital, Stanford, Calif (M.L., C.V., J.H.); Department of Neurology, Ente Ospedaliero Cantonale, Lugano, Switzerland (C.C.); Departments of Neurology (F.L., H.C., F.R.) and Radiology (F.M.), Hospital Geral de Fortaleza, Fortaleza, Brazil; Department of Neurology, Kansas University Medical Center, Kansas City, Kan (A.Q.); LifeBridge, Baltimore, Md (H.H.); and Boulder Statistics, Boulder, Colo (K.C.)
| | - Abid Qureshi
- From the Department of Radiology, New York University Langone Medical Center, 660 First Ave, 2nd Floor, New York, NY 10016 (S.D.); Department of Neurology, Stanford University Hospital, Stanford, Calif (M.L., C.V., J.H.); Department of Neurology, Ente Ospedaliero Cantonale, Lugano, Switzerland (C.C.); Departments of Neurology (F.L., H.C., F.R.) and Radiology (F.M.), Hospital Geral de Fortaleza, Fortaleza, Brazil; Department of Neurology, Kansas University Medical Center, Kansas City, Kan (A.Q.); LifeBridge, Baltimore, Md (H.H.); and Boulder Statistics, Boulder, Colo (K.C.)
| | - Hafez Haerian
- From the Department of Radiology, New York University Langone Medical Center, 660 First Ave, 2nd Floor, New York, NY 10016 (S.D.); Department of Neurology, Stanford University Hospital, Stanford, Calif (M.L., C.V., J.H.); Department of Neurology, Ente Ospedaliero Cantonale, Lugano, Switzerland (C.C.); Departments of Neurology (F.L., H.C., F.R.) and Radiology (F.M.), Hospital Geral de Fortaleza, Fortaleza, Brazil; Department of Neurology, Kansas University Medical Center, Kansas City, Kan (A.Q.); LifeBridge, Baltimore, Md (H.H.); and Boulder Statistics, Boulder, Colo (K.C.)
| | - Francisco Mont'Alverne
- From the Department of Radiology, New York University Langone Medical Center, 660 First Ave, 2nd Floor, New York, NY 10016 (S.D.); Department of Neurology, Stanford University Hospital, Stanford, Calif (M.L., C.V., J.H.); Department of Neurology, Ente Ospedaliero Cantonale, Lugano, Switzerland (C.C.); Departments of Neurology (F.L., H.C., F.R.) and Radiology (F.M.), Hospital Geral de Fortaleza, Fortaleza, Brazil; Department of Neurology, Kansas University Medical Center, Kansas City, Kan (A.Q.); LifeBridge, Baltimore, Md (H.H.); and Boulder Statistics, Boulder, Colo (K.C.)
| | - Karen Copeland
- From the Department of Radiology, New York University Langone Medical Center, 660 First Ave, 2nd Floor, New York, NY 10016 (S.D.); Department of Neurology, Stanford University Hospital, Stanford, Calif (M.L., C.V., J.H.); Department of Neurology, Ente Ospedaliero Cantonale, Lugano, Switzerland (C.C.); Departments of Neurology (F.L., H.C., F.R.) and Radiology (F.M.), Hospital Geral de Fortaleza, Fortaleza, Brazil; Department of Neurology, Kansas University Medical Center, Kansas City, Kan (A.Q.); LifeBridge, Baltimore, Md (H.H.); and Boulder Statistics, Boulder, Colo (K.C.)
| | - Jeremy Heit
- From the Department of Radiology, New York University Langone Medical Center, 660 First Ave, 2nd Floor, New York, NY 10016 (S.D.); Department of Neurology, Stanford University Hospital, Stanford, Calif (M.L., C.V., J.H.); Department of Neurology, Ente Ospedaliero Cantonale, Lugano, Switzerland (C.C.); Departments of Neurology (F.L., H.C., F.R.) and Radiology (F.M.), Hospital Geral de Fortaleza, Fortaleza, Brazil; Department of Neurology, Kansas University Medical Center, Kansas City, Kan (A.Q.); LifeBridge, Baltimore, Md (H.H.); and Boulder Statistics, Boulder, Colo (K.C.)
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Recanalization Therapy for Acute Ischemic Stroke with Large Vessel Occlusion: Where We Are and What Comes Next? Transl Stroke Res 2021; 12:369-381. [PMID: 33409732 PMCID: PMC8055567 DOI: 10.1007/s12975-020-00879-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/15/2020] [Accepted: 11/18/2020] [Indexed: 12/18/2022]
Abstract
In the past 5 years, the success of multiple randomized controlled trials of recanalization therapy with endovascular thrombectomy has transformed the treatment of acute ischemic stroke with large vessel occlusion. The evidence from these trials has now established endovascular thrombectomy as standard of care. This review will discuss the chronological evolution of large vessel occlusion treatment from early medical therapy with tissue plasminogen activator to the latest mechanical thrombectomy. Additionally, it will highlight the potential areas in endovascular thrombectomy for acute ischemic stroke open to exploration and further progress in the next decade.
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Lee SJ, Liu B, Rane N, Mitchell P, Dowling R, Yan B. Correlation between CT angiography and digital subtraction angiography in acute ischemic strokes. Clin Neurol Neurosurg 2020; 200:106399. [PMID: 33338821 DOI: 10.1016/j.clineuro.2020.106399] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVE CT angiography (CTA) is not necessarily performed for all acute ischemic strokes due to variations in national guidelines across different regions. It follows that in the absence of CTA, missed identification of large vessel occlusion (LVO) potentially leads to opportunity lost for endovascular thrombectomy. Although the accuracy of CTA is well validated in chronic arterial stenosis, it has not been adequately investigated in acute ischemic stroke. We aimed to investigate the accuracy of CTA compared with digital subtraction angiography (DSA) in detecting LVO in acute ischemic stroke. METHODS This was a retrospective study of acute ischemic strokes with large vessel occlusion which underwent endovascular thrombectomy. We included patients who had a CTA prior to DSA and did not receive intravenous thrombolysis. Images were reviewed by 2 blinded assessors. Positive predictive value (PPV), and negative predictive value (NPV) of CTA were calculated against DSA. RESULTS Seventy-seven patients were included. The median age was 67 (IQR 57-78) and 46 (59.7 %) were male. Median NIHSS was 18 (IQR 12-22). There were 284 arterial segments categorized into 215 anterior arterial segments in 54 patients and 69 posterior arterial segments in 23 patients. The median time between CTA and DSA was 126 min (IQR 91-153 min). CTA showed PPV of 91.1 % and NPV of 95.1 % compared with DSA. CONCLUSIONS We showed that CTA was reasonably accurate in identifying large vessel occlusion in acute ischemic stroke. We propose that current regional guidelines should include CTA for all acute ischemic strokes.
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Affiliation(s)
- Su Jin Lee
- Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, Australia.
| | - Belinda Liu
- Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, Australia.
| | - Neil Rane
- Department of Radiology, Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia.
| | - Peter Mitchell
- Department of Radiology, Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia.
| | - Richard Dowling
- Department of Radiology, Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia.
| | - Bernard Yan
- Department of Radiology, Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia; Department of Neurology, Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia.
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Fasen BACM, Heijboer RJJ, Hulsmans FJH, Kwee RM. Diagnostic performance of single-phase CT angiography in detecting large vessel occlusion in ischemic stroke: A systematic review. Eur J Radiol 2020; 134:109458. [PMID: 33302028 DOI: 10.1016/j.ejrad.2020.109458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 09/24/2020] [Accepted: 11/30/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE To systematically review the diagnostic performance of single-phase CT angiography (CTA) in detecting intracranial large vessel occlusion (LVO). METHOD MEDLINE and Embase were searched for studies investigating the diagnostic performance of single-phase CTA in detecting LVO. Study quality was assessed. Sensitivity and specificity were calculated and meta-analyzed with a bivariate random-effects model. Heterogeneity was assessed with a chi-squared test. RESULTS Eleven studies were included. High risk of bias with regard to "patient selection", "reference standard", and "flow and timing" was present in 4, 1, and 2 studies, respectively. In 7 studies, it was unclear whether reference tests were interpreted blinded to CTA readings. There was variability in types of vessel segments analyzed, resulting in heterogeneous sensitivity and specificity (P < 0.05). Two studies provided data for the proximal anterior circulation (distal intracranial carotid artery, A1-, A2-, M1- and M2-segments), with pooled sensitivity of 88.4 % (95 % CI: 62.2-97.2 %) and pooled specificity of 98.5 % (95 % CI: 33.2-100 %). One study suggested that multiphase CTA improved agreement between nonexperts and an expert in detecting A1-, A2-, M1-, M2-, and M3-segment occlusions compared to single-phase CTA (ĸ = 0.72-0.76 vs. ĸ = 0.32-0.45). No other included study reported added value of advanced CTA (CT perfusion, 4D-CTA, or multiphase CTA) compared to single-phase CTA in detecting proximal anterior circulation LVO. CONCLUSION There is lack of high-quality studies on the diagnostic performance of single-phase CTA for LVO detection in the proximal anterior circulation. The added value of advanced CTA techniques in detecting proximal anterior circulation LVO is not completely clear yet.
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Affiliation(s)
- Bram A C M Fasen
- Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, the Netherlands
| | - Roeland J J Heijboer
- Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, the Netherlands
| | - Frans-Jan H Hulsmans
- Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, the Netherlands
| | - Robert M Kwee
- Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, the Netherlands.
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Hartman J, Goiney C, Carlson B, Moran S, Hippe DS, Zecevic M, Mossa-Basha M. ACR Appropriateness Criteria Facilitate Judicious Use of CT Angiography for Stroke Workup in the Emergency Department. J Am Coll Radiol 2020; 17:1230-1236. [DOI: 10.1016/j.jacr.2020.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 04/04/2020] [Accepted: 04/07/2020] [Indexed: 10/24/2022]
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Radiation exposure of computed tomography imaging for the assessment of acute stroke. Neuroradiology 2020; 63:511-518. [PMID: 32901338 PMCID: PMC7966220 DOI: 10.1007/s00234-020-02548-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/31/2020] [Indexed: 11/22/2022]
Abstract
Purpose To assess suspected acute stroke, the computed tomography (CT) protocol contains a non-contrast CT (NCCT), a CT angiography (CTA), and a CT perfusion (CTP). Due to assumably high radiation doses of the complete protocol, the aim of this study is to examine radiation exposure and to establish diagnostic reference levels (DRLs). Methods In this retrospective study, dose data of 921 patients with initial CT imaging for suspected acute stroke and dose monitoring with a DICOM header–based tracking and monitoring software were analyzed. Between June 2017 and January 2020, 1655 CT scans were included, which were performed on three different modern multi-slice CT scanners, including 921 NCCT, 465 CTA, and 269 CTP scans. Radiation exposure was reported for CT dose index (CTDIvol) and dose-length product (DLP). DRLs were set at the 75th percentile of dose distribution. Results DRLs were assessed for each step (CTDIvol/DLP): NCCT 33.9 mGy/527.8 mGy cm and CTA 13.7 mGy/478.3 mGy cm. Radiation exposure of CTP was invariable and depended on CT device and its protocol settings with CTDIvol 124.9–258.2 mGy and DLP 1852.6–3044.3 mGy cm. Conclusion Performing complementary CT techniques such as CTA and CTP for the assessment of acute stroke increases total radiation exposure. Hence, the revised DRLs for the complete protocol are required, where our local DRLs may help as benchmarks.
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Arnold SA, Platt SR, Gendron KP, West FD. Imaging Ischemic and Hemorrhagic Disease of the Brain in Dogs. Front Vet Sci 2020; 7:279. [PMID: 32528985 PMCID: PMC7266937 DOI: 10.3389/fvets.2020.00279] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/27/2020] [Indexed: 01/12/2023] Open
Abstract
Strokes, both ischemic and hemorrhagic, are the most common underlying cause of acute, non-progressive encephalopathy in dogs. In effect, substantial information detailing the underlying causes and predisposing factors, affected vessels, imaging features, and outcomes based on location and extent of injury is available. The features of canine strokes on both computed tomography (CT) and magnetic resonance imaging (MRI) have been described in numerous studies. This summary article serves as a compilation of these various descriptions. Drawing from the established and emerging stroke evaluation sequences used in the investigation of strokes in humans, this summary describes all theoretically available sequences. Particular detail is given to logistics of image acquisition, description of imaging findings, and each sequence's advantages and disadvantages. As the imaging features of both forms of strokes are highly representative of the underlying pathophysiologic stages in the hours to months following stroke onset, the descriptions of strokes at various stages are also discussed. It is unlikely that canine strokes can be diagnosed within the same rapid time frame as human strokes, and therefore the opportunity for thrombolytic intervention in ischemic strokes is unattainable. However, a thorough understanding of the appearance of strokes at various stages can aid the clinician when presented with a patient that has developed a stroke in the days or weeks prior to evaluation. Additionally, investigation into new imaging techniques may increase the sensitivity and specificity of stroke diagnosis, as well as provide new ways to monitor strokes over time.
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Affiliation(s)
- Susan A Arnold
- Department of Veterinary Clinical Sciences, University of Minnesota Twin Cities, St. Paul, MN, United States
| | - Simon R Platt
- Department of Small Animal Medicine and Surgery, University of Georgia, Athens, GA, United States
| | - Karine P Gendron
- Department of Small Animal Medicine and Surgery, University of Georgia, Athens, GA, United States
| | - Franklin D West
- Department of Small Animal Medicine and Surgery, University of Georgia, Athens, GA, United States
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23
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Detection of emergent large vessel occlusion stroke with CT angiography is high across all levels of radiology training and grayscale viewing methods. Eur Radiol 2020; 30:4447-4453. [PMID: 32232790 DOI: 10.1007/s00330-020-06814-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 02/28/2020] [Accepted: 03/16/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES CT angiography (CTA) is essential in acute stroke to detect emergent large vessel occlusions (ELVO) and must be interpreted by radiologists with and without subspecialized training. Additionally, grayscale inversion has been suggested to improve diagnostic accuracy in other radiology applications. This study examines diagnostic performance in ELVO detection between neuroradiologists, non-neuroradiologists, and radiology residents using standard and grayscale inversion viewing methods. METHODS A random, counterbalanced experimental design was used, where 18 radiologists with varying experiences interpreted the same patient images with and without grayscale inversion. Confirmed positive and negative ELVO cases were randomly ordered using a balanced design. Sensitivity, specificity, positive and negative predictive values as well as confidence, subjective assessment of image quality, time to ELVO detection, and overall interpretation time were examined between grayscale inversion (on/off) by experience level using generalized mixed modeling assuming a binary, negative binomial, and binomial distributions, respectively. RESULTS All groups of radiologists had high sensitivity and specificity for ELVO detection (all > .94). Neuroradiologists were faster than non-neuroradiologists and residents in interpretation time, with a mean of 47 s to detect ELVO, as compared with 59 and 74 s, respectively. Residents were subjectively less confident than attending physicians. With respect to grayscale inversion, no differences were observed between groups with grayscale inversion vs. standard viewing for diagnostic performance (p = 0.30), detection time (p = .45), overall interpretation time (p = .97), and confidence (p = .20). CONCLUSIONS Diagnostic performance in ELVO detection with CTA was high across all levels of radiologist training level. Grayscale inversion offered no significant detection advantage. KEY POINTS • Stroke is an acute vascular syndrome that requires acute vascular imaging. • Proximal large vessel occlusions can be identified quickly and accurately by radiologists across all training levels. • Grayscale inversion demonstrated minimal detectable benefit in the detection of proximal large vessel occlusions.
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24
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Myung JW, Kim JH, Cho J, Park I, Kim HY, Beom JH. Contrast-Induced Acute Kidney Injury in Radiologic Management of Acute Ischemic Stroke in the Emergency Setting. AJNR Am J Neuroradiol 2020; 41:632-636. [PMID: 32165364 DOI: 10.3174/ajnr.a6472] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 02/05/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE The use of invasive cerebral angiography with CTA for active treatment of patients with suspected ischemic strokes has been increasing recently. This study aimed to identify the incidence of postcontrast acute kidney injury using baseline renal function when CTA and cerebral angiography were performed sequentially. MATERIALS AND METHODS This retrospective observational study evaluated adults (18 years of age or older) with ischemic stroke who underwent CTA and cerebral angiography sequentially between 2010 and 2018. The incidence of postcontrast acute kidney injury was determined using the baseline estimated glomerular filtration rate. The value of the baseline estimated glomerular filtration rate at which the occurrence of postcontrast acute kidney injury increased was also determined. RESULTS Postcontrast acute kidney injury occurred in 57/601 (9.5%) patients. Those with a baseline estimated glomerular filtration rate of <30 mL/min/1.73 m2 showed a higher incidence of acute kidney injury. Age, chronic kidney disease, medication (nonsteroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, β blockers, statins, and insulin) use following contrast media exposure, and serum albumin affected the incidence of postcontrast acute kidney injury. The incidence of postcontrast acute kidney injury increased when the baseline estimated glomerular filtration rate was <43 mL/min/1.73 m2. CONCLUSIONS Patients with low baseline renal function had the highest incidence of postcontrast acute kidney injury after CTA and cerebral angiography, but no fatal adverse effects were documented. Thus, patients suspected of having a stroke should be actively managed with respect to neurovascular function.
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Affiliation(s)
- J W Myung
- From the Department of Emergency Medicine (J.W.M., J.H.K., J.C., I.P., J.H.B.)
| | - J H Kim
- From the Department of Emergency Medicine (J.W.M., J.H.K., J.C., I.P., J.H.B.)
| | - J Cho
- From the Department of Emergency Medicine (J.W.M., J.H.K., J.C., I.P., J.H.B.)
| | - I Park
- From the Department of Emergency Medicine (J.W.M., J.H.K., J.C., I.P., J.H.B.)
| | - H Y Kim
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics (H.Y.K.), Yonsei University College of Medicine, Seoul, Republic of Korea
| | - J H Beom
- From the Department of Emergency Medicine (J.W.M., J.H.K., J.C., I.P., J.H.B.),
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25
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Rowley H, Vagal A. Stroke and Stroke Mimics: Diagnosis and Treatment. IDKD SPRINGER SERIES 2020. [DOI: 10.1007/978-3-030-38490-6_3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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26
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Inhuber S, Sollmann N, Schlaeger S, Dieckmeyer M, Burian E, Kohlmeyer C, Karampinos DC, Kirschke JS, Baum T, Kreuzpointner F, Schwirtz A. Associations of thigh muscle fat infiltration with isometric strength measurements based on chemical shift encoding-based water-fat magnetic resonance imaging. Eur Radiol Exp 2019; 3:45. [PMID: 31748839 PMCID: PMC6868073 DOI: 10.1186/s41747-019-0123-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 09/13/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Assessment of the thigh muscle fat composition using magnetic resonance imaging (MRI) can provide surrogate markers in subjects suffering from various musculoskeletal disorders including knee osteoarthritis or neuromuscular diseases. However, little is known about the relationship with muscle strength. Therefore, we investigated the associations of thigh muscle fat with isometric strength measurements. METHODS Twenty healthy subjects (10 females; median age 27 years, range 22-41 years) underwent chemical shift encoding-based water-fat MRI, followed by bilateral extraction of the proton density fat fraction (PDFF) and calculation of relative cross-sectional area (relCSA) of quadriceps and ischiocrural muscles. Relative maximum voluntary isometric contraction (relMVIC) in knee extension and flexion was measured with a rotational dynamometer. Correlations between PDFF, relCSA, and relMVIC were evaluated, and multivariate regression was applied to identify significant predictors of muscle strength. RESULTS Significant correlations between the PDFF and relMVIC were observed for quadriceps and ischiocrural muscles bilaterally (p = 0.001 to 0.049). PDFF, but not relCSA, was a statistically significant (p = 0.001 to 0.049) predictor of relMVIC in multivariate regression models, except for left-sided relMVIC in extension. In this case, PDFF (p = 0.005) and relCSA (p = 0.015) of quadriceps muscles significantly contributed to the statistical model with R2adj = 0.548. CONCLUSION Chemical shift encoding-based water-fat MRI could detect changes in muscle composition by quantifying muscular fat that correlates well with both extensor and flexor relMVIC of the thigh. Our results help to initiate early, individualised treatments to maintain or improve muscle function in subjects who do not or not yet show pathological fatty muscle infiltration.
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Affiliation(s)
- Stephanie Inhuber
- Department of Sport and Health Sciences, Technische Universität München, Georg-Brauchle-Ring 60/62, 80992, Munich, Germany.
| | - Nico Sollmann
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Sarah Schlaeger
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany.,Department of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Michael Dieckmeyer
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany.,Department of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Egon Burian
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Caroline Kohlmeyer
- Department of Sport and Health Sciences, Technische Universität München, Georg-Brauchle-Ring 60/62, 80992, Munich, Germany
| | - Dimitrios C Karampinos
- Department of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Jan S Kirschke
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Thomas Baum
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Florian Kreuzpointner
- Department of Sport and Health Sciences, Technische Universität München, Georg-Brauchle-Ring 60/62, 80992, Munich, Germany
| | - Ansgar Schwirtz
- Department of Sport and Health Sciences, Technische Universität München, Georg-Brauchle-Ring 60/62, 80992, Munich, Germany
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Amukotuwa SA, Straka M, Dehkharghani S, Bammer R. Fast Automatic Detection of Large Vessel Occlusions on CT Angiography. Stroke 2019; 50:3431-3438. [PMID: 31679501 DOI: 10.1161/strokeaha.119.027076] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background and Purpose- Accurate and rapid detection of anterior circulation large vessel occlusion (LVO) is of paramount importance in patients with acute stroke due to the potentially rapid infarction of at-risk tissue and the limited therapeutic window for endovascular clot retrieval. Hence, the optimal threshold of a new, fully automated software-based approach for LVO detection was determined, and its diagnostic performance evaluated in a large cohort study. Methods- For this retrospective study, data were pooled from: 2 stroke trials, DEFUSE 2 (n=62; 07/08-09/11) and DEFUSE 3 (n=213; 05/17-05/18); a cohort of endovascular clot retrieval candidates (n=82; August 2, 2014-August 30, 2015) and normals (n=111; June 6, 2017-January 28, 2019) from a single quaternary center; and code stroke patients (n=501; January 1, 2017-December 31, 2018) from a single regional hospital. All CTAs were assessed by the automated algorithm. Consensus reads by 2 neuroradiologists served as the reference standard. ROC analysis was used to assess diagnostic performance of the algorithm for detection of (1) anterior circulation LVOs involving the intracranial internal carotid artery or M1 segment middle cerebral artery (M1-MCA); (2) anterior circulation LVOs and proximal M2 segment MCA (M2-MCA) occlusions; and (3) individual segment occlusions. Results- CTAs from 926 patients (median age 70 years, interquartile range: 58-80; 422 females) were analyzed. Three hundred ninety-five patients had an anterior circulation LVO or M2-MCA occlusion (National Institutes of Health Stroke Scale 14 [median], interquartile range: 9-19). Sensitivity and specificity were 97% and 74%, respectively, for LVO detection, and 95% and 79%, respectively, when M2 occlusions were included. On analysis by occlusion site, sensitivities were 90% (M2-MCA), 97% (M1-MCA), and 97% (intracranial internal carotid artery) with corresponding area-under-the-ROC-curves of 0.874 (M2), 0.962 (M1), and 0.997 (intracranial internal carotid artery). Conclusions- Intracranial anterior circulation LVOs and proximal M2 occlusions can be rapidly and reliably detected by an automated detection tool, which may facilitate intra- and inter-instutional workflows and emergent imaging triage in the care of patients with stroke.
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Affiliation(s)
- Shalini A Amukotuwa
- From the Diagnostic Imaging, Monash Medical Centre, Clayton, VIC, Australia (S.A.A.).,Department of Radiology, University Hospital Geelong, VIC, Australia (S.A.A.).,Department of Radiology and Medicine, Royal Melbourne Hospital, Parkville, VIC, Australia (S.A.A., R.B.)
| | - Matus Straka
- Department of Neurology, Stanford Stroke Center, Stanford University, CA (M.S.)
| | | | - Roland Bammer
- Department of Radiology and Medicine, Royal Melbourne Hospital, Parkville, VIC, Australia (S.A.A., R.B.).,Florey Institute of Neurosciences, Parkville, VIC Australia (R.B.).,Department of Radiology, 3DQ Lab, Stanford University, CA (R.B)
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28
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Kim MS, Kim GS. Single Centre Experience on Decision Making for Mechanical Thrombectomy Based on Single-Phase CT Angiography by Including NCCT and Maximum Intensity Projection Images - A Comparison with Magnetic Resonance Imaging after Non-Contrast CT. J Korean Neurosurg Soc 2019; 63:188-201. [PMID: 31658804 PMCID: PMC7054116 DOI: 10.3340/jkns.2019.0131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 09/01/2019] [Indexed: 11/27/2022] Open
Abstract
Objective The purpose of this study was to suggest that computed tomography angiography (CTA) is valuable as the only preliminary examination for mechanical thrombectomy (MT). MT after single examination of CTA including non-contrast computed tomography (NCCT) and maximum intensity projection (MIP) improves door-to-puncture time as well as results in favorable outcomes.
Methods A total of 157 patients who underwent MT at Dong Kang Medical Center from April 2015 to March 2019 were divided into two groups based on the examination performed prior to MT : CTA group who underwent CTA with NCCT and MIP, and NCCT+magnetic resonance image (MRi) group who underwent MRI including perfusion images after NCCT. In the two groups, time to CTA imaging or NCCT+MRi imaging after symptom onset, and time to arterial puncture and reperfusion were characterized as time-related outcomes. The evaluation of vascular recanalization after MT was defined as a modified thrombolysis in cerebral infarction (mTICI) scale. National Institutes of Health Stroke Scale (NIHSS) was assessed at the time of the visit to the emergency room and modified Rankin Scale (mRS) was assessed after 90 days.
Results Typically, there were 34 patients in the CTA group and 33 patients in the NCCT+MRi group. A significantly shorter delay for door-to-puncture time was observed (mean, 86±22.1 vs. 176±47.5 minutes; p<0.01). Also, a significantly shorter door-to-imege time in the CTA group was observed (mean, 13±6.8 vs. 93±30.8 minutes; p<0.01). Moreover, a significantly shorter onset-to-puncture time was observed (mean, 195±128.0 vs. 314±157.6 minutes; p<0.01). Reperfusion result of mTICI ≥2b was 100% (34/34) in the CTA group and 94% (31/33) in the NCCT+MRi group, and mTICI 3 in 74% (25/34) in the CTA group and 73% (24/33) in the NCCT+MRi group. Favorable functional outcomes (mRS score ≤2 at 90 days) were 68% (23/34) in the CTA group and 60% (20/33) in the NCCT+MRi group.
Conclusion A single-phase CTA including NCCT and MIP images was performed as a single preliminary examination, which led to a reduction in the time of the procedure and resulted in good results of prognosis. Consequently, it is concluded that this method is of sufficient value as the only preliminary examination for decision making.
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Affiliation(s)
- Myeong Soo Kim
- Department of Neurosurgery, Dong Kang Medical Center, Ulsan, Korea
| | - Gi Sung Kim
- Department of Radiology, Dong Kang Medical Center, Ulsan, Korea
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29
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Amukotuwa SA, Straka M, Smith H, Chandra RV, Dehkharghani S, Fischbein NJ, Bammer R. Automated Detection of Intracranial Large Vessel Occlusions on Computed Tomography Angiography. Stroke 2019; 50:2790-2798. [DOI: 10.1161/strokeaha.119.026259] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background and Purpose—
Endovascular thrombectomy is highly effective in acute ischemic stroke patients with an anterior circulation large vessel occlusion (LVO), decreasing morbidity and mortality. Accurate and prompt identification of LVOs is imperative because these patients have large volumes of tissue that are at risk of infarction without timely reperfusion, and the treatment window is limited to 24 hours. We assessed the accuracy and speed of a commercially available fully automated LVO-detection tool in a cohort of patients presenting to a regional hospital with suspected stroke.
Methods—
Consecutive patients who underwent multimodal computed tomography with thin-slice computed tomography angiography between January 1, 2017 and December 31, 2018 for suspected acute ischemic stroke within 24 hours of onset were retrospectively identified. The multimodal computed tomographies were assessed by 2 neuroradiologists in consensus for the presence of an intracranial anterior circulation LVO or M2-segment middle cerebral artery occlusion (the reference standard). The patients’ computed tomography angiographies were then processed using an automated LVO-detection algorithm (RAPID CTA). Receiver-operating characteristic analysis was used to determine sensitivity, specificity, and negative predictive value of the algorithm for detection of (1) an LVO and (2) either an LVO or M2-segment middle cerebral artery occlusion.
Results—
CTAs from 477 patients were analyzed (271 men and 206 women; median age, 71; IQR, 60–80). Median processing time was 158 seconds (IQR, 150–167 seconds). Seventy-eight patients had an anterior circulation LVO, and 28 had an isolated M2-segment middle cerebral artery occlusion. The sensitivity, negative predictive value, and specificity were 0.94, 0.98, and 0.76, respectively for detection of an intracranial LVO and 0.92, 0.97, and 0.81, respectively for detection of either an intracranial LVO or M2-segment middle cerebral artery occlusion.
Conclusions—
The fully automated algorithm had very high sensitivity and negative predictive value for LVO detection with fast processing times, suggesting that it can be used in the emergent setting as a screening tool to alert radiologists and expedite formal diagnosis.
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Affiliation(s)
- Shalini A. Amukotuwa
- From the Diagnostic Imaging, Monash Health, Clayton, Australia and Department of Radiology, Barwon Health, Geelong, Australia (S.A.A.)
| | - Matus Straka
- Stanford Stroke Center, Stanford University School of Medicine, CA (M.S.)
| | - Heather Smith
- Department of Neurology, Barwon Health, Geelong, Australia (H.S.)
| | | | - Seena Dehkharghani
- Department of Radiology, New York University Langone Medical Center (S.D.)
| | | | - Roland Bammer
- Department of Radiology, University of Melbourne, Parkville, Australia (R.B.)
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30
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Tube Current Reduction in CT Angiography: How Low Can We Go in Imaging of Patients With Suspected Acute Stroke? AJR Am J Roentgenol 2019; 213:410-416. [DOI: 10.2214/ajr.18.20954] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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31
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Yu W, Jiang WJ. A Simple Imaging Guide for Endovascular Thrombectomy in Acute Ischemic Stroke: From Time Window to Perfusion Mismatch and Beyond. Front Neurol 2019; 10:502. [PMID: 31178813 PMCID: PMC6543836 DOI: 10.3389/fneur.2019.00502] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/25/2019] [Indexed: 01/01/2023] Open
Affiliation(s)
- Wengui Yu
- Department of Neurology, University of California Irvine, Irvine, CA, United States
| | - Wei-Jian Jiang
- New Era Stroke Care and Research Institute, The Rocket Force General Hospital, Beijing, China
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32
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Huang X, Alakbarzade V, Khandanpour N, Pereira AC. Management of a wake-up stroke. Pract Neurol 2019; 19:326-331. [PMID: 30872357 DOI: 10.1136/practneurol-2018-002179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 01/11/2019] [Accepted: 01/15/2019] [Indexed: 01/01/2023]
Abstract
Current national guidelines advocate intravenous thrombolysis to treat patients with acute ischaemic stroke presenting within 4.5 hours from symptom onset, and thrombectomy for patients with anterior circulation ischaemic stroke from large vessel occlusion presenting within 6 hours from onset. However, a substantial group of patients presents with acute ischaemic stroke beyond these time windows or has an unknown time of onset. Recent studies are set to revolutionise treatment for these patients. Using MRI diffusion/FLAIR (fluid-attenuated inversion recovery) mismatch, it is possible to identify patients within 4.5 hours from onset and safely deliver thrombolysis. Using CT perfusion imaging, it is possible to identify subjects with a middle cerebral artery syndrome who have an extensive area of ischaemic brain but as yet have only a small area of infarction who may benefit from urgent thrombectomy in up to 24 hours. Here, we highlight the recent advances in late window stroke treatment and their potential contribution to clinical practice.
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Affiliation(s)
- Xuya Huang
- Department of Neurology, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Vafa Alakbarzade
- Department of Neurology, St. George's University Hospitals NHS Foundation Trust, London, UK.,Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Nader Khandanpour
- Department of Neurology, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Anthony C Pereira
- Department of Neurology, St. George's University Hospitals NHS Foundation Trust, London, UK
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33
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Kim DH, Kim B, Jung C, Nam HS, Lee JS, Kim JW, Lee WJ, Seo WK, Heo JH, Baik SK, Kim BM, Rha JH. Consensus Statements by Korean Society of Interventional Neuroradiology and Korean Stroke Society: Hyperacute Endovascular Treatment Workflow to Reduce Door-to-Reperfusion Time. Korean J Radiol 2018; 19:838-848. [PMID: 30174472 PMCID: PMC6082772 DOI: 10.3348/kjr.2018.19.5.838] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 06/06/2018] [Indexed: 02/01/2023] Open
Abstract
Recent clinical trials demonstrated the clinical benefit of endovascular treatment (EVT) in patients with acute ischemic stroke due to large vessel occlusion. These trials confirmed that good outcome after EVT depends on the time interval from symptom onset to reperfusion and that in-hospital delay leads to poor clinical outcome. However, there has been no universally accepted in-hospital workflow and performance benchmark for rapid reperfusion. Additionally, wide variety in workflow for EVT is present between each stroke centers. In this consensus statement, Korean Society of Interventional Neuroradiology and Korean Stroke Society Joint Task Force Team propose a standard workflow to reduce door-to-reperfusion time for stroke patients eligible for EVT. This includes early stroke identification and pre-hospital notification to stroke team of receiving hospital in pre-hospital phase, the transfer of stroke patients from door of the emergency department to computed tomography (CT) room, warming call to neurointervention (NI) team for EVT candidate prior to imaging, NI team preparation in parallel with thrombolysis, direct transportation from CT room to angiography suite following immediate decision of EVT and standardized procedure for rapid reperfusion. Implementation of optimized workflow will improve stroke time process metrics and clinical outcome of the patient treated with EVT.
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Affiliation(s)
- Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan 49201, Korea
| | - Byungjun Kim
- Department of Radiology, Korea University Anam Hospital, Seoul 02841, Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam 13620, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University Severance Hospital, Seoul 03722, Korea
| | - Jin Soo Lee
- Department of Neurology, Ajou University School of Medicine, Suwon 16499, Korea
| | - Jin Woo Kim
- Department of Radiology, Inje Univeristy Ilsan Paik Hospital, Goyang 10380, Korea
| | - Woong Jae Lee
- Department of Radiology, Chung-Ang University Hospital, Seoul 06973, Korea
| | - Woo-Keun Seo
- Department of Neurology, Sungkyunkwan University, Samsung Medical Center, Seoul 06351, Korea
| | - Ji-Hoe Heo
- Department of Neurology, Yonsei University Severance Hospital, Seoul 03722, Korea
| | - Seung Kug Baik
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan 50612, Korea
| | - Byung Moon Kim
- Department of Radiology, Yonsei University Severance Hospital, Seoul 03722, Korea
| | - Joung-Ho Rha
- Department of Neurology, Inha University Hospital, Incheon 22332, Korea
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34
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Rudkin S, Cerejo R, Tayal A, Goldberg MF. Imaging of acute ischemic stroke. Emerg Radiol 2018; 25:659-672. [DOI: 10.1007/s10140-018-1623-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/26/2018] [Indexed: 10/28/2022]
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35
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Kim DH, Kim B, Jung C, Nam HS, Lee JS, Kim JW, Lee WJ, Seo WK, Heo JH, Baik SK, Kim BM, Rha JH. Consensus Statements by Korean Society of Interventional Neuroradiology and Korean Stroke Society: Hyperacute Endovascular Treatment Workflow to Reduce Door-to-Reperfusion Time. J Korean Med Sci 2018; 33:e143. [PMID: 29736159 PMCID: PMC5934519 DOI: 10.3346/jkms.2018.33.e143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/20/2018] [Indexed: 11/20/2022] Open
Abstract
Recent clinical trials demonstrated the clinical benefit of endovascular treatment (EVT) in patients with acute ischemic stroke due to large vessel occlusion. These trials confirmed that good outcome after EVT depends on the time interval from symptom onset to reperfusion and that in-hospital delay leads to poor clinical outcome. However, there has been no universally accepted in-hospital workflow and performance benchmark for rapid reperfusion. Additionally, wide variety in workflow for EVT is present between each stroke centers. In this consensus statement, Korean Society of Interventional Neuroradiology and Korean Stroke Society Joint Task Force Team propose a standard workflow to reduce door-to-reperfusion time for stroke patients eligible for EVT. This includes early stroke identification and pre-hospital notification to stroke team of receiving hospital in pre-hospital phase, the transfer of stroke patients from door of the emergency department to computed tomography (CT) room, warming call to neurointervention team for EVT candidate prior to imaging, neurointervention team preparation in parallel with thrombolysis, direct transportation from CT room to angiography suite following immediate decision of EVT and standardized procedure for rapid reperfusion. Implementation of optimized workflow will improve stroke time process metrics and clinical outcome of the patient treated with EVT.
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Affiliation(s)
- Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan, Korea
| | - Byungjun Kim
- Department of Radiology, Korea University Anam Hospital, Seoul, Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University Severance Hospital, Seoul, Korea
| | - Jin Soo Lee
- Department of Neurology, Ajou University School of Medicine, Suwon, Korea
| | - Jin Woo Kim
- Department of Radiology, Inje Univeristy Ilsan Paik Hospital, Goyang, Korea
| | - Woong Jae Lee
- Department of Radiology, Chung-Ang University Hospital, Seoul, Korea
| | - Woo-Keun Seo
- Department of Neurology, Sungkyunkwan University, Samsung Medical Center, Seoul, Korea
| | - Ji-Hoe Heo
- Department of Neurology, Yonsei University Severance Hospital, Seoul, Korea
| | - Seung Kug Baik
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Byung Moon Kim
- Department of Radiology, Yonsei University Severance Hospital, Seoul, Korea
| | - Joung-Ho Rha
- Department of Neurology, Inha University Hospital, Incheon, Korea
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Yi HJ, Sung JH, Lee DH, Yang SH, Hong JT. A useful diagnostic method to reduce the in-hospital time delay for mechanical thrombectomy: volume perfusion computed tomography with added vessel reconstruction. J Neurosurg 2018:1-8. [PMID: 29652229 DOI: 10.3171/2017.10.jns171971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 10/16/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEVolume perfusion CT (VPCT) with added CT angiography (CTA)-like reconstruction from VPCT source data (VPCTA) can reveal multiple intracranial parameters. The authors examined the usefulness of VPCTA in terms of reducing the in-hospital time delay for mechanical thrombectomy.METHODSA total of 180 patients who underwent mechanical thrombectomy at the authors' institution between January 2014 and March 2017 were divided into 2 groups: a CTA-based thrombectomy decision group (group 1: CTA) and a VPCTA-based decision group (group 2: VPCTA). Multiple time interval categories (from symptom onset to groin puncture, from hospital arrival to groin puncture, procedure time, from symptom onset to reperfusion, and from hospital arrival to reperfusion) were reviewed. All patients underwent clinical assessment with the National Institutes of Health Stroke Scale score and the modified Rankin Scale, and radiological results were evaluated by the Thrombolysis in Cerebral Infarction score.RESULTSIn all of the time interval categories except for procedure time, the VPCTA group showed a significantly shorter in-hospital time delay during the prethrombectomy period than did the CTA group. The 3-month modified Rankin Scale score was significantly lower in the VPCTA group (2.8) compared with the CTA group (3.5) (p = 0.003). However, there were no statistically significant differences between the 2 groups in the other clinical and radiological outcomes.CONCLUSIONSCompared with CTA, VPCTA significantly reduced the in-hospital time delay during the prethrombectomy period.
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Abstract
PURPOSE OF REVIEW This article provides an overview of cerebrovascular hemodynamics, acute stroke pathophysiology, and collateral circulation, which are pivotal in the modern imaging of ischemic stroke that guides the care of the patient with stroke. RECENT FINDINGS Neuroimaging provides extensive information on the brain and vascular health. Multimodal CT and MRI delineate the hemodynamics of ischemic stroke that may be used to guide treatment decisions and prognosticate regarding expected outcomes. Mismatch imaging with either CT or MRI may identify patients with salvageable regions who are at risk and likely to benefit from reperfusion therapy, even if they are outside the standard time window. Imaging of collateral circulation and determination of collateral grade may predict greater reperfusion, lower hemorrhage risk, and better functional outcome. Current neuroimaging technology also enables the identification of patients at high risk of hemorrhagic transformation or those who may be harmed by treatment or unlikely to benefit from it. SUMMARY This article reviews the use and impact of imaging for the patient with ischemic stroke, emphasizing how imaging builds upon clinical evaluation to establish diagnosis or etiology, reveal key pathophysiology, and guide therapeutic decisions.
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Atchaneeyasakul K, Tipirneni A, Khandelwal P, Saini V, Ronca R, Lord S, Sur S, Guada L, Ramdas K, Peterson E, Yavagal D. Utilizing CT with Maximum Intensity Projection Reconstruction Bypassing CTA Improves Time to Groin Puncture in Large Vessel Occlusion Stroke Thrombectomy. INTERVENTIONAL NEUROLOGY 2017; 6:147-152. [PMID: 29118791 DOI: 10.1159/000464300] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background and Purpose Prior to thrombectomy for proximal anterior circulation large vessel occlusion (LVO) stroke, recent trials have utilized CT angiography (CTA) for vascular imaging immediately following noncontrast CT (NCCT) for decision-making, but thin-section NCCT with automated maximum intensity projection (MIP) reconstruction also has high accuracy in demonstrating the site of an occluding thrombus. We hypothesized that performing thin-section NCCT with MIP alone prior to thrombectomy improves the time to groin puncture (GP) compared to performing CTA after NCCT. Materials and Methods We performed a retrospective cohort study of anterior circulation LVO thrombectomy at our tertiary care academic medical center. All stroke patients evaluated with thin-section NCCT (0.625 mm) with automated MIP reconstructions alone and those who had additional CTA were included. We excluded transfer patients, in-hospital strokes, posterior circulation strokes, and patients that were evaluated with stroke imaging other than NCCT or CTA prior to thrombectomy. The study groups were compared for duration from NCCT to GP and total stroke imaging duration. Results From March 2008 through August 2015, 34 thrombectomy patients met the inclusion/exclusion criteria - 13 in the NCCT and 20 in the NCCT+CTA group. The total stroke imaging duration was shorter in the NCCT group than in the NCCT+CTA group (2 min [1-6] vs. 28 min [23-65]; p < 0.001). The NCCT-only group had a shorter time from NCCT to GP (68 min [32-99] vs. 104 min [79-128]; p = 0.030). Conclusion Avoiding advanced imaging for patients with anterior circulation LVO in whom thin-section NCCT with MIPs reveals a hyperdense sign significantly shortens the imaging-to-GP time.
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Affiliation(s)
| | - Anita Tipirneni
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Priyank Khandelwal
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Vasu Saini
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Richard Ronca
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Steven Lord
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Samir Sur
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Luis Guada
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Kevin Ramdas
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Eric Peterson
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Dileep Yavagal
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA.,Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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Vilela P, Rowley HA. Brain ischemia: CT and MRI techniques in acute ischemic stroke. Eur J Radiol 2017; 96:162-172. [DOI: 10.1016/j.ejrad.2017.08.014] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 08/07/2017] [Accepted: 08/12/2017] [Indexed: 11/17/2022]
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40
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Neuhaus V, Große Hokamp N, Abdullayev N, Maus V, Kabbasch C, Mpotsaris A, Maintz D, Borggrefe J. Comparison of virtual monoenergetic and polyenergetic images reconstructed from dual-layer detector CT angiography of the head and neck. Eur Radiol 2017; 28:1102-1110. [DOI: 10.1007/s00330-017-5081-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 08/31/2017] [Accepted: 09/13/2017] [Indexed: 02/01/2023]
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41
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Byrne D, Sugrue G, Stanley E, Walsh JP, Murphy S, Kavanagh EC, MacMahon PJ. Improved Detection of Anterior Circulation Occlusions: The "Delayed Vessel Sign" on Multiphase CT Angiography. AJNR Am J Neuroradiol 2017; 38:1911-1916. [PMID: 28798219 DOI: 10.3174/ajnr.a5317] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 05/27/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Multiphase CTA, a technique to dynamically assess the vasculature in acute ischemic stroke, was primarily developed to evaluate collateral filling. We have observed that it is also useful in identifying distal anterior circulation occlusions due to delayed anterior circulation opacification on multiphase CTA, an observation we term the "delayed vessel sign." We aimed to determine the usefulness of this sign by comparing multiphase CTA with single-phase CTA. MATERIALS AND METHODS All 23 distal anterior circulation occlusions during a 2-year period were included. Ten M1-segment occlusions and 10 cases without a vessel occlusion were also included. All patients had follow-up imaging confirming the diagnosis. Initially, the noncontrast CT and first phase of the multiphase CTA study for each patient were blindly evaluated (2 neuroradiologists, 2 radiology trainees) for an anterior circulation occlusion. Readers' confidence, speed, and sensitivity of detection were recorded. Readers were then educated on the "delayed vessel sign," and each multiphase CTA study was re-examined for a vessel occlusion after at least 14 days. RESULTS There was significant improvement in the sensitivity of detection of distal anterior circulation vessel occlusions (P < .001), overall confidence (P < .001), and time taken to interpret (P < .001) with multiphase CTA compared with single-phase CTA. Readers preferred MIP images compared with source images in >90% of cases. CONCLUSIONS The delayed vessel sign is a reliable indicator of anterior circulation vessel occlusion, particularly in cases involving distal branches. Assessment of the later phases of multiphase CTA for the delayed vessel sign leads to a significant improvement in the speed and confidence of interpretation, compared with single-phase CTA.
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Affiliation(s)
- D Byrne
- From the Departments of Radiology (D.B., G.S., E.S., E.C.K., P.J.M.)
| | - G Sugrue
- From the Departments of Radiology (D.B., G.S., E.S., E.C.K., P.J.M.)
| | - E Stanley
- From the Departments of Radiology (D.B., G.S., E.S., E.C.K., P.J.M.)
| | - J P Walsh
- Department of Radiology (J.P.W.), St. James's Hospital, Dublin, Ireland
| | - S Murphy
- Stroke Medicine (S.M.), Mater Misericordiae University Hospital, Dublin, Ireland.,School of Medicine (S.M., E.C.K., P.J.M.), University College Dublin, Dublin, Ireland.,Royal College of Surgeons in Ireland Medical School (S.M.), Dublin, Ireland
| | - E C Kavanagh
- From the Departments of Radiology (D.B., G.S., E.S., E.C.K., P.J.M.).,School of Medicine (S.M., E.C.K., P.J.M.), University College Dublin, Dublin, Ireland
| | - P J MacMahon
- From the Departments of Radiology (D.B., G.S., E.S., E.C.K., P.J.M.).,School of Medicine (S.M., E.C.K., P.J.M.), University College Dublin, Dublin, Ireland
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42
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Detection of single-phase CTA occult vessel occlusions in acute ischemic stroke using CT perfusion-based wavelet-transformed angiography. Eur Radiol 2017; 27:2657-2664. [DOI: 10.1007/s00330-016-4613-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/21/2016] [Accepted: 09/15/2016] [Indexed: 10/20/2022]
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43
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Abstract
Advances in mechanical thrombectomy techniques have resulted in improved, recanalization and functional outcomes in acute stroke, as demonstrated in recent, randomized trials comparing mechanical thrombectomy with thrombolysis. In conjunction with the technological advancements in thrombectomy devices, there has been better appreciation of stricter patient selection criteria for endovascular therapy based on pre-procedural imaging, including clot location, infarct volume, and penumbral territory at risk. Pre-procedural imaging performed to assess suitability for endovascular therapy commonly provides information on clot characteristics, such as clot location, length, density, and susceptibility, which can influence and may predict the efficacy of intravenous and endovascular treatments. The purpose of this review is to evaluate the role of clot imaging in acute large vessel occlusion strokes and discuss the relevance of clot imaging to thrombolytic and endovascular therapy.
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44
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Abstract
In this chapter we review the optimal imaging modalities for subacute and chronic stroke. We discuss the utility of computed tomography (CT) and multimodal CT imaging. Further, we analyze the importance of specific magnetic resonance imaging sequences, such as diffusion-weighted imaging for acute ischemic stroke, T2/fluid-attenuated inversion recovery for subacute and chronic stroke, and susceptibility imaging for detection of intracranial hemorrhages. Different ischemic stroke mechanisms are reviewed, and how these imaging modalities may aid in the determination of such. Further, we analyze how topographic patterns in ischemic stroke may provide important clues to the diagnosis, in addition to the temporal evolution of the stroke. Lastly, specific cerebrovascular occlusive diseases are reviewed, with emphasis on the optimal imaging modalities and their findings in each condition.
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45
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Catanese L, Tarsia J, Fisher M. Acute Ischemic Stroke Therapy Overview. Circ Res 2017; 120:541-558. [DOI: 10.1161/circresaha.116.309278] [Citation(s) in RCA: 194] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 07/30/2016] [Accepted: 08/14/2016] [Indexed: 12/21/2022]
Abstract
The treatment of acute ischemic stroke has undergone dramatic changes recently subsequent to the demonstrated efficacy of intra-arterial (IA) device-based therapy in multiple trials. The selection of patients for both intravenous and IA therapy is based on timely imaging with either computed tomography or magnetic resonance imaging, and if IA therapy is considered noninvasive, angiography with one of these modalities is necessary to document a large-vessel occlusion amenable for intervention. More advanced computed tomography and magnetic resonance imaging studies are available that can be used to identify a small ischemic core and ischemic penumbra, and this information will contribute increasingly in treatment decisions as the therapeutic time window is lengthened. Intravenous thrombolysis with tissue-type plasminogen activator remains the mainstay of acute stroke therapy within the initial 4.5 hours after stroke onset, despite the lack of Food and Drug Administration approval in the 3- to 4.5-hour time window. In patients with proximal, large-vessel occlusions, IA device-based treatment should be initiated in patients with small/moderate-sized ischemic cores who can be treated within 6 hours of stroke onset. The organization and implementation of regional stroke care systems will be needed to treat as many eligible patients as expeditiously as possible. Novel treatment paradigms can be envisioned combining neuroprotection with IA device treatment to potentially increase the number of patients who can be treated despite long transport times and to ameliorate the consequences of reperfusion injury. Acute stroke treatment has entered a golden age, and many additional advances can be anticipated.
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Affiliation(s)
- Luciana Catanese
- From the Department of Neurology, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
| | - Joseph Tarsia
- From the Department of Neurology, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
| | - Marc Fisher
- From the Department of Neurology, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
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46
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McDermott M, Jacobs T, Morgenstern L. Critical care in acute ischemic stroke. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:153-176. [PMID: 28187798 DOI: 10.1016/b978-0-444-63600-3.00010-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Most ischemic strokes are managed on the ward or on designated stroke units. A significant proportion of patients with ischemic stroke require more specialized care. Several studies have shown improved outcomes for patients with acute ischemic stroke when neurocritical care services are available. Features of acute ischemic stroke patients requiring intensive care unit-level care include airway or respiratory compromise; large cerebral or cerebellar hemisphere infarction with swelling; infarction with symptomatic hemorrhagic transformation; infarction complicated by seizures; and a large proportion of patients require close management of blood pressure after thrombolytics. In this chapter, we discuss aspects of acute ischemic stroke care that are of particular relevance to a neurointensivist, covering neuropathology, neurodiagnostics and imaging, blood pressure management, glycemic control, temperature management, and the selection and timing of antithrombotics. We also focus on the care of patients who have received intravenous thrombolysis or mechanical thrombectomy. Complex clinical decision making in decompressive hemicraniectomy for hemispheric infarction and urgent management of basilar artery thrombosis are specifically addressed.
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Affiliation(s)
- M McDermott
- Stroke Program, University of Michigan, Ann Arbor, MI, USA.
| | - T Jacobs
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - L Morgenstern
- Stroke Program, University of Michigan, Ann Arbor, MI, USA
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Association of Cortical Vein Filling with Clot Location and Clinical Outcomes in Acute Ischaemic Stroke Patients. Sci Rep 2016; 6:38525. [PMID: 27917948 PMCID: PMC5137111 DOI: 10.1038/srep38525] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 11/11/2016] [Indexed: 01/19/2023] Open
Abstract
Delay in cortical vein filling during the late-venous phase (delayed-LCVF) is characterized by opacification of cerebral veins despite contrast clearance from contralateral veins on dynamic computed tomography angiography (dCTA) in acute ischemic stroke (AIS) patients. The aim of the study was to investigate the associations of delayed-LCVF with clot location, reperfusion status at 24 hours, and 90-days functional outcome in AIS patients who received reperfusion therapy. A prospective cohort of AIS patients treated with intravenous thrombolysis was studied. Groupwise comparison, univariate, and multivariate regression analyses were used to study the association of delayed-LCVF with clot location and clinical outcomes. Of 93 patients (mean age = 72 ± 12 years) with hemispheric AIS included in the study, 46 (49%) demonstrated delayed-LCVF. Patients with delayed-LCVF demonstrated a significantly higher proportion of proximal occlusion (72% vs 13%, P =< 0.0001), and poor reperfusion at 24 hours (41% vs 11%, P = 0.001). The proportion of poor functional outcome at 90 days was not significantly different (22/56 (48%) vs 17/61 (36%), P = 0.297). The appearance of delayed-LCVF on baseline dCTA may be a surrogate for large vessel occlusion, and an early marker for poor 24-hour angiographic reperfusion.
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48
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Ehrlich ME, Turner HL, Currie LJ, Wintermark M, Worrall BB, Southerland AM. Safety of Computed Tomographic Angiography in the Evaluation of Patients With Acute Stroke. Stroke 2016; 47:2045-50. [DOI: 10.1161/strokeaha.116.013973] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 05/31/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Noncontrasted head computed tomography (NCHCT) has long been the standard of care for acute stroke imaging. New guidelines recommending advanced vascular imaging to identify eligible patients for endovascular therapy have renewed safety concerns on the use of contrast in the emergent setting without laboratory confirmation of renal function.
Methods—
We compared computed tomographic angiography (CTA) versus NCHCT alone during acute stroke evaluation with focus on renal safety and timeliness of therapy delivery. We reviewed data on all emergency department patients for whom the Acute Stroke Intervention Team was activated between December 2013 and September 2014. Primary outcomes included acute kidney injury and change in serum creatinine from presentation to 24 to 48 hours (Δ serum creatinine [Cr]). We assessed therapy delay using door-to-CT and door-to-needle times.
Results—
Of 289 patients requiring Acute Stroke Intervention Team activation, 157 received CTA and 132 NCHCT only. There was no difference between groups in mean Cr at 24 to 48 hours (1.06 CTA; 1.40 NCHCT;
P
=0.059), ΔCr (−0.07 CTA, −0.11 NCHCT,
P
=0.489), or rates of acute kidney injury (5 CTA, 7 NCHCT,
P
=0.422). There was no significant difference in mean intravenous tissue plasminogen activator treatment times (68.11 minutes CTA, 81.36 minutes NCHCT;
P
=0.577). In the 157 patients who underwent CTA, 16 (10.2%) vascular anomalies and 55 (35.0%) high-grade stenoses or occlusions were identified.
Conclusions—
CTA acquisition during acute stroke evaluation was safe with regards to renal function and did not delay appropriate therapy delivery. Acute CTA acquisition offers additional clinical value in rapid identification of vascular abnormalities.
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Affiliation(s)
- Matthew E. Ehrlich
- From the Department of Neurology, University of Virginia, Charlottesville (M.E.E., H.L.T., L.J.C., B.B.W., A.M.S.); and Department of Radiology, Stanford University, CA (M.W.)
| | - Heather L. Turner
- From the Department of Neurology, University of Virginia, Charlottesville (M.E.E., H.L.T., L.J.C., B.B.W., A.M.S.); and Department of Radiology, Stanford University, CA (M.W.)
| | - Lillian J. Currie
- From the Department of Neurology, University of Virginia, Charlottesville (M.E.E., H.L.T., L.J.C., B.B.W., A.M.S.); and Department of Radiology, Stanford University, CA (M.W.)
| | - Max Wintermark
- From the Department of Neurology, University of Virginia, Charlottesville (M.E.E., H.L.T., L.J.C., B.B.W., A.M.S.); and Department of Radiology, Stanford University, CA (M.W.)
| | - Bradford B. Worrall
- From the Department of Neurology, University of Virginia, Charlottesville (M.E.E., H.L.T., L.J.C., B.B.W., A.M.S.); and Department of Radiology, Stanford University, CA (M.W.)
| | - Andrew M. Southerland
- From the Department of Neurology, University of Virginia, Charlottesville (M.E.E., H.L.T., L.J.C., B.B.W., A.M.S.); and Department of Radiology, Stanford University, CA (M.W.)
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Affiliation(s)
| | - Rhannon Lobo
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Arindam Kar
- Imperial College Healthcare NHS Trust, London, UK
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50
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Endovascular Reperfusion Strategies for Acute Stroke. JACC Cardiovasc Interv 2016; 9:307-317. [DOI: 10.1016/j.jcin.2015.11.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 10/29/2015] [Accepted: 11/03/2015] [Indexed: 11/23/2022]
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