1
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Rodríguez MJ, Graziani A, Seoane JS, Di Napoli L, Pérez Akly M, Besada C. Radiological predictors of final infarct volume in patients with proximal vascular occlusion. RADIOLOGIA 2023; 65:414-422. [PMID: 37758332 DOI: 10.1016/j.rxeng.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 12/22/2021] [Indexed: 10/03/2023]
Abstract
INTRODUCTION Various clinical and radiologic variables impact the neurologic prognosis of patients with ischemic cerebrovascular accidents. About 30% of ischemic cerebrovascular accidents are caused by proximal obstruction of the anterior circulation; in these cases, systemic thrombolysis is of limited usefulness. CT angiography is indicated in candidates for endovascular treatment. Various radiologic factors, including the grade of leptomeningeal collateral circulation, as well as the length, density, and extension of the thrombus, have been identified as predictors of neurologic prognosis after anterior ischemic cerebrovascular accidents due to proximal vascular obstruction. Final infarct volume correlations with mortality and long-term functional outcome in these patients. This study aimed to determine the best predictors of final infarct volume on CT angiography in patients with ischemic cerebral accidents due to proximal occlusion. MATERIALS AND METHODS This retrospective observational study included adults with ischemic cerebrovascular accidents due to obstruction of the anterior circulation diagnosed by CT angiography in the period comprising June 2009 through December 2019. We measured the length and density of the thrombus in unenhanced CT images, and we used the clot burden score to record the grade of leptomeningeal collateral circulation and the extension of the thrombus. Then we measured the final infarct volume on follow-up CT and analyzed the correlations among these radiologic factors in the infarct volume. RESULTS We included 54 patients [mean age, 82 y; 41 (75%) women] with ischemic cerebrovascular accidents due to proximal occlusion. About 60% of the cerebrovascular accidents affected the right cerebral hemisphere, and the most commonly affected vessel was the M1 segment of the medial cerebral artery (40.7%). Final infarct volume correlated with the grade of leptomeningeal collateral circulation (p=0.03) and with the clot burden score (p=0.01). Neither the length nor the density of the thrombus correlated with final infarct volume. CONCLUSION The final infarct volume can be estimated on the initial CT angiogram. Nevertheless, we found no useful predictive factors in unenhanced CT images. The best independent radiologic predictors of the final infarct volume are the grade of collateral circulation and the clot burden score, especially in patients who did not undergo mechanical thrombectomy, because mechanical thrombectomy improves outcomes. These factors are important for decision making in the management of patients with ischemic cerebrovascular accidents due to proximal occlusion.
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Affiliation(s)
- M J Rodríguez
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - A Graziani
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - J S Seoane
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - L Di Napoli
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - M Pérez Akly
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - C Besada
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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2
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Predictores radiológicos del volumen final del infarto cerebral en pacientes con obstrucción vascular proximal. RADIOLOGIA 2022. [DOI: 10.1016/j.rx.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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3
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Kim YD, Nam HS, Yoo J, Park H, Sohn SI, Hong JH, Kim BM, Kim DJ, Bang OY, Seo WK, Chung JW, Lee KY, Jung YH, Lee HS, Ahn SH, Shin DH, Choi HY, Cho HJ, Baek JH, Kim GS, Seo KD, Kim SH, Song TJ, Kim J, Han SW, Park JH, Lee SI, Heo J, Choi JK, Heo JH. Prediction of Early Recanalization after Intravenous Thrombolysis in Patients with Large-Vessel Occlusion. J Stroke 2021; 23:244-252. [PMID: 34102759 PMCID: PMC8189851 DOI: 10.5853/jos.2020.03622] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 02/10/2021] [Indexed: 11/26/2022] Open
Abstract
Background and Purpose We aimed to develop a model predicting early recanalization after intravenous tissue plasminogen activator (t-PA) treatment in large-vessel occlusion.
Methods Using data from two different multicenter prospective cohorts, we determined the factors associated with early recanalization immediately after t-PA in stroke patients with large-vessel occlusion, and developed and validated a prediction model for early recanalization. Clot volume was semiautomatically measured on thin-section computed tomography using software, and the degree of collaterals was determined using the Tan score. Follow-up angiographic studies were performed immediately after t-PA treatment to assess early recanalization.
Results Early recanalization, assessed 61.0±44.7 minutes after t-PA bolus, was achieved in 15.5% (15/97) in the derivation cohort and in 10.5% (8/76) in the validation cohort. Clot volume (odds ratio [OR], 0.979; 95% confidence interval [CI], 0.961 to 0.997; P=0.020) and good collaterals (OR, 6.129; 95% CI, 1.592 to 23.594; P=0.008) were significant factors associated with early recanalization. The area under the curve (AUC) of the model including clot volume was 0.819 (95% CI, 0.720 to 0.917) and 0.842 (95% CI, 0.746 to 0.938) in the derivation and validation cohorts, respectively. The AUC improved when good collaterals were added (derivation cohort: AUC, 0.876; 95% CI, 0.802 to 0.950; P=0.164; validation cohort: AUC, 0.949; 95% CI, 0.886 to 1.000; P=0.036). The integrated discrimination improvement also showed significantly improved prediction (0.097; 95% CI, 0.009 to 0.185; P=0.032).
Conclusions The model using clot volume and collaterals predicted early recanalization after intravenous t-PA and had a high performance. This model may aid in determining the recanalization treatment strategy in stroke patients with large-vessel occlusion.
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Affiliation(s)
- Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Joonsang Yoo
- Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea.,Department of Neurology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Hyungjong Park
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea
| | - Sung-Il Sohn
- Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea
| | - Jeong-Ho Hong
- Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea
| | - Byung Moon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Joon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo-Keun Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong-Won Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung-Yul Lee
- Department of Neurology, Gangnam Severance Hospital, Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Korea
| | - Yo Han Jung
- Department of Neurology, Gangnam Severance Hospital, Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Changwon Fatima Hospital, Changwon, Korea
| | - Hye Sun Lee
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Seong Hwan Ahn
- Department of Neurology, Chosun University College of Medicine, Gwangju, Korea
| | - Dong Hoon Shin
- Department of Neurology, Gachon University Gil Medical Center, Incheon, Korea
| | - Hye-Yeon Choi
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Han-Jin Cho
- Department of Neurology, Pusan National University School of Medicine, Busan, Korea
| | - Jang-Hyun Baek
- Department of Neurology, National Medical Center, Seoul, Korea.,Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gyu Sik Kim
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Kwon-Duk Seo
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Korea.,Department of Neurology, Wonkwang University Sanbon Hospital, Wonkwang University School of Medicine, Sanbon, Korea
| | - Seo Hyun Kim
- Department of Neurology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Tae-Jin Song
- Department of Neurology, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea.,Department of Neurology, Ewha Womans University Seoul Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Jinkwon Kim
- Department of Neurology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea.,Department of Neurology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Sang Won Han
- Department of Neurology, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Joong Hyun Park
- Department of Neurology, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Sung Ik Lee
- Department of Neurology, Wonkwang University Sanbon Hospital, Wonkwang University School of Medicine, Sanbon, Korea
| | - JoonNyung Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Kyo Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
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4
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Yu Y, Xie Y, Thamm T, Gong E, Ouyang J, Huang C, Christensen S, Marks MP, Lansberg MG, Albers GW, Zaharchuk G. Use of Deep Learning to Predict Final Ischemic Stroke Lesions From Initial Magnetic Resonance Imaging. JAMA Netw Open 2020; 3:e200772. [PMID: 32163165 PMCID: PMC7068232 DOI: 10.1001/jamanetworkopen.2020.0772] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
IMPORTANCE Predicting infarct size and location is important for decision-making and prognosis in patients with acute stroke. OBJECTIVES To determine whether a deep learning model can predict final infarct lesions using magnetic resonance images (MRIs) acquired at initial presentation (baseline) and to compare the model with current clinical prediction methods. DESIGN, SETTING, AND PARTICIPANTS In this multicenter prognostic study, a specific type of neural network for image segmentation (U-net) was trained, validated, and tested using patients from the Imaging Collaterals in Acute Stroke (iCAS) study from April 14, 2014, to April 15, 2018, and the Diffusion Weighted Imaging Evaluation for Understanding Stroke Evolution Study-2 (DEFUSE-2) study from July 14, 2008, to September 17, 2011 (reported in October 2012). Patients underwent baseline perfusion-weighted and diffusion-weighted imaging and MRI at 3 to 7 days after baseline. Patients were grouped into unknown, minimal, partial, and major reperfusion status based on 24-hour imaging results. Baseline images acquired at presentation were inputs, and the final true infarct lesion at 3 to 7 days was considered the ground truth for the model. The model calculated the probability of infarction for every voxel, which can be thresholded to produce a prediction. Data were analyzed from July 1, 2018, to March 7, 2019. MAIN OUTCOMES AND MEASURES Area under the curve, Dice score coefficient (DSC) (a metric from 0-1 indicating the extent of overlap between the prediction and the ground truth; a DSC of ≥0.5 represents significant overlap), and volume error. Current clinical methods were compared with model performance in subgroups of patients with minimal or major reperfusion. RESULTS Among the 182 patients included in the model (97 women [53.3%]; mean [SD] age, 65 [16] years), the deep learning model achieved a median area under the curve of 0.92 (interquartile range [IQR], 0.87-0.96), DSC of 0.53 (IQR, 0.31-0.68), and volume error of 9 (IQR, -14 to 29) mL. In subgroups with minimal (DSC, 0.58 [IQR, 0.31-0.67] vs 0.55 [IQR, 0.40-0.65]; P = .37) or major (DSC, 0.48 [IQR, 0.29-0.65] vs 0.45 [IQR, 0.15-0.54]; P = .002) reperfusion for which comparison with existing clinical methods was possible, the deep learning model had comparable or better performance. CONCLUSIONS AND RELEVANCE The deep learning model appears to have successfully predicted infarct lesions from baseline imaging without reperfusion information and achieved comparable performance to existing clinical methods. Predicting the subacute infarct lesion may help clinicians prepare for decompression treatment and aid in patient selection for neuroprotective clinical trials.
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Affiliation(s)
- Yannan Yu
- Department of Radiology, Stanford University, Stanford, California
| | - Yuan Xie
- Department of Radiology, Stanford University, Stanford, California
| | - Thoralf Thamm
- Department of Radiology, Stanford University, Stanford, California
- Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Enhao Gong
- Department of Electrical Engineering, Stanford University, Stanford, California
| | - Jiahong Ouyang
- Department of Electrical Engineering, Stanford University, Stanford, California
| | - Charles Huang
- Department of Electrical Engineering, Stanford University, Stanford, California
| | | | - Michael P. Marks
- Department of Radiology, Stanford University, Stanford, California
| | | | | | - Greg Zaharchuk
- Department of Radiology, Stanford University, Stanford, California
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5
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Li G, Wu G, Qin Z, Li H, Cheng X, Cai Y. Prognostic Value of Clot Burden Score in Acute Ischemic Stroke after Reperfusion Therapies: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2019; 28:104293. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.07.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 06/12/2019] [Accepted: 07/10/2019] [Indexed: 01/08/2023] Open
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6
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Takahashi EA, Reisenauer CJ, Stockland AH, Bjarnason H, Neisen MJ, Neidert NB, Harmsen WS, Day CN, Misra S. Pulmonary embolism attenuation is a potential imaging biomarker for pulmonary artery hemodynamic improvement after catheter-directed thrombolysis. Vasc Med 2018; 23:134-138. [PMID: 29498612 DOI: 10.1177/1358863x18756504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This study examined the potential correlation between pulmonary embolism (PE) attenuation on computed tomography pulmonary angiography (CTPA) and pulmonary artery hemodynamic response to catheter-directed thrombolysis (CDT) in 10 patients with submassive PE. Treatment parameters, PE attenuation, clot burden, computed tomography signs of right ventricle dysfunction and right ventricular systolic pressure at echocardiography were retrospectively analyzed to determine correlation with pulmonary artery pressure improvement using Spearman correlation. A single reader, blinded to the treatment results, measured PE attenuation of all patients. There was a significant positive correlation between PE attenuation and absolute pulmonary artery pressure improvement with a Spearman correlation of 0.741, p=0.014. When attenuation was greater than or equal to the median (44.5 HU, n=5), CDT was associated with significantly better pulmonary artery pressure improvement ( p=0.037). Clot attenuation at CTPA may be a potential imaging biomarker for predicting pulmonary artery pressure improvement after CDT.
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Affiliation(s)
| | - Christopher J Reisenauer
- 1 Department of Radiology, Mayo Clinic, Rochester, MN, USA.,2 Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, MN, USA
| | - Andrew H Stockland
- 1 Department of Radiology, Mayo Clinic, Rochester, MN, USA.,2 Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, MN, USA
| | - Haraldur Bjarnason
- 1 Department of Radiology, Mayo Clinic, Rochester, MN, USA.,2 Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, MN, USA
| | - Melissa J Neisen
- 1 Department of Radiology, Mayo Clinic, Rochester, MN, USA.,2 Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, MN, USA
| | - Newton B Neidert
- 1 Department of Radiology, Mayo Clinic, Rochester, MN, USA.,2 Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, MN, USA
| | - William S Harmsen
- 1 Department of Radiology, Mayo Clinic, Rochester, MN, USA.,3 Department of Clinical Statistics, Mayo Clinic, Rochester, MN, USA
| | - Courtney N Day
- 3 Department of Clinical Statistics, Mayo Clinic, Rochester, MN, USA
| | - Sanjay Misra
- 1 Department of Radiology, Mayo Clinic, Rochester, MN, USA.,2 Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, MN, USA
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7
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Bouslama M, Haussen DC, Grossberg JA, Dehkharghani S, Bowen MT, Rebello LC, Bianchi NA, Frankel MR, Nogueira RG. Computed Tomographic Perfusion Selection and Clinical Outcomes After Endovascular Therapy in Large Vessel Occlusion Stroke. Stroke 2017; 48:1271-1277. [DOI: 10.1161/strokeaha.116.015636] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 02/09/2017] [Accepted: 02/13/2017] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Different imaging paradigms have been used to select patients for endovascular therapy in stroke. We sought to determine whether computed tomographic perfusion (CTP) selection improves endovascular therapy outcomes compared with noncontrast computed tomography alone.
Methods—
Review of a prospectively collected registry of anterior circulation stroke patients undergoing stent-retriever thrombectomy at a tertiary care center between September 2010 and March 2016. Patients undergoing CTP were compared with those with noncontrast computed tomography alone. The primary outcome was the shift in the 90-day modified Rankin scale (mRS).
Results—
A total of 602 patients were included. CTP-selected patients (n=365, 61%) were younger (
P
=0.02) and had fewer comorbidities. CTP selection (n=365, 61%) was associated with a favorable 90-day mRS shift (adjusted odds ratio [aOR]=1.49; 95% confidence interval [CI], 1.06–2.09;
P
=0.02), higher rates of good outcomes (90-day mRS score 0–2: 52.9% versus 40.4%;
P
=0.005), modified Thrombolysis in Cerebral Infarction-3 reperfusion (54.8% versus 40.1%;
P
<0.001), smaller final infarct volumes (24.7 mL [9.8–63.1 mL] versus 34.6 mL [13.1–88 mL];
P
=0.017), and lower mortality (16.6% versus 26.8%;
P
=0.005). When matched on age, National Institutes of Health Stroke Scale (NIHSS) score, and glucose (n=424), CTP remained associated with a favorable 90-day mRS shift (
P
=0.016), lower mortality (
P
=0.02), and higher rates of reperfusion (
P
<0.001). CTP better predicted functional outcomes in patients presenting after 6 hours (as assessed by comparison of logistic regression models: Akaike information criterion: 199.35 versus 287.49 and Bayesian information criterion: 196.71 versus 283.27) and those with an Alberta Stroke Program Early Computed Tomography Score ≤7 (Akaike information criterion: 216.69 versus 334.96 and Bayesian information criterion: 213.6 versus 329.94).
Conclusions—
CTP selection is associated with a favorable mRS shift in patients undergoing stent-retriever thrombectomy. Future prospective studies are warranted.
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Affiliation(s)
- Mehdi Bouslama
- From the Department of Neurology, Neurosurgery and Radiology, Grady Memorial Hospital and Emory University School of Medicine, Atlanta, GA
| | - Diogo C. Haussen
- From the Department of Neurology, Neurosurgery and Radiology, Grady Memorial Hospital and Emory University School of Medicine, Atlanta, GA
| | - Jonathan A. Grossberg
- From the Department of Neurology, Neurosurgery and Radiology, Grady Memorial Hospital and Emory University School of Medicine, Atlanta, GA
| | - Seena Dehkharghani
- From the Department of Neurology, Neurosurgery and Radiology, Grady Memorial Hospital and Emory University School of Medicine, Atlanta, GA
| | - Meredith T. Bowen
- From the Department of Neurology, Neurosurgery and Radiology, Grady Memorial Hospital and Emory University School of Medicine, Atlanta, GA
| | - Leticia C. Rebello
- From the Department of Neurology, Neurosurgery and Radiology, Grady Memorial Hospital and Emory University School of Medicine, Atlanta, GA
| | - Nicolas A. Bianchi
- From the Department of Neurology, Neurosurgery and Radiology, Grady Memorial Hospital and Emory University School of Medicine, Atlanta, GA
| | - Michael R. Frankel
- From the Department of Neurology, Neurosurgery and Radiology, Grady Memorial Hospital and Emory University School of Medicine, Atlanta, GA
| | - Raul G. Nogueira
- From the Department of Neurology, Neurosurgery and Radiology, Grady Memorial Hospital and Emory University School of Medicine, Atlanta, GA
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8
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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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9
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Leng X, Lan L, Liu L, Leung TW, Wong KS. Good collateral circulation predicts favorable outcomes in intravenous thrombolysis: a systematic review and meta-analysis. Eur J Neurol 2016; 23:1738-1749. [PMID: 27478977 DOI: 10.1111/ene.13111] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 06/27/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Baseline collateral status has been correlated with outcomes of acute ischaemic stroke patients receiving intravenous thrombolysis (IVT) in previous studies. We carried out the current systematic review and meta-analysis to synthesize currently available evidence regarding such correlations. METHODS Full-text articles published since 2000 were retrieved and screened. The overall effect sizes of good versus poor collateral status over a series of outcomes and certain baseline features were estimated by random-effects models and presented in risk ratios (RRs) or mean differences. RESULTS Overall, 28 (3057 patients) and 14 (1584 patients) studies were included in qualitative and quantitative synthesis, respectively. Compared with poor pre-treatment collateral status, good collaterals showed a beneficial effect over the primary outcome of a favorable functional outcome at 3 or 6 months [RR, 2.45; 95% confidence interval, 1.94-3.09; P < 0.001] in acute ischaemic stroke patients receiving IVT treatment. However, such an effect tended to be different between studies with prescribed time windows of 3, 4.5 and > 4.5 h (up to 7 h), with the RRs being 2.21, 2.48 and 5.00, respectively (I2 = 53%). Good pre-treatment collaterals were also associated with a smaller infarct size at baseline, and a lower rate of symptomatic intracranial hemorrhage and a higher rate of neurological improvement early after IVT treatment. CONCLUSIONS The present study has demonstrated the prognostic value of baseline collateral circulation for outcomes of acute ischaemic stroke patients receiving intravenous reperfusion therapies, studied with different time windows of up to 7 h after ictus for IVT therapy.
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Affiliation(s)
- X Leng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - L Lan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - L Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - T W Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - K S Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
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10
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Kaschka IN, Kloska SP, Struffert T, Engelhorn T, Gölitz P, Kurka N, Köhrmann M, Schwab S, Doerfler A. Clinical and radiological outcome after mechanical thrombectomy in acute ischemic stroke: What matters? Neuroradiol J 2016; 29:99-105. [PMID: 26932163 DOI: 10.1177/1971400916628170] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Recent studies have shown the efficacy of mechanical thrombectomy in acute ischemic stroke. We sought to identify prognostic parameters for clinical and radiological outcome after mechanical thrombectomy. METHODS In 34 patients (age 72 ± 13 years, 64.7% women) with acute occlusion of the distal ICA and/or M1 segment who were treated with mechanical thrombectomy, the Spearman correlation was performed to assess potential prognostic outcome parameters (age, NIHSS, ASPECT, thrombus length (TL), clot burden score (CBS), relative filling time delay (rFTD), time to recanalization (TTR) and TICI score). The modified Rankin scale (mRS) and the Alberta Stroke Program Early CT (ASPECT) score were used for clinical and radiological outcome, respectively. Receiver operating characteristic (ROC) analysis was performed to assess parameters predicting favorable clinical (ΔmRS ≤ 2) and radiological outcome (ΔASPECT ≤ 2). RESULTS Variables associated with favorable clinical outcome included NIHSS, TL, TTR and TICI score (p ≤ 0.01) with NIHSS ≤ 15 (p = 0.001, area under the curve (AUC) 0.87), TL ≤ 2 cm (p = 0.017, AUC 0.75), TTR ≤ 231 min (p = 0.001 AUC 0.88) and TICI ≥ 2b (p = 0.050, AUC 0.70). Shorter TTR and higher TICI scores were associated with favorable radiological outcome (p < 0.001) with TTR ≤ 224 min (p = 0.023, AUC 0.77) and TICI ≥ 2b (p = 0.000, AUC 0.86). CONCLUSION Fast and complete recanalization is essential to achieve a favorable radiological and functional outcome after mechanical thrombectomy in acute ischemic stroke. Age, CBS and collateral supply play a subordinate role.
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Affiliation(s)
- Iris N Kaschka
- Department of Neuroradiology, University Hospital Erlangen, Germany
| | - Stephan P Kloska
- Department of Neuroradiology, University Hospital Erlangen, Germany
| | - Tobias Struffert
- Department of Neuroradiology, University Hospital Erlangen, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, University Hospital Erlangen, Germany
| | - Philipp Gölitz
- Department of Neuroradiology, University Hospital Erlangen, Germany
| | - Natalia Kurka
- Department of Neurology, University Hospital Erlangen, Germany
| | - Martin Köhrmann
- Department of Neurology, University Hospital Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Germany
| | - Arnd Doerfler
- Department of Neuroradiology, University Hospital Erlangen, Germany
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11
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Leiva-Salinas C, Patrie JT, Xin W, Michel P, Jovin T, Wintermark M. Prediction of Early Arterial Recanalization and Tissue Fate in the Selection of Patients With the Greatest Potential to Benefit From Intravenous Tissue-Type Plasminogen Activator. Stroke 2016; 47:397-403. [DOI: 10.1161/strokeaha.115.011066] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 11/11/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Carlos Leiva-Salinas
- From the Departments of Radiology (C.L.-S.) and Public Health Sciences (J.T.P., W.X.), University of Virginia, Charlottesville; Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (P.M.); Department of Neurology, University of Pittsburgh, PA (T.J.); and Neuroradiology Division, Department of Radiology, Stanford University, CA (M.W.)
| | - James T. Patrie
- From the Departments of Radiology (C.L.-S.) and Public Health Sciences (J.T.P., W.X.), University of Virginia, Charlottesville; Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (P.M.); Department of Neurology, University of Pittsburgh, PA (T.J.); and Neuroradiology Division, Department of Radiology, Stanford University, CA (M.W.)
| | - Wenjun Xin
- From the Departments of Radiology (C.L.-S.) and Public Health Sciences (J.T.P., W.X.), University of Virginia, Charlottesville; Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (P.M.); Department of Neurology, University of Pittsburgh, PA (T.J.); and Neuroradiology Division, Department of Radiology, Stanford University, CA (M.W.)
| | - Patrik Michel
- From the Departments of Radiology (C.L.-S.) and Public Health Sciences (J.T.P., W.X.), University of Virginia, Charlottesville; Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (P.M.); Department of Neurology, University of Pittsburgh, PA (T.J.); and Neuroradiology Division, Department of Radiology, Stanford University, CA (M.W.)
| | - Tudor Jovin
- From the Departments of Radiology (C.L.-S.) and Public Health Sciences (J.T.P., W.X.), University of Virginia, Charlottesville; Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (P.M.); Department of Neurology, University of Pittsburgh, PA (T.J.); and Neuroradiology Division, Department of Radiology, Stanford University, CA (M.W.)
| | - Max Wintermark
- From the Departments of Radiology (C.L.-S.) and Public Health Sciences (J.T.P., W.X.), University of Virginia, Charlottesville; Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (P.M.); Department of Neurology, University of Pittsburgh, PA (T.J.); and Neuroradiology Division, Department of Radiology, Stanford University, CA (M.W.)
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Mair G, von Kummer R, Lindley RI, Sandercock PAG, Wardlaw JM. Effect of X-Ray Attenuation of Arterial Obstructions on Intravenous Thrombolysis and Outcome after Ischemic Stroke. PLoS One 2015; 10:e0145683. [PMID: 26701648 PMCID: PMC4689396 DOI: 10.1371/journal.pone.0145683] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 12/07/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To assess whether the x-ray attenuation of intra-arterial obstruction measured on non-contrast CT in ischemic stroke can predict response to thrombolysis and subsequent functional outcome. METHODS The Third International Stroke Trial (IST-3) was a multicenter randomized-controlled trial of intravenous thrombolysis (rt-PA) given within six hours of ischemic stroke. Ethical approval and informed consent were obtained. In a subgroup of 109 IST-3 patients (38 men, median age 82 years), a single reader, masked to all clinical and other imaging data, manually measured x-ray attenuation (Hounsfield Units, HU) on non-contrast CT at the location of angiographically-proven intra-arterial obstructions, pre-randomization and at 24-48 hour follow-up. We calculated change in attenuation between scans. We assessed the impact of pre-randomization arterial obstruction attenuation on six-month functional outcome. RESULTS Most arterial obstructions (64/109, 59%) were hyperattenuating (mean 51.0 HU). Compared with control, treatment with rt-PA was associated with a greater, but non-significant, reduction in obstruction attenuation at follow-up (-8.0 HU versus -1.4 HU in patients allocated control, p = 0.117). In multivariable ordinal regression analysis controlled for patient age, stroke severity, location and extent of obstruction, time from stroke onset to baseline scan and rt-PA treatment allocation, the attenuation of pre-randomization arterial obstruction was not independently associated with six-month outcome (odds ratio = 0.99, 95% confidence interval = 0.94-1.03, p = 0.516). CONCLUSIONS In ischemic stroke, the x-ray attenuation of the arterial obstruction may decline more rapidly from baseline to 24-48 hours following treatment with thrombolysis but we found no evidence that baseline arterial obstruction attenuation predicts six-month outcome.
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Affiliation(s)
- Grant Mair
- Division of Neuroimaging Sciences, University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom
| | - Rüdiger von Kummer
- Department of Neuroradiology, Dresden University Stroke Centre, University Hospital, Dresden, Germany
| | - Richard I. Lindley
- Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Peter A. G. Sandercock
- Division of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom
| | - Joanna M. Wardlaw
- Division of Neuroimaging Sciences, University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom
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Tong E, Komlosi P, Wintermark M. One-stop-shop stroke imaging with functional CT. Eur J Radiol 2015; 84:2425-31. [DOI: 10.1016/j.ejrad.2014.11.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 11/19/2014] [Accepted: 11/24/2014] [Indexed: 10/24/2022]
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Meyer IA, Wintermark M, Démonet JF, Michel P. CTP in Transient Global Amnesia: A Single-Center Experience of 30 Patients. AJNR Am J Neuroradiol 2015; 36:1830-3. [PMID: 26045576 DOI: 10.3174/ajnr.a4370] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 03/02/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Medial temporal lobe abnormalities on DWI and functional imaging are occasionally observed in patients with transient global amnesia. We used CTP to study these patients during or briefly after resolution of their amnesic syndrome. MATERIALS AND METHODS From 2002 onward, patients satisfying clinical criteria for transient global amnesia who underwent CTP were included. Patients with additional clinical features suggesting transient ischemic attack or stroke and those with an ischemic lesion on subsequent DWI were excluded. If deemed necessary by the clinician, DWI was performed within 10 days. RESULTS Thirty patients with transient global amnesia underwent CTP at a median latency of 5.9 hours (interquartile range, 4.3-9.7 hours) after symptom onset. All findings, except for those in 1 patient, were normal, including those in the 14 patients with well-imaged hippocampi. In the patient with abnormal findings, CTP and PWI showed hypoperfusion in both lentiform nuclei extending into the insulae, with normalization on the repeat CTP 6 days later. In 10 patients, DWI was performed at a median latency of 2 days (interquartile range, 0-9 days). Of these, 2 showed punctate hippocampal lesions, often seen in transient global amnesia. In 2 patients excluded because of mildly atypical transient global amnesia and ischemic lesions on subsequent DWI, acute CTP findings were also normal. CONCLUSIONS Patients with transient global amnesia had normal CTP findings in the acute phase with the exception of 1 patient with transient hypoperfusion in both basal ganglia. If imaging is performed for typical and atypical transient global amnesia, DWI should be the preferred method.
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Affiliation(s)
- I A Meyer
- From the Neurology Service (I.A.M., P.M.)
| | - M Wintermark
- Department of Radiology (M.W.), Stanford University School of Medicine, Stanford, California
| | - J-F Démonet
- the Leenaards Memory Center (J.-F.D.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - P Michel
- From the Neurology Service (I.A.M., P.M.)
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15
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Kaschka IN, Kloska SP, Struffert T, Engelhorn T, Gölitz P, Kurka N, Köhrmann M, Schwab S, Doerfler A. Clot Burden and Collaterals in Anterior Circulation Stroke: Differences Between Single-Phase CTA and Multi-phase 4D-CTA. Clin Neuroradiol 2014; 26:309-15. [PMID: 25410583 DOI: 10.1007/s00062-014-0359-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 11/01/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE It has been reported that the extent of intravascular thrombi and the quality of collateral filling in computed tomography (CT) angiography are predictive for the clinical outcome in patients with acute stroke. We hypothesized that multi-phase four-dimensional CTA (4D-CTA) allows better assessment of clot burden and collateral flow compared with arterial single-phase CTA (CTA). METHODS In 49 patients (33 female; age: 77 ± 12 years) with acute anterior circulation stroke, CTA and 4D-CTA reconstructed from dynamic perfusion CT data were analyzed for absolute thrombus length (TL), clot burden score (CBS), and collateral score (CS). The length of the filling defect was also defined on thin-slice nonenhanced CT as corresponding hyperdense middle cerebral artery sign (HMCAS) when present. RESULTS There was good correlation (r = 0.62, p < 0.01) between the length of HMCAS (1.29 ± 0.62 cm) and TL in 4D-CTA (1.22 ± 0.51 cm). 4D-CTA and CTA significantly varied (p < 0.01) in TL (1.42 ± 0.73 cm (CTA) versus 1.11 ± 0.62 cm (4D-CTA)), CBS (median: 5, interquartile range: 4-7 (CTA) versus median: 6, interquartile range: 5-8 (4D-CTA); p < 0.001), and CS (median: 2, interquartile range: 1-2 (CTA) versus median: 3, interquartile range: 2-3 (4D-CTA); p < 0.001). Accordingly, CTA significantly overrated clot burden and underestimated collateral flow. CONCLUSIONS 4D-CTA more closely defines clot burden and collateral supply in anterior circulation stroke than CTA, implicating an additional diagnostic benefit.
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Affiliation(s)
- I N Kaschka
- Department of Neuroradiology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany.
| | - S P Kloska
- Department of Neuroradiology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - T Struffert
- Department of Neuroradiology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - T Engelhorn
- Department of Neuroradiology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - P Gölitz
- Department of Neuroradiology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - N Kurka
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - M Köhrmann
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - S Schwab
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - A Doerfler
- Department of Neuroradiology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
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