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Miller MM, Wideman B, Khan M, Henninger N. Hypoperfusion Intensity Ratio Is Associated with Early Neurologic Deficit Severity and Deterioration after Mechanical Thrombectomy in Large-Vessel Occlusion Ischemic Stroke. AJNR Am J Neuroradiol 2024; 45:879-886. [PMID: 38816020 DOI: 10.3174/ajnr.a8234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/09/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND AND PURPOSE The hypoperfusion intensity ratio is a surrogate marker for collateral status and a predictor of infarct growth, malignant cerebral edema, and hemorrhagic transformation. Its utility to predict a poor NIHSS score and early neurologic deterioration after mechanical thrombectomy for large vessel (LVO) versus distal and medium vessel occlusions (DMVO) has not been investigated. The objective of this study was to determine whether the higher hypoperfusion intensity ratio is associated with a worse NIHSS score at 24 hours post-mechanical thrombectomy and early neurologic deterioration in LVO versus DMVO acute ischemic stroke. MATERIALS AND METHODS This was a retrospective study of 231 patients with acute ischemic stroke with LVO or DMVO amenable for mechanical thrombectomy and available CTP for hypoperfusion intensity ratio assessment pre-mechanical thrombectomy. Clinical and imaging characteristics were abstracted from the medical records. The primary outcome was the NIHSS score at 24 hours post-mechanical thrombectomy. The secondary outcome was early neurologic deterioration, defined as a >4-point increase in the NIHSS score between the initial assessment and 24 hours post-mechanical thrombectomy. All analyses were first conducted in the entire cohort and then separately for the LVO versus DMVO groups. RESULTS The optimal hypoperfusion intensity ratio threshold to detect early neurologic deterioration was 0.54. A hypoperfusion intensity ratio ≥ 0.54 was more frequently present in LVO versus DMVO (n = 37 [77.1%] versus n = 11 [22.9%]; P < .001). On multivariable linear regression, the hypoperfusion intensity ratio ≥ 0.54 was independently associated with a worse NIHSS score at 24 hours post-mechanical thrombectomy in the entire cohort (β = 0.163; P = .002) and the LVO group (β = 0.210; P = .005), but not in the DMVO group. The early neurologic deterioration occurred in 26 (11.3%) subjects. On multivariable logistic regression, there was no association of the hypoperfusion intensity ratio ≥ 0.54 with early neurologic deterioration in the entire cohort. However, when analyzed separately, a hypoperfusion intensity ratio ≥ 0.54 significantly increased the odds of early neurologic deterioration in subjects with LVO (OR = 5.263; 95% CI, 1.170-23.674; P = .030) but not in the DMVO group. CONCLUSIONS The hypoperfusion intensity ratio ≥ 0.54 was independently associated with a worse 24-hour post-mechanical thrombectomy NIHSS score and early neurologic deterioration in LVO, but not in DMVO acute ischemic stroke. Pending confirmation in future, prospective studies assessing the hypoperfusion intensity ratio may help identify patients at risk of secondary decline to improve peri-thrombectomy care and clinical decision-making.
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Affiliation(s)
- Małgorzata M Miller
- From the Department of Neurosciences (M.M.M., B.W.), Corewell Health West, Grand Rapids, Michigan
- College of Human Medicine (M.M.M.), Michigan State University, Grand Rapids, Michigan
| | - Brian Wideman
- From the Department of Neurosciences (M.M.M., B.W.), Corewell Health West, Grand Rapids, Michigan
| | - Muhib Khan
- Department of Neurology (M.K.), Mayo Clinic, Rochester, Minnesota
| | - Nils Henninger
- Department of Neurology (N.H.), University of Massachusetts, Chan Medical School Worcester, Massachusetts
- Department of Psychiatry (N.H.), University of Massachusetts, Chan Medical School Worcester, Massachusetts
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Alotaibi FF, Alshahrani A, Mohamed G, AlShamrani MA, Bin Amir H, Alsaeed A, Heji A, Alghanmi S, Alqurishi M, Alanazi A, Aldraye H, Asiri M, Alqahtani M, Alreshaid AA, AlKawi A, AlHazzani A, AlZawahmah M, Alokaili RN, Shuaib A, Al-Ajlan FS. Diagnostic accuracy of large and medium vessel occlusions in acute stroke imaging by neurology residents and stroke fellows: A comparison of CT angiography alone and CT angiography with CT perfusion. Eur Stroke J 2024; 9:356-365. [PMID: 37990504 DOI: 10.1177/23969873231214218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023] Open
Abstract
INTRODUCTION Neurology senior residents and stroke fellows are first to clinically assess and interpret imaging studies of patients presenting to the emergency department with acute stroke. The aim of this study was to compare the diagnostic accuracy of brain CT angiography (CTA) with and without CT perfusion (CTP) between neurology senior residents and stroke fellows. METHODS In this neuroimaging study, nine practitioners (four senior neurology residents (SNRs) and five stroke fellows (SFs)) clinically assessed and interpreted the imaging data of 50 cases (15 normal images, 21 large vessel occlusions (LVOs) and 14 medium vessel occlusions (MeVOs) in two sessions, 1 week apart in comparison to final diagnosis of experienced neuroradiologist and experienced stroke neurologist consensus. Interrater agreement of CTA alone and CTA with CTP was quantified using kappa statistics, sensitivity, specificity and overall accuracy. RESULTS Overall, arterial occlusions were correctly identified in 221/315 (70.1%) with CTA alone and in 266/315 (84.4%) with CTA and CTP (p < 0.001). The sensitivity of overall arterial occlusions detection with CTA alone was 94.2% (95% CI: 90.8%-96.6%) while with addition of CTP was 98% (95% CI: 95.6%-99.3%), The specificity of CTA alone was 74.7% (95% CI: 67.2%-81.3%) which increased with CTP to 84.4% (95% CI: 77.7%-89.8%). The likelihood of correct identification with CTA alone was 156/189 (82.54%) for LVOs and 65/126 (51.59%) for MeVOs. This increased to 169/189 (89.42%; p = 0.054) for LVOs and 97/126 (76.98%; p < 0.001) for MeVOs when the CTA images with CTP were viewed. There was good overall interrater agreement between readers when using CTA alone (k 0.71, 95% CI, 0.62-0.80) and almost perfect (k 0.85, 95% CI, 0.76-0.94) when CTP was added to the image for interpretation. CTA and CTP had a significantly lower median interquartile range (IQR) interpretation time than CTA alone (114 [IQR, 103-120] s vs 156 [IQR, 133-160] s, p < 0.001). DISCUSSION In cerebral arterial occlusions, the rate of LVO and MeVOs detections increases when adding CTP to CTA. The accuracy and time for diagnosing arterial occlusion can be significantly improved if CTP is added to CTA. As MeVOs are commonly missed by front-line neurology senior residents or stroke fellows, cases with significant deficits and no apparent arterial occlusions need to be reviewed with neuroradiological expertise.
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Affiliation(s)
- Fawaz F Alotaibi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Asma Alshahrani
- Department of Biostatistics, Epidemiology, and Scientific Computing, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Gamal Mohamed
- Department of Biostatistics, Epidemiology, and Scientific Computing, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mohamed A AlShamrani
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hussain Bin Amir
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ali Alsaeed
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Alaa Heji
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Suwaidi Alghanmi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mohammed Alqurishi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Azhar Alanazi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hamad Aldraye
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Muhannad Asiri
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mohammed Alqahtani
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Abdulrahman A Alreshaid
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
| | - Ammar AlKawi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
| | - Adel AlHazzani
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
| | - Mohamed AlZawahmah
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Riyadh N Alokaili
- Department of Radiology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ashfaq Shuaib
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Fahad S Al-Ajlan
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
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Karamchandani RR, Satyanarayana S, Yang H, Rhoten JB, Strong D, Clemente JD, Defilipp G, Patel NM, Bernard JD, Stetler WR, Parish JM, Hines AU, Patel HN, Helms AM, Macko L, Williams L, Retelski J, Guzik AK, Wolfe SQ, Asimos AW. Predictors of devastating functional outcome despite successful basilar thrombectomy. Interv Neuroradiol 2023:15910199231216516. [PMID: 37990546 DOI: 10.1177/15910199231216516] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Basilar thrombosis frequently leads to poor functional outcomes, even with good endovascular reperfusion. We studied factors associated with severe disability or death in basilar thrombectomy patients achieving revascularization. METHODS We retrospectively analyzed records from a health system's code stroke registry, including successful basilar thrombectomy patients from January 2017 to May 2023 who were evaluated with pretreatment computed tomography perfusion. The primary outcome was devastating functional outcome (90-day modified Rankin Scale [mRS] score 5-6). A multivariable logistic regression model was constructed to determine independent predictors of the primary outcome. The area under the receiver operator characteristics curve (AUC) was calculated for the model distinguishing good from devastating outcome. RESULTS Among 64 included subjects, with mean (standard deviation) age 65.6 (14.1) years and median (interquartile range) National Institutes of Health Stroke Scale (NIHSS) 18 (5.75-24.5), the primary outcome occurred in 28 of 64 (43.8%) subjects. Presenting NIHSS (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.01-1.14, p = 0.02), initial glucose (OR 0.99, 95% CI 0.97-1.00, p < 0.05), and proximal occlusion site (OR 7.38, 95% CI 1.84-29.60, p < 0.01) were independently associated with 90-day mRS 5-6. The AUC for the multivariable model distinguishing outcomes was 0.81 (95% CI 0.70-0.92). CONCLUSION We have identified presenting stroke severity, lower glucose, and proximal basilar occlusion as predictors of devastating neurological outcome in successful basilar thrombectomy patients. These factors may be used in medical decision making or for patient selection in future clinical trials.
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Affiliation(s)
| | | | - Hongmei Yang
- Information and Analytics Services, Atrium Health, Charlotte, NC, USA
| | - Jeremy B Rhoten
- Department of Neurology, Neurosciences Institute, Atrium Health, Charlotte, NC, USA
| | - Dale Strong
- Information and Analytics Services, Atrium Health, Charlotte, NC, USA
| | - Jonathan D Clemente
- Charlotte Radiology, Neurosciences Institute, Atrium Health, Charlotte, NC, USA
| | - Gary Defilipp
- Charlotte Radiology, Neurosciences Institute, Atrium Health, Charlotte, NC, USA
| | - Nikhil M Patel
- Department of Internal Medicine, Pulmonary and Critical Care, Neurosciences Institute, Atrium Health, Charlotte, NC, USA
| | - Joe D Bernard
- Carolina Neurosurgery and Spine Associates, Neurosciences Institute, Atrium Health, Charlotte, NC, USA
| | - William R Stetler
- Carolina Neurosurgery and Spine Associates, Neurosciences Institute, Atrium Health, Charlotte, NC, USA
| | - Jonathan M Parish
- Carolina Neurosurgery and Spine Associates, Neurosciences Institute, Atrium Health, Charlotte, NC, USA
| | - Andrew U Hines
- Charlotte Radiology, Neurosciences Institute, Atrium Health, Charlotte, NC, USA
| | - Harsh N Patel
- Department of Neurology, Neurosciences Institute, Atrium Health, Charlotte, NC, USA
| | - Anna Maria Helms
- Department of Neurology, Neurosciences Institute, Atrium Health, Charlotte, NC, USA
| | - Lauren Macko
- Department of Neurology, Neurosciences Institute, Atrium Health, Charlotte, NC, USA
| | - Laura Williams
- Department of Neurology, Neurosciences Institute, Atrium Health, Charlotte, NC, USA
| | - Julia Retelski
- Department of Neurology, Neurosciences Institute, Atrium Health, Charlotte, NC, USA
| | - Amy K Guzik
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Stacey Q Wolfe
- Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Andrew W Asimos
- Department of Emergency Medicine, Neurosciences Institute, Atrium Health, Charlotte, NC, USA
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Yao K, Zu HB. Isolated transient vertigo due to TIA: challenge for diagnosis and therapy. J Neurol 2023; 270:769-779. [PMID: 36371598 DOI: 10.1007/s00415-022-11443-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 10/19/2022] [Accepted: 10/19/2022] [Indexed: 11/13/2022]
Abstract
As a prevalent vertigo disease in the clinic, isolated transient vertigo can present as a vertigo episode without focal signs and always free of symptoms on presentation. Previous studies showed a part of isolated transient vertigo events had a high risk of stroke during follow-up. However, how to discern posterior circulation ischemia become a great challenge for clinicians, especially in emergency, neurology, and ENT departments. Routine besides, hematological, and imaging examinations are often difficult provide a clear etiological diagnosis. Hence, this article reviews current knowledge about the epidemiology, risk factors, offending lesions, and clinical manifestation of transient ischemic attack (TIA) presenting as isolated transient vertigo. In addition, we summarize several advances in besides examinations, serum biomarkers, and imaging technologies to better identify stroke events. Finally, the current situation of therapy was briefly retrospected. Here we present a critical clinical puzzle that needs to be solved in the future. Of note, there is a still lack of high-quality studies in this field. The article reviews the keys to the diagnosis of isolated transient vertigo due to TIA and provides us with more methods to screen for high-risk stroke populations.
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Affiliation(s)
- Kai Yao
- Department of Neurology, Jinshan Hospital Affiliated to Fudan University, No. 1508 Longhang Road, Jinshan District, Shanghai, 201508, China
| | - Heng-Bing Zu
- Department of Neurology, Jinshan Hospital Affiliated to Fudan University, No. 1508 Longhang Road, Jinshan District, Shanghai, 201508, China.
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Value of CT Perfusion for Collateral Status Assessment in Patients with Acute Ischemic Stroke. Diagnostics (Basel) 2022; 12:diagnostics12123014. [PMID: 36553021 PMCID: PMC9777468 DOI: 10.3390/diagnostics12123014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/24/2022] [Accepted: 11/27/2022] [Indexed: 12/04/2022] Open
Abstract
Good collateral status in acute ischemic stroke patients is an important indicator for good outcomes. Perfusion imaging potentially allows for the simultaneous assessment of local perfusion and collateral status. We combined multiple CTP parameters to evaluate a CTP-based collateral score. We included 85 patients with a baseline CTP and single-phase CTA images from the MR CLEAN Registry. We evaluated patients' CTP parameters, including relative CBVs and tissue volumes with several time-to-maximum ranges, to be candidates for a CTP-based collateral score. The score candidate with the strongest association with CTA-based collateral score and a 90-day mRS was included for further analyses. We assessed the association of the CTP-based collateral score with the functional outcome (mRS 0-2) by analyzing three regression models: baseline prognostic factors (model 1), model 1 including the CTA-based collateral score (model 2), and model 1 including the CTP-based collateral score (model 3). The model performance was evaluated using C-statistic. Among the CTP-based collateral score candidates, relative CBVs with a time-to-maximum of 6-10 s showed a significant association with CTA-based collateral scores (p = 0.02) and mRS (p = 0.05) and was therefore selected for further analysis. Model 3 most accurately predicted favorable outcomes (C-statistic = 0.86, 95% CI: 0.77-0.94) although differences between regression models were not statistically significant. We introduced a CTP-based collateral score, which is significantly associated with functional outcome and may serve as an alternative collateral measure in settings where MR imaging is not feasible.
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6
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Liu F, Yang X, Hou C, Li Z, Li G, Zuo L. Diagnostic value of whole-brain computed tomographic perfusion imaging for suspected large artery occlusion stroke patients in emergency department. Acta Neurol Belg 2022; 122:1219-1227. [PMID: 35023071 DOI: 10.1007/s13760-021-01859-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 12/27/2021] [Indexed: 12/30/2022]
Abstract
PURPOSE To evaluate the diagnostic value of whole-brain computed tomographic perfusion (WB-CTP) in emergency department for suspected large artery occlusion stroke. METHODS Suspected large artery occlusion (LAO) stroke patients had initial WB-CTP in the neurological emergency department from August 2016 to August 2018 were retrospectively reviewed for analysis. The sensitivity and specificity of non-contrast computed tomographic scan (NCCT) or WB-CTP for diagnosis of cerebral infarction was compared between the anterior circulation and posterior circulation. The imaging characteristics of WB-CTP in patients with stroke-mimics were described. RESULTS Among the 300 included patients, 259 patients (86.3%) were finally diagnosed as cerebral infarction, 16 (5.3%) were transient ischemic attack, 10 (3.3%) were epileptic seizure and 3 (1%) were cerebral venous sinus thrombosis (CVST). For patients with final diagnosis of cerebral infarction, WB-CTP found abnormality in 206 cases (79.5%). NCCT had poor sensitivity (4.6%) but high specificity (100%) for cerebral infarction. The CTP imaging had a sensitivity of 81.2% in anterior circulation and 59.6% in posterior circulation stroke, both with good specificity (57.1% and 92.6%, respectively). 60% (6/10) of epileptic patients showed abnormal perfusion in CTP maps, which was inconsistent with cerebral arterial supply territories. Hypoperfusion manifestations were discovered in areas adjacent to occlusion sinus of all 3 CVST cases. CONCLUSION This retrospective study indicates WB-CTP can be useful in identifying acute ischemic stroke in emergency department, especially for patients with acute LAO stroke. Moreover, WB-CTP may have a value in differentiating stroke mimics such as epilepsy and CVST.
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Affiliation(s)
- Feifeng Liu
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xinyi Yang
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Changlong Hou
- Department of Radiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Zhiyu Li
- Department of Radiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Gang Li
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Lian Zuo
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China.
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7
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Liu XL, Hang Y, Cao Y, Jia Z, Zhao LB, Shi HB, Liu S. Tmax profile in computed tomography perfusion-based RAPID software maps influences outcome after mechanical thrombectomy in patients with basilar artery occlusion. J Neurointerv Surg 2022:neurintsurg-2021-018557. [PMID: 35580984 DOI: 10.1136/neurintsurg-2021-018557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 05/08/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Computed tomography perfusion (CTP) parameters have been shown to have predictive value for functional outcomes of patients with basilar artery occlusion (BAO). We report the predictive value of CTP-based software (CTP-Rapid Processing of Perfusion and Diffusion (RAPID); iSchemia View) for functional outcomes of patients with BAO after endovascular therapy (EVT). METHODS Patients with BAO who underwent EVT were retrospectively analyzed in our center from December 2019 to July 2021. Baseline characteristics and imaging parameters from non-contrast CT, CT angiography (CTA), and CTP-RAPID were collected for analysis. RESULTS Among the 55 patients enrolled in this study, 22 (40.0%) achieved a good functional outcome (modified Rankin Scale score ≤3 at 90 days). In the univariate analysis, posterior circulation Alberta Stroke Program Early CT Score, Basilar Artery on CT Angiography score, posterior circulation CTA score, posterior communicating artery deficiency, perfusion deficit volume in time to maximum (Tmax) >4 s, Tmax >6 s, and mismatch volume were associated with functional outcomes (all p<0.05). In the multivariate analysis, perfusion deficit volume in Tmax >6 s (OR 1.011 (95% CI 1.001 to 1.020)) and posterior circulation CTA score (OR 0.435 (95% CI 0.225 to 0.840)) remained independent outcome predictors (all p<0.05). CONCLUSIONS Perfusion deficit volume in Tmax >6 s on CTP-RAPID imaging maps and basilar artery on CTA score have potential as functional outcome predictors in patients with BAO after EVT.
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Affiliation(s)
- Xing-Long Liu
- Department of Interventional Radiology, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, Jiangsu, China
| | - Yu Hang
- Department of Interventional Radiology, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, Jiangsu, China
| | - Yuezhou Cao
- Department of Interventional Radiology, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, Jiangsu, China
| | - Zhenyu Jia
- Department of Interventional Radiology, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, Jiangsu, China
| | - Lin Bo Zhao
- Department of Interventional Radiology, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, Jiangsu, China
| | - Hai-Bin Shi
- Department of Interventional Radiology, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, Jiangsu, China
| | - Sheng Liu
- Department of Interventional Radiology, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, Jiangsu, China
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Ng MA. Posterior Circulation Ischaemic Stroke. Am J Med Sci 2022; 363:388-398. [PMID: 35104439 DOI: 10.1016/j.amjms.2021.10.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 06/09/2021] [Accepted: 10/21/2021] [Indexed: 11/16/2022]
Abstract
Posterior circulation ischaemic stroke (PCIS) is a disease of high burden. They account for 20-25% of all ischaemic strokes. However, it is relatively under-researched and requires more clinical attention, since it carries worse functional outcomes. Vertigo, visual disturbances and sensory/motor disturbances are found in PCIS. Large artery atherosclerosis and embolism are main causes of PCIS, while there is growing evidence that vertebrobasilar dolichoectasia is a key association. Hypertension is the commonest risk factor, while diabetes mellitus is more specific to PCIS. PCIS is diagnosed through neuroimaging techniques, which examine structural brain abnormalities, vascular patency and perfusion. PCIS, in line with ischaemic stroke in general, requires medical treatment and lifestyle modifications. This includes smoking cessation, weight control, and dietary alterations. Aspirin use also significantly improves survival outcomes. While intravascular and intra-arterial thrombolysis improve clinical outcomes, this is not proven conclusively for stenting and angioplasty. Future research on PCIS can focus on multi-centre epidemiological studies, clinically significant anatomical variants, and collateralisation.
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Affiliation(s)
- Mr Alexander Ng
- Department of Diagnostic Radiology, Li Ka Shing Faculty of Medicine, University of Hong Kong, Full Address: Block K, Queen Mary Hospital, Pokfulam Road, Hong Kong.
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Salerno A, Strambo D, Nannoni S, Dunet V, Michel P. Patterns of ischemic posterior circulation strokes: A clinical, anatomical, and radiological review. Int J Stroke 2021; 17:714-722. [PMID: 34581223 PMCID: PMC9358301 DOI: 10.1177/17474930211046758] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Posterior circulation and anterior circulation strokes share many clinical,
pathogenetic and radiological features, although some clinical signs are highly specific
to posterior circulation strokes. Arterial stenosis and occlusions occur in significant
numbers in both acute posterior circulation and anterior circulation strokes, making
them good candidates for endovascular treatment. Among posterior circulation strokes,
basilar artery occlusions stand out because of the diagnostic and acute treatment
challenges. Methods We reviewed the literature on clinical stroke syndromes and neuroimaging findings and
systematically describe for each anatomical site of stroke the detailed clinical and
radiological information (anatomical representation, diffusion weighted imaging and
angiographic sequences). The principles of neuroimaging of posterior circulation strokes
and the prognosis for each stroke localization are also discussed. Review summary Stroke syndromes in the territories of the vertebral, basilar, cerebellar, and
posterior cerebral arteries are presented. Features typical of posterior circulation
strokes are highlighted, including patterns of basilar artery occlusions. Clinical
severity and prognosis of posterior circulation strokes are highly variable, and given
that they are more difficult to detect on CT-based neuroimaging, magnetic resonance
imaging is the technique of choice in suspected posterior circulation strokes. Rapid
identification of arterial occlusion patterns may provide prognostic information and
support acute revascularization decisions. Conclusions Posterior circulation stroke syndromes tightly reflect lesion localization and arterial
occlusion patterns. Although many clinical and pathogenetic features are similar to
anterior circulation strokes, notable differences exist in terms of clinical
presentation, stroke mechanism, prognosis, and response to acute recanalization.
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Affiliation(s)
- Alexander Salerno
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Davide Strambo
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Stefania Nannoni
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Vincent Dunet
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Patrik Michel
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Switzerland
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10
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Affiliation(s)
- Sarah Lee
- Stanford Stroke Center and Division of Child Neurology, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA (S.L.)
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Goldman-Yassen AE, Straka M, Uhouse M, Dehkharghani S. Normative distribution of posterior circulation tissue time-to-maximum: Effects of anatomic variation, tracer kinetics, and implications for patient selection in posterior circulation ischemic stroke. J Cereb Blood Flow Metab 2021; 41:1912-1923. [PMID: 33444095 PMCID: PMC8327115 DOI: 10.1177/0271678x20982395] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The generalization of perfusion-based, anterior circulation large vessel occlusion selection criteria to posterior circulation stroke is not straightforward due to physiologic delay, which we posit produces physiologic prolongation of the posterior circulation perfusion time-to-maximum (Tmax). To assess normative Tmax distributions, patients undergoing CTA/CTP for suspected ischemic stroke between 1/2018-3/2019 were retrospectively identified. Subjects with any cerebrovascular stenoses, or with follow-up MRI or final clinical diagnosis of stroke were excluded. Posterior circulation anatomic variations were identified. CTP were processed in RAPID and segmented in a custom pipeline permitting manually-enforced arterial input function (AIF) and perfusion estimations constrained to pre-specified vascular territories. Seventy-one subjects (mean 64 ± 19 years) met inclusion. Median Tmax was significantly greater in the cerebellar hemispheres (right: 3.0 s, left: 2.9 s) and PCA territories (right: 2.9 s; left: 3.3 s) than in the anterior circulation (right: 2.4 s; left: 2.3 s, p < 0.001). Fetal PCA disposition eliminated ipsilateral PCA Tmax delays (p = 0.012). Median territorial Tmax was significantly lower with basilar versus any anterior circulation AIF for all vascular territories (p < 0.001). Significant baseline delays in posterior circulation Tmax are observed even without steno-occlusive disease and vary with anatomic variation and AIF selection. The potential for overestimation of at-risk volumes in the posterior circulation merits caution in future trials.
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Affiliation(s)
- Adam E Goldman-Yassen
- Department of Radiology, New York University Langone Medical Center, New York, NY, USA.,Department of Radiology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | | | - Michael Uhouse
- Department of Radiology, George Washington University, Washington, DC, USA
| | - Seena Dehkharghani
- Department of Radiology, New York University Langone Medical Center, New York, NY, USA.,Department of Neurology, New York University Langone Medical Center, New York, NY, USA
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12
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Multimodal CT pc-ASPECTS in infratentorial stroke: diagnostic and prognostic value. Neurol Sci 2021; 42:4231-4240. [PMID: 33590432 DOI: 10.1007/s10072-021-05072-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 01/18/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE Diagnosis of posterior circulation stroke may be challenged. National Institutes of Health Stroke Scale (NIHSS) and brain imaging (non-contrast brain computed tomography-CT) are used for diagnosis; evaluation on posterior circulation stroke remains a limit of NIHSS, and the value of non-contrast CT (NCCT) is limited due to artifacts caused by the bones of the base of the skull. We tested the validity and prognostic value of posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) in patients with posterior circulation stroke. METHODS Pc-ASPECTS allots the posterior circulation 10 points. We studied 50 patients with posterior circulation stroke. We applied pc-ASPECTS to NCCT, CT angiography, and CT Perfusion. We evaluated the correlation of pc-ASPECT with outcome parameters for stroke. RESULTS Out of 50 patients, CTP showed abnormalities in 34 cases. The pc-ASPECT score calculated on brain CT and on the brain CT + angio CT had a sensibility of 24%, calculated on brain CT, angio CT and CTPerfusion gain a sensibility of 72%. Pc-ASPECT MTT resulted to be the more reliable parameter: outcome given by NIHSS score at discharge, mRS at discharge, and at 3 months was more severe in patients with Pc-ASPECT MTT alteration. Outcome given by NIHSS score at discharge and mRS at discharge and 1 at 3 months was more severe in patients with higher NIHSS score at admission. CONCLUSION We evaluated the usefulness of pc-ASPECTS on CTP in predicting functional outcome in acute posterior circulation stroke that appears to be a powerful marker for predicting functional outcome.
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13
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Capasso R, Vallone S, Serra N, Zelent G, Verganti L, Sacchetti F, Bigliardi G, Picchetto L, Caranci F, Zini A. Qualitative versus automatic evaluation of CT perfusion parameters in acute posterior circulation ischaemic stroke. Neuroradiology 2020; 63:317-330. [PMID: 32813027 PMCID: PMC7880970 DOI: 10.1007/s00234-020-02517-6] [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: 04/28/2020] [Accepted: 08/06/2020] [Indexed: 11/29/2022]
Abstract
Purpose To compare the diagnostic accuracy (ACC) in the detection of acute posterior circulation strokes between qualitative evaluation of software-generated colour maps and automatic assessment of CT perfusion (CTP) parameters. Methods Were retrospectively collected 50 patients suspected of acute posterior circulation stroke who underwent to CTP (GE “Lightspeed”, 64 slices) within 24 h after symptom onset between January 2016 and December 2018. The Posterior circulation-Acute Stroke Prognosis Early CT Score (pc-ASPECTS) was used for quantifying the extent of ischaemic areas on non-contrast (NC)CT and colour-coded maps generated by CTP4 (GE) and RAPID (iSchemia View) software. Final pc-ASPECTS was calculated on follow-up NCCT and/or MRI (Philips Intera 3.0 T or Philips Achieva Ingenia 1.5 T). RAPID software also elaborated automatic quantitative mismatch maps. Results By qualitative evaluation of colour-coded maps, MTT-CTP4D and Tmax-RAPID showed the highest sensitivity (SE) (88.6% and 90.9%, respectively) and ACC (84% and 88%, respectively) compared with the other perfusion parameters (CBV, CBF). Baseline NCCT and CBF provided by RAPID quantitative perfusion mismatch maps had the lowest SE (29.6% and 6.8%, respectively) and ACC (38% and 18%, respectively). CBF and Tmax assessment provided by quantitative RAPID perfusion mismatch maps showed significant lower SE and ACC than qualitative evaluation. No significant differences were found between the pc-ASPECTSs assessed on colour-coded MTT and Tmax maps neither between the scores assessed on colour-coded CBV-CTP4D and CBF-RAPID maps. Conclusion Qualitative analysis of colour-coded maps resulted more sensitive and accurate in the detection of ischaemic changes than automatic quantitative analysis.
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Affiliation(s)
- Raffaella Capasso
- Department of Medicine and Health Science "V. Tiberio", University of Molise, Via Francesco De Sanctis, 1, 86100, Campobasso, Italy. .,Department of Precision Medicine, School of Medicine, "Luigi Vanvitelli" University of Campania, Naples, Italy.
| | - Stefano Vallone
- Neuroradiology Unit, Ospedale Civile S.Agostino-Estense, Azienda Ospedaliero-Universitaria di Modena, Dipartimento di Neuroscienze, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicola Serra
- Statistic Unit, Department of Public Health, University of Federico II, Naples, Italy
| | - Gabriele Zelent
- Neuroradiology Unit, Ospedale Civile S.Agostino-Estense, Azienda Ospedaliero-Universitaria di Modena, Dipartimento di Neuroscienze, University of Modena and Reggio Emilia, Modena, Italy
| | - Luca Verganti
- Neuroradiology Unit, Ospedale Civile S.Agostino-Estense, Azienda Ospedaliero-Universitaria di Modena, Dipartimento di Neuroscienze, University of Modena and Reggio Emilia, Modena, Italy
| | - Federico Sacchetti
- Neuroradiology Unit, Ospedale Civile S.Agostino-Estense, Azienda Ospedaliero-Universitaria di Modena, Dipartimento di Neuroscienze, University of Modena and Reggio Emilia, Modena, Italy
| | - Guido Bigliardi
- Stroke Unit, Ospedale Civile S.Agostino-Estense, Azienda Ospedaliero-Universitaria di Modena, Dipartimento di Neuroscienze, University of Modena and Reggio Emilia, Modena, Italy
| | - Livio Picchetto
- Stroke Unit, Ospedale Civile S.Agostino-Estense, Azienda Ospedaliero-Universitaria di Modena, Dipartimento di Neuroscienze, University of Modena and Reggio Emilia, Modena, Italy
| | - Ferdinando Caranci
- Department of Medicine and Health Science "V. Tiberio", University of Molise, Via Francesco De Sanctis, 1, 86100, Campobasso, Italy.,Department of Precision Medicine, School of Medicine, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
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14
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Machner B, Choi JH, Neumann A, Trillenberg P, Helmchen C. What guides decision-making on intravenous thrombolysis in acute vestibular syndrome and suspected ischemic stroke in the posterior circulation? J Neurol 2020; 268:249-264. [PMID: 32772173 PMCID: PMC7815559 DOI: 10.1007/s00415-020-10134-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 11/28/2022]
Abstract
Intravenous thrombolysis (IVT) is rarely performed in dizzy patients with acute vestibular syndrome (AVS) or acute imbalance (AIS) even if posterior circulation stroke (PCS) is suspected. Decision-making may be affected by uncertainties in discriminating central from peripheral vestibulopathy or concerns of IVT-related harm, particularly intracerebral hemorrhage (ICH), but related studies are missing. Using an in-house register of dizzy patients coming to the emergency room, we identified 29 AVS/AIS patients who presented within 4.5 h after onset, revealed clinical signs indicative of PCS (central oculomotor signs, mild focal abnormalities), and had non-contrast computed tomography (NCCT). Patients treated with IVT (n = 15) were compared to NoIVT patients (n = 14) with regard to clinical and imaging (including perfusion computed tomography, CTP) parameters, occurrence of ICH and short-term clinical outcome (NIHSS improvement; ability to walk independently). IVT and NoIVT patients did not differ in baseline characteristics, central oculomotor signs, or clinical outcome. IVT patients more often exhibited disabling vestibular symptoms (severe dizziness/vertigo, inability to stand unsupported) and focal abnormalities than NoIVT patients. There was no ICH in either group. CTP was performed in 0% of NoIVT versus 80% of IVT patients, seven of twelve revealing posterior circulation hypoperfusion. Comparison of initial hypoperfusion (CTP) and final stroke (NCCT) revealed IVT-related benefit (smaller lesion) in three of seven IVT patients. In AVS/AIS patients with suspected PCS, disabling vestibular symptoms, focal neurological deficits, and hypoperfusion on CTP seem to direct decision-making pro IVT. In our small cohort, there were no significant IVT-related clinical benefits, no IVT-related ICHs, and salvage of brain tissue in some patients.
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Affiliation(s)
- Björn Machner
- Department of Neurology, University Hospitals Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Jin Hee Choi
- Department of Neurology, University Hospitals Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Alexander Neumann
- Department of Neuroradiology, University Hospitals Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Peter Trillenberg
- Department of Neurology, University Hospitals Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Christoph Helmchen
- Department of Neurology, University Hospitals Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
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15
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Wong ML, Flower EN, Edlow JA. A Primer on Computed Tomography Perfusion Imaging for the Emergency Physician. J Emerg Med 2020; 58:260-268. [PMID: 32156437 DOI: 10.1016/j.jemermed.2019.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 11/20/2019] [Accepted: 12/04/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Brain noncontrast computed tomography (CT), CT angiography, and magnetic resonance imaging have been used clinically for decades, and emergency physicians have a good understanding of their indications, the meaning of their results, and some facility with the interpretation of CT. However, brain CT perfusion (CTP) is relatively new and emergency physicians are less familiar with its basic concepts, indications, and role in managing patients with neurological emergencies. OBJECTIVE We will review the parameters of clinical interest on a CTP report, and how to incorporate them into clinical decision-making. DISCUSSION Endovascular therapies paired with CTP have opened up a new frontier in stroke management for severely debilitated stroke patients. It is important for emergency physicians to have an understanding of CTP and how to use it clinically. CONCLUSION Taking care of patients with large-vessel occlusions is multidisciplinary, and emergency physicians need to understand CTP imaging and its clinical utility.
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Affiliation(s)
- Matthew L Wong
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Elisa N Flower
- Harvard Medical School, Boston, Massachusetts; Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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16
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Vagal A, Wintermark M, Nael K, Bivard A, Parsons M, Grossman AW, Khatri P. Automated CT perfusion imaging for acute ischemic stroke: Pearls and pitfalls for real-world use. Neurology 2019; 93:888-898. [PMID: 31636160 DOI: 10.1212/wnl.0000000000008481] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 08/19/2019] [Indexed: 11/15/2022] Open
Abstract
Recent positive trials have thrust acute cerebral perfusion imaging into the routine evaluation of acute ischemic stroke. Updated guidelines state that in patients with anterior circulation large vessel occlusions presenting beyond 6 hours from time last known well, advanced imaging selection including perfusion-based selection is necessary. Centers that receive patients with acute stroke must now have the capability to perform and interpret CT or magnetic resonance perfusion imaging or provide rapid transfer to centers with the capability of selecting patients for a highly impactful endovascular therapy, particularly in delayed time windows. Many stroke centers are quickly incorporating the use of automated perfusion processing software to interpret perfusion raw data. As CT perfusion (CTP) is being assimilated in real-world clinical practice, it is essential to understand the basics of perfusion acquisition, quantification, and interpretation. It is equally important to recognize the common technical and clinical diagnostic challenges of automated CTP including ischemic core and penumbral misclassifications that could result in underestimation or overestimation of the core and penumbra volumes. This review highlights the pitfalls of automated CTP along with practical pearls to address the common challenges. This is particularly tailored to aid the acute stroke clinician who must interpret automated perfusion studies in an emergency setting to make time-dependent treatment decisions for patients with acute ischemic stroke.
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Affiliation(s)
- Achala Vagal
- From the Departments of Radiology (A.V), Neurology (P.K), and Neurosurgery (A.G), University of Cincinnati Medical Center, OH; Department of Radiology (M.W), Stanford University and Healthcare, CA, Department of Neurology (M.P., A.B.), Royal Melbourne Hospital, Melbourne Brain Centre, University of Melbourne, Australia; and Department of Radiology (K.N.), Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Max Wintermark
- From the Departments of Radiology (A.V), Neurology (P.K), and Neurosurgery (A.G), University of Cincinnati Medical Center, OH; Department of Radiology (M.W), Stanford University and Healthcare, CA, Department of Neurology (M.P., A.B.), Royal Melbourne Hospital, Melbourne Brain Centre, University of Melbourne, Australia; and Department of Radiology (K.N.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kambiz Nael
- From the Departments of Radiology (A.V), Neurology (P.K), and Neurosurgery (A.G), University of Cincinnati Medical Center, OH; Department of Radiology (M.W), Stanford University and Healthcare, CA, Department of Neurology (M.P., A.B.), Royal Melbourne Hospital, Melbourne Brain Centre, University of Melbourne, Australia; and Department of Radiology (K.N.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Andrew Bivard
- From the Departments of Radiology (A.V), Neurology (P.K), and Neurosurgery (A.G), University of Cincinnati Medical Center, OH; Department of Radiology (M.W), Stanford University and Healthcare, CA, Department of Neurology (M.P., A.B.), Royal Melbourne Hospital, Melbourne Brain Centre, University of Melbourne, Australia; and Department of Radiology (K.N.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mark Parsons
- From the Departments of Radiology (A.V), Neurology (P.K), and Neurosurgery (A.G), University of Cincinnati Medical Center, OH; Department of Radiology (M.W), Stanford University and Healthcare, CA, Department of Neurology (M.P., A.B.), Royal Melbourne Hospital, Melbourne Brain Centre, University of Melbourne, Australia; and Department of Radiology (K.N.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Aaron W Grossman
- From the Departments of Radiology (A.V), Neurology (P.K), and Neurosurgery (A.G), University of Cincinnati Medical Center, OH; Department of Radiology (M.W), Stanford University and Healthcare, CA, Department of Neurology (M.P., A.B.), Royal Melbourne Hospital, Melbourne Brain Centre, University of Melbourne, Australia; and Department of Radiology (K.N.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Pooja Khatri
- From the Departments of Radiology (A.V), Neurology (P.K), and Neurosurgery (A.G), University of Cincinnati Medical Center, OH; Department of Radiology (M.W), Stanford University and Healthcare, CA, Department of Neurology (M.P., A.B.), Royal Melbourne Hospital, Melbourne Brain Centre, University of Melbourne, Australia; and Department of Radiology (K.N.), Icahn School of Medicine at Mount Sinai, New York, NY
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17
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Dorňák T, Král M, Šaňák D, Kaňovský P. Intravenous Thrombolysis in Posterior Circulation Stroke. Front Neurol 2019; 10:417. [PMID: 31080436 PMCID: PMC6497784 DOI: 10.3389/fneur.2019.00417] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 04/05/2019] [Indexed: 12/27/2022] Open
Abstract
Background: Intravenous thrombolysis (IVT) is a standard treatment for both anterior circulation ischemic stroke (ACIS) and posterior circulation ischemic stroke (PCIS). PCIS is a clinical syndrome associated with ischemia-related changes in the territory of the posterior circulation arteries. Embolism is the most common stroke mechanism in posterior circulation. PCIS represents 12–19% of all IVT-treated strokes. Methods and Results: We searched the PubMed database for assessments of intracerebral hemorrhage (ICH) and clinical outcome in PCIS patients treated with IVT. ICH occurs in 0–6.9% of posterior ischemic stroke depending on the definition of symptomatic ICH, and any ICH in 17–23.4% of posterior ischemic stroke. For patients with PCIS, 38–49% have a favorable outcome (mRS 0–1) after IVT. Better clinical outcomes occur more often in patients with PCIS than in those with ACIS. The mortality rate among PCIS patients treated with IVT ranges from 9 to 19%; it does not differ significantly between PCIS and ACIS. Conclusions: Up to date, no data about PCIS and IVT are available from RTCs. Based on limited results from retrospective clinical studies and case series, IVT is safer for use in PCIS than in ACIS. Patients with brainstem ischemia, vertebral artery occlusion, and absence of basilar or posterior cerebral artery occlusion could be considered for treatment with IVT even in borderline cases. Time to IVT in PCIS seems to be a less crucial factor than in ACIS. IVT for PCIS may be beneficial even after 4.5 h from symptom onset.
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Affiliation(s)
- Tomáš Dorňák
- Department of Neurology, Palacky University and University Hospital, Olomouc, Czechia
| | - Michal Král
- Department of Neurology, Palacky University and University Hospital, Olomouc, Czechia
| | - Daniel Šaňák
- Department of Neurology, Palacky University and University Hospital, Olomouc, Czechia
| | - Petr Kaňovský
- Department of Neurology, Palacky University and University Hospital, Olomouc, Czechia
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18
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Krishnan K, Bassilious K, Eriksen E, Bath PM, Sprigg N, Brækken SK, Ihle-Hansen H, Horn MA, Sandset EC. Posterior circulation stroke diagnosis using HINTS in patients presenting with acute vestibular syndrome: A systematic review. Eur Stroke J 2019; 4:233-239. [PMID: 31984230 DOI: 10.1177/2396987319843701] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 03/20/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose Acute vestibular syndrome - vertigo, nausea/vomiting, nystagmus and gait unsteadiness - is common, and differentiating posterior circulation stroke from a peripheral cause can be challenging. The National Institute of Health Stroke Scale (NIHSS) does not include acute vestibular syndrome, and early computed tomography scanning cannot rule out acute ischaemia. A positive Head Impulse-Nystagmus-Test of Skew (HINTS) test suggests posterior circulation stroke in acute vestibular syndrome when any of three signs are present: normal horizontal head impulse, gaze-direction nystagmus or eye skew deviation. This systematic review examined the accuracy of positive HINTS in identifying posterior circulation stroke in acute vestibular syndrome patients. Methods We searched MEDLINE (1966 to 21 December 2017), EMBASE (1980 to December 2017), Web of Science and scanned bibliographies. Two authors independently screened relevant articles and extracted data. We included studies where HINTS was used to identify posterior circulation stroke with diagnosis confirmed using magnetic resonance imaging. Findings Six studies (n = 644 patients) were identified. Acute stroke was confirmed in 200 (31.1%) patients. There was a 15-fold increased risk of posterior circulation stroke in patients with positive HINTS test compared to those with no abnormality (RR: 15.84, 95% CI: 5.25-47.79). For any stroke, the pooled sensitivity was 95.5% (95% CI: 92.6-98.4%) and specificity was 71.2% (95% CI: 67.0-75.4%). Discussion and Conclusion The data suggest that the HINTS test as one element of clinical evaluation is useful to differentiate posterior circulation stroke from peripheral causes in acute vestibular syndrome. Further studies are needed to validate HINTS as a clinical prediction tool in emergency department settings and selection of patients for reperfusion treatment.
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Affiliation(s)
- Kailash Krishnan
- Stroke, Acute Medicine, Nottingham University Hospitals, Nottingham, UK
| | | | - Erik Eriksen
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Philip M Bath
- Stroke, Acute Medicine, Nottingham University Hospitals, Nottingham, UK.,Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Nikola Sprigg
- Stroke, Acute Medicine, Nottingham University Hospitals, Nottingham, UK.,Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | | | | | | | - Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway.,Research and Development, The Norwegian Air Ambulance Foundation, Oslo, Norway
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19
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Pallesen LP, Barlinn K, Puetz V. Role of Decompressive Craniectomy in Ischemic Stroke. Front Neurol 2019; 9:1119. [PMID: 30687210 PMCID: PMC6333741 DOI: 10.3389/fneur.2018.01119] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 12/06/2018] [Indexed: 12/12/2022] Open
Abstract
Ischemic stroke is one of the leading causes for death and disability worldwide. In patients with large space-occupying infarction, the subsequent edema complicated by transtentorial herniation poses a lethal threat. Especially in patients with malignant middle cerebral artery infarction, brain swelling secondary to the vessel occlusion is associated with high mortality. By decompressive craniectomy, a significant proportion of the skull is surgically removed, allowing the ischemic tissue to shift through the surgical defect rather than to the unaffected regions of the brain, thus avoiding secondary damage due to increased intracranial pressure. Several studies have shown that decompressive craniectomy reduces the mortality rate in patients with malignant cerebral artery infarction. However, this is done for the cost of a higher proportion of patients who survive with severe disability. In this review, we will describe the clinical and radiological features of malignant middle cerebral artery infarction and the role of decompressive craniectomy and additional therapies in this condition. We will also discuss large cerebellar stroke and the possibilities of suboccipital craniectomy.
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Affiliation(s)
- Lars-Peder Pallesen
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Volker Puetz
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
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20
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Furlanis G, Ajčević M, Stragapede L, Lugnan C, Ridolfi M, Caruso P, Naccarato M, Ukmar M, Manganotti P. Ischemic Volume and Neurological Deficit: Correlation of Computed Tomography Perfusion with the National Institutes of Health Stroke Scale Score in Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2018; 27:2200-2207. [PMID: 29724610 DOI: 10.1016/j.jstrokecerebrovasdis.2018.04.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/27/2018] [Accepted: 04/03/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The National Institutes of Health Stroke Scale (NIHSS) is the most adopted stroke patients' evaluation tool in emergency settings to assess the severity of stroke and to determine the patients' eligibility for specific treatments. Computed tomography perfusion (CTP) is crucial to identify salvageable tissue that can benefit from the reperfusion treatment. The aim of this study is to identify the relation between the NIHSS scores and the hypoperfused volumes evaluated by CTP in patients with hyperacute ischemic stroke. METHODS This retrospective study was conducted on 105 patients with ischemic stroke who underwent NIHSS assessment and CTP in the hyperacute phase. Hypoperfused volume was evaluated by CTP maps processed with semi-automatic algorithm. An analysis was conducted to determine the degree of correlation between the NIHSS scores and the ischemic lesion volumes and to investigate the relation between the anterior and the posterior circulation strokes, as well as between the right and the left hemispheric strokes. RESULTS A significant correlation was found between ischemic volume and NIHSS score at baseline (r = .82; P < .0001) in the entire cohort. A high NIHSS-volume correlation was identified in the anterior circulation stroke (r = .76; P < .0001); whereas, it was nonsignificant in the posterior circulation stroke. NIHSS score and volume correlated for the left and the right hemispheric strokes (r = .83 and .81; P < .0001), showing a slightly higher slope in the left. CONCLUSION This study showed a strong correlation between the baseline NIHSS score and the ischemic volume estimated by CTP. We confirmed that NIHSS is a reliable predictor of perfusion deficits in acute ischemic stroke. CTP allows fast imaging assessment in the hyperacute phase. The results highlight the importance of these diagnostic tools in the assessment of stroke severity and in acute decision-making.
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Affiliation(s)
- Giovanni Furlanis
- Clinical Unit of Neurology, Department of Medical Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy.
| | - Miloš Ajčević
- Clinical Unit of Neurology, Department of Medical Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Lara Stragapede
- Clinical Unit of Neurology, Department of Medical Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Carlo Lugnan
- Clinical Unit of Neurology, Department of Medical Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Mariana Ridolfi
- Clinical Unit of Neurology, Department of Medical Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Paola Caruso
- Clinical Unit of Neurology, Department of Medical Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Marcello Naccarato
- Clinical Unit of Neurology, Department of Medical Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Maja Ukmar
- Radiology Unit, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Paolo Manganotti
- Clinical Unit of Neurology, Department of Medical Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
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