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Lin L, Wang Y, Chen C, Bivard A, Butcher K, Garcia-Esperon C, Spratt NJ, Levi CR, Cheng X, Dong Q, Parsons MW. Exploring ischemic core growth rate and endovascular therapy benefit in large core patients. J Cereb Blood Flow Metab 2024:271678X241242911. [PMID: 39054948 DOI: 10.1177/0271678x241242911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
After stroke onset, ischemic brain tissue will progress to infarction unless blood flow is restored. Core growth rate measures the infarction speed from stroke onset. This multicenter cohort study aimed to explore whether core growth rate influences benefit from the reperfusion treatment of endovascular thrombectomy in large ischemic core stroke patients. It identified 134 patients with large core volume >70 mL assessed on brain perfusion image within 9 hours of stroke onset. Of 134 patients, 71 received endovascular thrombectomy and 63 did not receive the treatment. Overall, poor outcomes were frequent, with 3-month severed disability or death rate at 56% in treatment group and 68% in no treatment group (p = 0.156). Patients were then stratified by core growth rate. For patients with 'ultrafast core growth' of >70 mL/hour, rates of poor outcome were especially high in patients without endovascular thrombectomy (n = 13/14, 93%) and relatively lower in patients received the treatment (n = 12/20, 60%, p = 0.033). In contrast, for patients with core growth rate <70 mL/hour, there was not a large difference in poor outcomes between patients with and without the treatment (55% vs. 61%, p = 0.522). Therefore, patients with 'ultrafast core growth' might stand to benefit the most from endovascular treatment.
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Affiliation(s)
- Longting Lin
- South West Sydney Clinical Campuses, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- University of Newcastle, Newcastle, Australia
| | - Yueming Wang
- Huashan Hospital, Fudan University, Shanghai, China
- Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | | | - Andrew Bivard
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Kenneth Butcher
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Carlos Garcia-Esperon
- University of Newcastle, Newcastle, Australia
- Hunter Medical Research Institute, Newcastle, Australia
- Department of Neurology, John Hunter Hospital, Newcastle, Australia
| | - Neil J Spratt
- University of Newcastle, Newcastle, Australia
- Hunter Medical Research Institute, Newcastle, Australia
- Department of Neurology, John Hunter Hospital, Newcastle, Australia
| | - Christopher R Levi
- University of Newcastle, Newcastle, Australia
- Hunter Medical Research Institute, Newcastle, Australia
- Department of Neurology, John Hunter Hospital, Newcastle, Australia
| | - Xin Cheng
- Huashan Hospital, Fudan University, Shanghai, China
| | - Qiang Dong
- Huashan Hospital, Fudan University, Shanghai, China
| | - Mark W Parsons
- South West Sydney Clinical Campuses, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- University of Newcastle, Newcastle, Australia
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
- Hunter Medical Research Institute, Newcastle, Australia
- Department of Neurology, John Hunter Hospital, Newcastle, Australia
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Fainardi E, Busto G, Morotti A. Automated advanced imaging in acute ischemic stroke. Certainties and uncertainties. Eur J Radiol Open 2023; 11:100524. [PMID: 37771657 PMCID: PMC10523426 DOI: 10.1016/j.ejro.2023.100524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/12/2023] [Accepted: 09/13/2023] [Indexed: 09/30/2023] Open
Abstract
The purpose of this is study was to review pearls and pitfalls of advanced imaging, such as computed tomography perfusion and diffusion-weighed imaging and perfusion-weighted imaging in the selection of acute ischemic stroke (AIS) patients suitable for endovascular treatment (EVT) in the late time window (6-24 h from symptom onset). Advanced imaging can quantify infarct core and ischemic penumbra using specific threshold values and provides optimal selection parameters, collectively called target mismatch. More precisely, target mismatch criteria consist of core volume and/or penumbra volume and mismatch ratio (the ratio between total hypoperfusion and core volumes) with precise cut-off values. The parameters of target mismatch are automatically calculated with dedicated software packages that allow a quick and standardized interpretation of advanced imaging. However, this approach has several limitations leading to a misclassification of core and penumbra volumes. In fact, automatic software platforms are affected by technical artifacts and are not interchangeable due to a remarkable vendor-dependent variability, resulting in different estimate of target mismatch parameters. In addition, advanced imaging is not completely accurate in detecting infarct core, that can be under- or overestimated. Finally, the selection of candidates for EVT remains currently suboptimal due to the high rates of futile reperfusion and overselection caused by the use of very stringent inclusion criteria. For these reasons, some investigators recently proposed to replace advanced with conventional imaging in the selection for EVT, after the demonstration that non-contrast CT ASPECTS and computed tomography angiography collateral evaluation are not inferior to advanced images in predicting outcome in AIS patients treated with EVT. However, other authors confirmed that CTP and PWI/DWI postprocessed images are superior to conventional imaging in establishing the eligibility of patients for EVT. Therefore, the routine application of automatic assessment of advanced imaging remains a matter of debate. Recent findings suggest that the combination of conventional and advanced imaging might improving our selection criteria.
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Affiliation(s)
- Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Italy
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Giorgio Busto
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Andrea Morotti
- Department of Neurological and Vision Sciences, Neurology Unit, ASST Spedali Civili, Brescia, Italy
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Lim NE, Chia B, Bulsara MK, Parsons M, Hankey GJ, Bivard A. Automated CT Perfusion Detection of the Acute Infarct Core in Ischemic Stroke: A Systematic Review and Meta-Analysis. Cerebrovasc Dis 2023; 52:97-109. [PMID: 35661075 DOI: 10.1159/000524916] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 04/27/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION In patients with acute ischemic stroke, the location and volume of an irreversible infarct core determine prognosis and treatment. We aimed to determine if automated CT perfusion (CTP) is non-inferior to diffusion-weighted imaging (DWI) or fluid-attenuated inversion recovery (FLAIR) in predicting the acute infarct core. METHODS In this systematic review and meta-analysis, we searched MEDLINE and EMBASE from 1960 to December 2020. Five outcome measures were examined: volumetric difference, volumetric correlation, sensitivity and specificity at the patient level, Dice coefficient, and sensitivity and specificity at the voxel level. A random-effects meta-analysis was performed for volumetric difference and correlation. RESULTS From 3,986 studies retrieved, 48 studies met our inclusion criteria with 46 studies on anterior circulation, one study on posterior circulation, and one study on lacunar infarct strokes. In anterior circulation stroke, there were no significant mean volumetric differences between CTP and acute DWI (cerebral blood flow [CBF] 0.52 mL, 95% CI [-0.07, 1.11], I2 0.0%; relative CBF [rCBF] 3.01 mL, 95% CI [-0.46, 6.48], I2 82.6%; relative cerebral blood volume [rCBV] -12.84 mL, 95% CI [-38.56, 12.88], I2 96.2%) and between CTP and delayed DWI or FLAIR (rCBF -1.29 mL, 95% CI [-6.49, 3.92], I2 91.8%; rCBV -5.80 mL, 95% CI [-16.20, 4.60], I2 84.2%). Mean correlation between CTP and acute DWI was 0.90 (95% CI [0.80, 0.95], I2 60.0%) for rCBF and 0.84 (95% CI [0.58, 0.94], I2 93.5%) for rCBV. Mean correlation between CTP and delayed DWI or FLAIR was 0.74 (95% CI [0.57, 0.85], I2 94.6%) for rCBF and 0.90 (95% CI [0.69, 0.97], I2 93.1%) for rCBV. Sensitivity and specificity at the patient level were reported by three studies and Dice coefficient by four studies. Statistical analysis could not be performed for sensitivity and specificity at the voxel level. Limited evidence was available for posterior circulation or lacunar infarct strokes. CONCLUSION Due to significant heterogeneity and insufficient high-quality studies reporting each outcome, there is insufficient evidence to reliably determine the accuracy of CTP prediction of the infarct core compared to DWI or FLAIR.
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Affiliation(s)
- Nicholas E Lim
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Nedlands, Washington, Australia
| | - Benjamin Chia
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Nedlands, Washington, Australia
| | - Max K Bulsara
- Institute for Health Research, University of Notre Dame, Fremantle, Washington, Australia
| | - Mark Parsons
- Melbourne Brain Centre, University of Melbourne, Parkville, Victoria, Australia.,Department of Neurology Liverpool Hospital, The Ingham Institute of Applied Medical Research, University of New South Wales South Western Clinical School, Liverpool, New South Wales, Australia
| | - Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Nedlands, Washington, Australia.,Department of Neurology, Sir Charles Gairdner Hospital, Perth, Washington, Australia
| | - Andrew Bivard
- Melbourne Brain Centre, University of Melbourne, Parkville, Victoria, Australia
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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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A subtle connection between crossed cerebellar diaschisis and supratentorial collateral circulation in subacute and chronic ischemic stroke. J Stroke Cerebrovasc Dis 2022; 31:106856. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/02/2022] [Accepted: 10/20/2022] [Indexed: 11/21/2022] Open
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Bindu TS, Vyas S, Khandelwal N, Bhatia V, Dhandapani S, Kumar A, Ahuja CK. Role of whole-brain computed tomography perfusion in head injury patients to predict outcome. Indian J Radiol Imaging 2021; 27:268-273. [PMID: 29089671 PMCID: PMC5644316 DOI: 10.4103/ijri.ijri_454_16] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
PURPOSE To evaluate utility, pattern, and extent of perfusion abnormalities in traumatic brain injury by using whole-brain computed tomography perfusion (CTP) and to assess co-relation of CTP data clinically with Glasgow outcome score (GOS). MATERIALS AND METHODS Prospective analytic evaluation of the traumatic head injury patients who were immediately taken up for CTP was done. Patient's demographic, clinical, and radiological findings were tabulated and analyzed. GOS was measured by a neurosurgeon after 3 months of trauma who was blinded to CTP results. RESULTS Of the 78 patients included in this study, 28 patients were found to have GOS 5, 19 of them had GOS 4, 27 of them had GOS 3, and 4 of them had a GOS 2. Higher mean cerebral blood flow (CBF) and cerebral blood volume (CBV) values were observed in those who had a better GOS, i.e., 4 or 5, whereas those in the GOS range ≤3 had lower mean CBF and CBV values. CONCLUSION Statistically significant positive correlation was found between cerebral perfusion parameters with that of GOS. CBF of frontal area shows better correlation with GOS. CBF was the most important predictor among all the perfusion parameters.
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Affiliation(s)
- T S Bindu
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sameer Vyas
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Niranjan Khandelwal
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Bhatia
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sivashanmugam Dhandapani
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Kumar
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Chirag K Ahuja
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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A Novel Fast CT Perfusion Core-Penumbra Mismatch Score: Correlation With Stroke Outcome. Neurologist 2021; 26:41-46. [PMID: 33646988 DOI: 10.1097/nrl.0000000000000315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Advanced neuroimaging can identify patients who can most benefit from reperfusion treatment, discriminating between ischemic core and penumbra area in a quick and accurate manner. Despite core-penumbra mismatch being an independent prognostic factor, computed tomography perfusion (CTP) assessment is still debated in hyperacute decision-making. The authors aimed to study a novel CTP mismatch score in emergency settings and to investigate its relation with clinical outcome in acute ischemic stroke patients treated with intravenous thrombolysis (IVT). METHODS Neuroimaging and clinical data of 226 consecutive acute ischemic stroke patients were analyzed. The study population was divided into 5 different CTP scores: (0) without perfusion deficit, (1) only penumbra, (2) penumbra > core, (3) core ≥ penumbra, (4) only core. For differences in outcome between treated and nontreated patients, and among CTP core-penumbra groups to be assessed, the authors have evaluated the outcome in terms of National Institutes of Health Stroke Scale (NIHSS) and modified Rankin scale (mRS) at discharge and symptomatic intracerebral hemorrhage. RESULTS A decrease in NIHSS was statistically greater in IVT-treated patients compared to nontreated patients showing only penumbra (ΔNIHSS%: 80.0% vs. 50.0%; P=0.0023) or no perfusion deficit (ΔNIHSS%: 89.4% vs. 61.5%; P=0.027) on CTP maps. The same trend was found in other groups without significant difference. A significant correlation was found in IVT patients between core/penumbra score and outcome in terms of ΔNIHSS (Kendall τ=-0.19; P=0.004). CONCLUSIONS The authors proposed a novel immediate CTP assessment to score perfusion mismatch in emergency settings to guide clinicians' decision-making for aggressive treatment and to prevent stroke-related disability.
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Early EEG Alterations Correlate with CTP Hypoperfused Volumes and Neurological Deficit: A Wireless EEG Study in Hyper-Acute Ischemic Stroke. Ann Biomed Eng 2021; 49:2150-2158. [PMID: 33604799 PMCID: PMC8455382 DOI: 10.1007/s10439-021-02735-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 01/17/2021] [Indexed: 12/19/2022]
Abstract
Brain electrical activity in acute ischemic stroke is related to the hypoperfusion of cerebral tissue as manifestation of neurovascular coupling. EEG could be applicable for bedside functional monitoring in emergency settings. We aimed to investigate the relation between hyper-acute ischemic stroke EEG changes, measured with bedside wireless-EEG, and hypoperfused core-penumbra CT-perfusion (CTP) volumes. In addition, we investigated the association of EEG and CTP parameters with neurological deficit measured by NIHSS. We analyzed and processed EEG, CTP and clinical data of 31 anterior acute ischemic stroke patients registered within 4.5 h from symptom onset. Delta/alpha ratio (DAR), (delta + theta)/(alpha + beta) ratio (DTABR) and relative delta power correlated directly (ρ = 0.72; 0.63; 0.65, respectively), while alpha correlated inversely (ρ = − 0.66) with total hypoperfused volume. DAR, DTBAR and relative delta and alpha parameters also correlated with ischemic core volume (ρ = 0.55; 0.50; 0.59; − 0.51, respectively). The same EEG parameters and CTP volumes showed significant relation with NIHSS at admission. The multivariate stepwise regression showed that DAR was the strongest predictor of NIHSS at admission (p < 0.001). The results of this study showed that hyper-acute alterations of EEG parameters are highly related to the extent of hypoperfused tissue highlighting the value of quantitative EEG as a possible complementary tool in the evaluation of stroke severity and its potential role in acute ischemic stroke monitoring.
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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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Furlanis G, Ajčević M, Scali I, Buoite Stella A, Olivo S, Lugnan C, Caruso P, Pozzi Mucelli RA, Accardo A, Cova MA, Naccarato M, Manganotti P. CT perfusion in hyper-acute ischemic stroke: the acid test for COVID-19 fear. Neuroradiology 2021; 63:1419-1427. [PMID: 33532920 PMCID: PMC7853703 DOI: 10.1007/s00234-021-02639-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/06/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE The fear of COVID-19 infection may discourage patients from going to the hospital even in case of sudden onset of disabling symptoms. There is growing evidence of the reduction of stroke admissions and higher prevalence of severe clinical presentation. Yet, no studies have investigated the perfusion pattern of acute strokes admitted during the lockdown. We aimed to evaluate the effects of the COVID-19 pandemic on hyper-acute stroke CT perfusion (CTP) pattern during the first months of the pandemic in Italy. METHODS In this retrospective observational study, we analyzed CTP images and clinical data of ischemic stroke patients admitted between 9 March and 2 June 2020 that underwent CTP (n = 30), to compare ischemic volumes and clinical features with stroke patients admitted during the same period in 2019 (n = 51). In particular, CTP images were processed to calculate total hypoperfused volumes, core volumes, and mismatch. The final infarct volumes were calculated on follow-up CT. RESULTS Significantly higher total CTP hypoperfused volume (83.3 vs 18.5 ml, p = 0.003), core volume (27.8 vs 1.0 ml, p < 0.001), and unfavorable mismatch (0.51 vs 0.91, p < 0.001) were found during the COVID-19 period compared to no-COVID-19 one. The more unfavorable perfusion pattern at admission resulted in higher infarct volume on follow-up CT during COVID-19 (35.5 vs 3.0 ml, p < 0.001). During lockdown, a reduction of stroke admissions (- 37%) and a higher prevalence of severe clinical presentation (NIHSS ≥ 10; 53% vs 36%, p = 0.029) were observed. CONCLUSION The results of CTP analysis provided a better insight in the higher prevalence of major severity stroke patients during the COVID-19 period.
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Affiliation(s)
- Giovanni Furlanis
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste - ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy
| | - Miloš Ajčević
- Department of Engineering and Architecture, University of Trieste, Via A. Valerio, 10, 34127, Trieste, Italy.
| | - Ilario Scali
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste - ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy
| | - Alex Buoite Stella
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste - ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy
| | - Sasha Olivo
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste - ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy
| | - Carlo Lugnan
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste - ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy
| | - Paola Caruso
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste - ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy
| | - Roberta Antea Pozzi Mucelli
- Radiology Unit, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste - ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy
| | - Agostino Accardo
- Department of Engineering and Architecture, University of Trieste, Via A. Valerio, 10, 34127, Trieste, Italy
| | - Maria Assunta Cova
- Radiology Unit, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste - ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy
| | - Marcello Naccarato
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste - ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy
| | - Paolo Manganotti
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste - ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy
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Cao W, Ling Y, Yang L, Wu F, Cheng X, Dong Q. Assessment of Ischemic Volumes by Using Relative Filling Time Delay on CTP Source Image in Patients with Acute Stroke with Anterior Circulation Large Vessel Occlusions. AJNR Am J Neuroradiol 2020; 41:1611-1617. [PMID: 32819905 DOI: 10.3174/ajnr.a6718] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 06/10/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Thrombectomy up to 24 hours after stroke onset in patients with specific ischemic brain volumes remains a challenge, because many stroke centers do not apply specialized software to calculate ischemic volumes at advanced imaging. We aimed to establish the association between relative filling time delay on CTP source imaging and ischemic volume parameters and the infarct penumbra to core volume mismatch in patients with acute ischemic stroke. MATERIALS AND METHODS Consecutive patients with acute ischemic stroke and with M1 segment MCA with or without terminal ICA occlusions on baseline CTA and CTP within 24 hours of stroke symptom onset were included. Ischemic volumes were analyzed with software based on CTP maps. Relative filling time delay was classified into 4 grades-grade 0: relative filling time delay = 0 seconds; grade 1: relative filling time delay >0 to ≤4 seconds; grade 2: relative filling time delay >4 to ≤8 seconds; and grade 3: relative filling time delay > 8 seconds. Differences in ischemic volume parameters among relative filling time delay grades were tested. RESULTS We recruited 138 patients (median age, 69 years; 62.3% male). Different median volumes of the infarct core (grade 0, 7.3 mL; grade 1, 23.3 mL; grade 2, 45.7 mL; grade 3, 135 mL [P < .001]) and the penumbra (grade 0, 47.6 mL; grade 1, 90 mL; grade 2, 110 mL; grade 3, 92 mL [P = .043]) were observed among relative filling time delay grades. Target mismatch (defined by the criteria of the DEFUSE 3 trial) was identified in 71.7% of the patients (99/138). A relative filling time delay grade ≤ 1 independently predicted target mismatch, with a sensitivity of 0.79 (95% CI, 0.7-0.87) and a specificity of 0.66 (95% CI, 0.49-0.8). CONCLUSIONS Relative filling time delay grade based on CTP source imaging is a simple and effective parameter for evaluating ischemic volumes and target mismatch in patients with acute ischemic stroke. Further studies that compare relative filling time delay grade with clinical functional outcomes are necessary.
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Affiliation(s)
- W Cao
- From the Department of Neurology and Institute of Neurology (W.C., Y.L., L.Y., F.W., X.C., Q.D.), Huashan Hospital, Fudan University, Shanghai, China
| | - Y Ling
- From the Department of Neurology and Institute of Neurology (W.C., Y.L., L.Y., F.W., X.C., Q.D.), Huashan Hospital, Fudan University, Shanghai, China
| | - L Yang
- From the Department of Neurology and Institute of Neurology (W.C., Y.L., L.Y., F.W., X.C., Q.D.), Huashan Hospital, Fudan University, Shanghai, China
| | - F Wu
- From the Department of Neurology and Institute of Neurology (W.C., Y.L., L.Y., F.W., X.C., Q.D.), Huashan Hospital, Fudan University, Shanghai, China
| | - X Cheng
- From the Department of Neurology and Institute of Neurology (W.C., Y.L., L.Y., F.W., X.C., Q.D.), Huashan Hospital, Fudan University, Shanghai, China
| | - Q Dong
- From the Department of Neurology and Institute of Neurology (W.C., Y.L., L.Y., F.W., X.C., Q.D.), Huashan Hospital, Fudan University, Shanghai, China .,State Key Laboratory of Medical Neurobiology (Q.D.), Fudan University, Shanghai, China
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Naccarato M, Ajčević M, Furlanis G, Lugnan C, Buoite Stella A, Scali I, Caruso P, Stragapede L, Ukmar M, Manganotti P. Novel quantitative approach for crossed cerebellar diaschisis detection in acute ischemic stroke using CT perfusion. J Neurol Sci 2020; 416:117008. [PMID: 32738477 DOI: 10.1016/j.jns.2020.117008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 06/08/2020] [Accepted: 06/26/2020] [Indexed: 01/31/2023]
Abstract
PURPOSE Crossed cerebellar diaschisis (CCD) is a common finding in hyper-acute ischemic stroke, related to supratentorial dysfunction of the contralateral hemisphere. Several studies investigated a possible relationship between CCD and clinical outcomes but still no evidence emerged. We proposed a novel quantitative whole cerebellum analysis using CT perfusion (CTP) imaging to investigate the relationship between CCD and stroke severity, hypoperfused volume and outcome measures. METHODS 55 patients with supratentorial ischemic stroke who underwent CTP evaluation within 4.5 h since symptom onset were enrolled. CCD was evaluated by CTP image-processing and by calculating the mean transit time (MTT)-map asymmetry index in the whole cerebellum. MTT asymmetry correlation with ischemic volume and clinical outcomes was investigated. RESULTS MTT asymmetry was found in most of the included patients and significantly correlated with NIH Stroke Scale (NIHSS) score at baseline and CTP ischemic volume. MTT asymmetry was significantly correlated with hemorrhagic transformation, NIHSS and modified Rankin Scale (mRS) score on discharge in treated patients. CONCLUSIONS CCD was detectable by CTP in acute supratentorial ischemic stroke by processing the whole cerebellum volume. CCD perfusion asymmetry was significantly correlated with neurological and perfusion deficit on admission as well as with clinical outcomes in treated patients.
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Affiliation(s)
- Marcello Naccarato
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Miloš Ajčević
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy; Department of Engineering and Architecture, University of Trieste, Trieste, Italy
| | - Giovanni Furlanis
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy.
| | - Carlo Lugnan
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Alex Buoite Stella
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Ilario Scali
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Paola Caruso
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Lara Stragapede
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health 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 Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
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Garcia-Esperon C, Spratt NJ, Gangadharan S, Miteff F, Bivard A, Lillicrap T, Tomari S, Levi CR, Parsons MW. Computed Tomography Perfusion Identifies Patients With Stroke With Impaired Cardiac Function. Stroke 2020; 51:498-503. [PMID: 31896345 DOI: 10.1161/strokeaha.119.027255] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background and Purpose- Low left ventricular ejection fraction (LVEF) leads to worse outcomes after stroke. We hypothesized that the arterial input function (AIF) variability on perfusion computed tomography, especially the time between scan onset and end of AIF (SO-EndAIF), would reflect reduction of cardiac output. Methods- Retrospective analysis of consecutive stroke patients, who underwent computed tomography between January 2013 and September 2018, was performed in 2 parts. (1) To determine the correlation between SO-EndAIF and LVEF, all patients with a transthoracic echocardiogram performed ±6 months from the time of stroke were included. LVEF was dichotomized as either normal (≥50%) or decreased (<50%). (2) AIF was compared with hypoperfusion volume, defined as delay time >3 seconds and with clinical outcome measured using 3-month modified Rankin Scale. Results- A total of 732 ischemic stroke patients underwent computed tomography, 231 with transthoracic echocardiogram were included in part (1), 393 with outcome data were included in part (2). In part (1), 193/231 (83.5%) had normal LVEF (median 61%) and 38/231 (16.5%) decreased LVEF (median 39%). The low-LVEF group had significantly prolonged SO-EndAIF compared with normal-LVEF group (mean of 39.7 versus 26 second; P<0.001), and larger hypoperfusion lesions (94.9 versus 37.6 mL; P<0.001). SO-EndAIF time was strongly associated with EF, with an area under the curve of 0.86. Twenty nine seconds was the best threshold to distinguish between normal and impaired EF (area under the curve, 0.77). In part (2), the SO-EndAIF ≥29 second group had larger hypoperfusion volumes (21.8 versus 89.7 mL; P<0.001) and infarct core (12.2 versus 2.3 mL; P<0.0001) and patients with SO-EndAIF ≥29 seconds had fewer excellent or good clinical outcomes (modified Rankin Scale score 0-1; 40% versus 22%; OR, 2.79; P<0.001, modified Rankin Scale score 0-2; 65% versus 35%; OR, 1.41; P=0.033). Conclusions- AIF width correlates with ejection fraction in acute ischemic stroke. A 29-second threshold from scan onset to end of AIF accurately predicts reduced LVEF and identifies patients more likely to have worse outcomes after stroke.
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Affiliation(s)
- Carlos Garcia-Esperon
- From the Department of Neurology, John Hunter Hospital (C.G.-E., N.J.S., S.G., F.M., C.R.L.), University of Newcastle, Australia.,Hunter Medical Research Institute (C.G.-E., N.J.S., F.M., T.L., S.T., C.R.L., M.W.P.), University of Newcastle, Australia
| | - Neil J Spratt
- From the Department of Neurology, John Hunter Hospital (C.G.-E., N.J.S., S.G., F.M., C.R.L.), University of Newcastle, Australia.,Hunter Medical Research Institute (C.G.-E., N.J.S., F.M., T.L., S.T., C.R.L., M.W.P.), University of Newcastle, Australia
| | - Shyam Gangadharan
- From the Department of Neurology, John Hunter Hospital (C.G.-E., N.J.S., S.G., F.M., C.R.L.), University of Newcastle, Australia
| | - Ferdinand Miteff
- From the Department of Neurology, John Hunter Hospital (C.G.-E., N.J.S., S.G., F.M., C.R.L.), University of Newcastle, Australia.,Hunter Medical Research Institute (C.G.-E., N.J.S., F.M., T.L., S.T., C.R.L., M.W.P.), University of Newcastle, Australia
| | - Andrew Bivard
- Department of Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (A.B., M.W.P.)
| | - Thomas Lillicrap
- Hunter Medical Research Institute (C.G.-E., N.J.S., F.M., T.L., S.T., C.R.L., M.W.P.), University of Newcastle, Australia
| | - Shinya Tomari
- Hunter Medical Research Institute (C.G.-E., N.J.S., F.M., T.L., S.T., C.R.L., M.W.P.), University of Newcastle, Australia
| | - Christopher R Levi
- From the Department of Neurology, John Hunter Hospital (C.G.-E., N.J.S., S.G., F.M., C.R.L.), University of Newcastle, Australia.,Hunter Medical Research Institute (C.G.-E., N.J.S., F.M., T.L., S.T., C.R.L., M.W.P.), University of Newcastle, Australia
| | - Mark W Parsons
- Hunter Medical Research Institute (C.G.-E., N.J.S., F.M., T.L., S.T., C.R.L., M.W.P.), University of Newcastle, Australia.,Department of Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (A.B., M.W.P.)
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Caruso P, Ajčević M, Furlanis G, Ridolfi M, Lugnan C, Cillotto T, Naccarato M, Manganotti P. Thrombolysis safety and effectiveness in acute ischemic stroke patients with pre-morbid disability. J Clin Neurosci 2019; 72:180-184. [PMID: 31875830 DOI: 10.1016/j.jocn.2019.11.047] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 11/30/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Recombinant tissue plasminogen activator (rt-PA) is the first-line therapy demonstrated to be safe and effective in acute ischemic stroke. People with pre-existing severe dementia or physical disability are usually excluded from rt-PA. The aim of our study was to investigate rt-PA safety and effectiveness in acute stroke with pre-existing disability (mRS ≥ 2). METHODS The study encompassed 35 acute ischemic stroke patients with mRS ≥ 2 treated with rt-PA. In order to assess the differences in clinical outcome in three disability groups (mRS = 2; 3; 4/5), the following parameters were evaluated: intracerebral hemorrhage, mortality, NIHSS, ΔNIHSS and mRS. RESULTS Baseline-NIHSS and age were not significantly different among groups. Mortality was higher in the pre-morbid mRS 4/5 group (44%) than in the pre-morbid mRS2 (16.7%) and mRS 3 groups (21.4%). In survived patients, median ΔNIHSS% was higher in the mRS2 and 3 groups (-63.3% and -92.3%, respectively) than in the mRS4/5 group (-9.1%). The 247 rt-PA treated subjects with mRS < 2 in the same period showed lower mortality rate (4.7%), lower sICH (5%), lower mRS at discharge (median 1; range 0-6) and similar ΔNIHSS% (-75%). CONCLUSION Patients with mRS 2 and 3 may benefit from rt-PA with a moderate risk of sICH and mortality.
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Affiliation(s)
- Paola Caruso
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy.
| | - Miloš Ajčević
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy; NEUROFARBA Department, Neuroscience Section, University of Florence, Italy; Department of Engineering and Architecture, University of Trieste, Trieste, Italy
| | - Giovanni Furlanis
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Mariana Ridolfi
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Carlo Lugnan
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Tommaso Cillotto
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Marcello Naccarato
- Clinical Unit of Neurology, 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 Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
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Stragapede L, Furlanis G, Ajčević M, Ridolfi M, Caruso P, Naccarato M, Ukmar M, Manganotti P. Brain oscillatory activity and CT perfusion in hyper-acute ischemic stroke. J Clin Neurosci 2019; 69:184-189. [PMID: 31409548 DOI: 10.1016/j.jocn.2019.07.068] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 07/29/2019] [Indexed: 01/24/2023]
Abstract
OBJECTIVES The combined use of perfusion neuroimaging and brain oscillatory activity may provide a better clinical picture of neurovascular coupling of the injured area in ischemic stroke. The aim is to assess stroke-related topographic electroencephalography (EEG) changes during the earliest phase of ischemic stroke and to compare them with hypoperfusion identified by computer tomography perfusion (CTP). PATIENTS AND METHODS The study included 15 patients with ischemic stroke, who underwent both CTP and EEG recording within 4.5 h. Topographic representation of power for each band was calculated and compared with hypoperfusion areas estimated by CTP maps. RESULTS Predominance of slow delta frequencies was found in all patients. The main finding is the agreement between slow rhythms hemispheric prevalence on EEG maps and cerebral hypoperfusion area identified using CTP. CONCLUSION The results of this preliminary study show that the combined use of EEG and CTP, as highly available techniques, in acute ischemic stroke may be helpful in clinical practice and provide information about functional and metabolic aspects of brain involvement. The joint use of these methodologies may give a better clinical insight of the functionality of injured area in the hyperacute phase.
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Affiliation(s)
- Lara Stragapede
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy.
| | - Giovanni Furlanis
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Miloš Ajčević
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Mariana Ridolfi
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Paola Caruso
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Marcello Naccarato
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health 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 Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
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Bill O, Inácio NM, Lambrou D, Wintermark M, Ntaios G, Dunet V, Michel P. Focal Hypoperfusion in Acute Ischemic Stroke Perfusion CT: Clinical and Radiologic Predictors and Accuracy for Infarct Prediction. AJNR Am J Neuroradiol 2019; 40:483-489. [PMID: 30792249 DOI: 10.3174/ajnr.a5984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 12/30/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Perfusion CT may improve the diagnostic performance of noncontrast CT in acute ischemic stroke. We assessed predictors of focal hypoperfusion in acute ischemic stroke and perfusion CT performance in predicting infarction on follow-up imaging. MATERIALS AND METHODS Patients from the Acute STroke Registry and Analysis of Lausanne data base with acute ischemic stroke and perfusion CT were included. Clinical and radiologic data were collected. We identified predictors of focal hypoperfusion using multivariate analyses. RESULTS From the 2216 patients with perfusion CT, 38.2% had an acute ischemic lesion on NCCT and 73.3% had focal hypoperfusion on perfusion CT. After we analyzed 104 covariates, high-admission NIHSS, visual field defect, aphasia, hemineglect, sensory deficits, and impaired consciousness were positively associated with focal hypoperfusion. Negative associations were pure posterior circulation, lacunar strokes, and anticoagulation. After integrating radiologic variables into the multivariate analyses, we found that visual field defect, sensory deficits, hemineglect, early ischemic changes on NCCT, anterior circulation, cardioembolic etiology, and arterial occlusion were positively associated with focal hypoperfusion, whereas increasing onset-to-CT delay, chronic vascular lesions, and lacunar etiology showed negative association. Sensitivity, specificity, and positive and negative predictive values of focal hypoperfusion on perfusion CT for infarct detection on follow-up MR imaging were 66.5%, 79.4%, 96.2%, and 22.8%, respectively, with an overall accuracy of 76.8%. CONCLUSIONS Compared with NCCT, perfusion CT doubles the sensitivity in detecting acute ischemic stroke. Focal hypoperfusion is independently predicted by stroke severity, cortical clinical deficits, nonlacunar supratentorial strokes, and shorter onset-to-imaging delays. A high proportion of patients with focal hypoperfusion developed infarction on subsequent imaging, as did some patients without focal hypoperfusion, indicating the complementarity of perfusion CT and MR imaging in acute ischemic stroke.
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Affiliation(s)
- O Bill
- From the Neurology Service (O.B., D.L., P.M.), Department of Clinical Neurosciences .,Stroke Unit (O.B.), Groupement Hospitalier de l'Ouest Lausannois, Nyon, Switzerland
| | - N M Inácio
- Neurology Department (N.M.I.), Hospital Beatriz Ângelo, Loures, Portugal
| | - D Lambrou
- From the Neurology Service (O.B., D.L., P.M.), Department of Clinical Neurosciences
| | - M Wintermark
- Department of Radiology (M.W.), Neuroradiology Division, Stanford University and Medical Center, Stanford, California
| | - G Ntaios
- Department of Medicine (G.N.), University of Thessaly, Larissa, Greece
| | - V Dunet
- Department of Diagnostic and Interventional Radiology (V.D.), Lausanne University Hospital, Lausanne, Switzerland
| | - P Michel
- From the Neurology Service (O.B., D.L., P.M.), Department of Clinical Neurosciences
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17
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An acute stroke CT imaging algorithm incorporating automated perfusion analysis. Emerg Radiol 2019; 26:319-329. [PMID: 30706257 DOI: 10.1007/s10140-019-01675-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 01/15/2019] [Indexed: 12/16/2022]
Abstract
In this paper, we propose a CT imaging algorithm for patients presenting with suspected acute stroke that incorporates automated CT perfusion (CTP) imaging. The algorithm details evaluation of the non-contrast CT (NCCT) for hemorrhage and acute ischemia, calculation of ASPECTS, with performance and interpretation of CTP if appropriate. In particular, we consider the key steps in expeditious interpretation of non-contrast CT and CT angiography in the context of suspected acute ischemic stroke. Given the recent expansion of the "imaging based" treatment window for thrombectomy from 6 to 24 h in the 2018 American Heart Association stroke guidelines, we consider the key criteria in the decision to perform CT perfusion and the patient cohorts in which this might be most helpful. We also describe how imaging findings might be incorporated into the treatment paradigm for suspected with acute ischemic stroke and we allude to some of the most frequently encountered pitfalls associated with CTP which we think will be particularly helpful for radiologists and stroke physicians who are considering adding CT perfusion to their work-up for acute stroke.
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18
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Tian H, Parsons MW, Levi CR, Cheng X, Aviv RI, Spratt NJ, Kleinig TJ, O'Brien B, Butcher KS, Lin L, Zhang J, Dong Q, Chen C, Bivard A. Intravenous Thrombolysis May Not Improve Clinical Outcome of Acute Ischemic Stroke Patients Without a Baseline Vessel Occlusion. Front Neurol 2018; 9:405. [PMID: 29928251 PMCID: PMC5997810 DOI: 10.3389/fneur.2018.00405] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/17/2018] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: The benefit of thrombolysis in ischemic stroke patients without a visible vessel occlusion still requires investigation. This study tested the hypothesis that non-lacunar stroke patients with no visible vessel occlusion on baseline imaging would have a favorable outcome regardless of treatment with alteplase. Methods: We utilized a prospectively collected registry of ischemic stroke patients [the International Stroke Perfusion Imaging Registry (INSPIRE)] who had baseline computed tomographic perfusion and computed tomographic angiography. The rates of patients achieving modified Rankin Scale (mRS) 0-1 were compared between alteplase treated and untreated patients using logistic regression to generate odds ratios. Results: Of 1569 patients in the INSPIRE registry, 1,277 were eligible for inclusion. Of these, 306 (24%) had no identifiable occlusion and were eligible for alteplase, with 141 (46%) of these patients receiving thrombolysis. The treated and untreated groups had significantly different median baseline National Institutes of Health Stroke Scale (NIHSS) [alteplase 8, interquartile range (IQR) 5-10, untreated 6, IQR 4-8, P < 0.001] and median volume of baseline perfusion lesion [alteplase 5.6 mL, IQR 1.3-17.7 mL, untreated 2.6 mL, IQR 0-6.7 mL, P < 0.001]. After propensity analysis, alteplase treated patients without a vessel occlusion were less likely to have an excellent outcome (mRS 0-1; 56%) than untreated (78.8%, OR, 0.42, 95% confidence interval, 0.24-0.75, P = 0.003). Conclusions: In this non-randomized comparison, alteplase treatment in patients without an identifiable vessel occlusion did not result in higher rates of favorable outcome compared to untreated. However, treated patients displayed less favorable baseline prognostic factors than the untreated group. Further studies may be required to confirm this data.
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Affiliation(s)
- Huiqiao Tian
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Mark W Parsons
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Christopher R Levi
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Xin Cheng
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Richard I Aviv
- Division of Neuroradiology, Department of Medical Imaging, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Neil J Spratt
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Billy O'Brien
- Department of Neurology, Gosford Hospital, Gosford, NSW, Australia
| | - Kenneth S Butcher
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Longting Lin
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Jingfen Zhang
- Department of Neurology, Baotou Central Hospital, Baotou, China
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Chushuang Chen
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Andrew Bivard
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
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19
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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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20
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Garcia-Esperon C, Bivard A, Levi C, Parsons M. Use of computed tomography perfusion for acute stroke in routine clinical practice: Complex scenarios, mimics, and artifacts. Int J Stroke 2018. [PMID: 29543142 DOI: 10.1177/1747493018765493] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Computed tomography perfusion is becoming widely accepted and used in acute stroke treatment. Computed tomography perfusion provides pathophysiological information needed in the acute decision making. Moreover, computed tomography perfusion shows excellent correlation with diffusion-weighted imaging and perfusion-weighted sequences to evaluate core and penumbra volumes. Multimodal computed tomography perfusion has practical advantages over magnetic resonance imaging, including availability, accessibility, and speed. Nevertheless, it bears some limitations, as the limited accuracy for small ischemic lesions or brainstem ischemia. Interpretation of the computed tomography perfusion maps can sometimes be difficult. The stroke neurologist faces complex or atypical cases of cerebral ischemia and stroke mimics, and needs to decide whether the "lesions" on computed tomography perfusion are real or artifact. Aims The purpose of this review is, based on clinical cases from a comprehensive stroke center, to describe the added value that computed tomography perfusion can provide to the stroke physician in the acute phase before a treatment decision is made.
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Affiliation(s)
- Carlos Garcia-Esperon
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia.,2 Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Andrew Bivard
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia.,2 Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Christopher Levi
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia.,2 Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Mark Parsons
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia.,2 Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
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Alemseged F, Shah DG, Bivard A, Kleinig TJ, Yassi N, Diomedi M, Di Giuliano F, Sharma G, Drew R, Yan B, Dowling RJ, Bush S, Sallustio F, Caltagirone C, Mercuri NB, Floris R, Parsons MW, Levi CR, Mitchell PJ, Davis SM, Campbell BCV. Cerebral blood volume lesion extent predicts functional outcome in patients with vertebral and basilar artery occlusion. Int J Stroke 2017; 14:540-547. [DOI: 10.1177/1747493017744465] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background CT perfusion may improve diagnostic accuracy in posterior circulation stroke. The posterior circulation Acute Stroke Prognosis Early CT score (pc-ASPECTS) on Computed Tomography Angiography source images (CTA-SI) predicts functional outcome in patients with basilar artery occlusion. Aims We assessed the prognostic value of pc-ASPECTS on CT perfusion in patients with vertebral and basilar artery occlusion (VBAO) in comparison with CTA-SI. Methods Whole-brain CT perfusion from consecutive stroke patients with VBAO at four stroke centers was retrospectively analyzed. pc-ASPECTS – a 10-point score assessing hypoattenuation on CTA-SI – was calculated from CT perfusion parameters as focally reduced cerebral blood flow or cerebral blood volume, focally increased time to peak of the deconvolved tissue residue function (Tmax) or mean transit time. Two investigators independently reviewed the images. Reliability was assessed with intraclass correlation coefficient. Good outcome was defined as modified Rankin scale ≤3 at three months. Results We included 60 patients with VBAO. After assessment of four CT perfusion maps simultaneously, area-under-ROC curve (AROC) was 0.83 (95%CI 0.72–0.93) for cerebral blood volume, 0.76 (95%CI 0.64–0.89) for cerebral blood flow, 0.77 (95%CI 0.64–0.89) for Tmax, 0.70 (95%CI 0.56–0.84) for mean transit time versus area-under-ROC curve 0.64 (95%CI 0.50–0.79) for CTA-SI. Cerebral blood volume had greater accuracy compared with CTA-SI for poor outcome (p = 0.04). In logistic regression analysis, cerebral blood volume pc-ASPECTS≤8 was independently associated with poor outcome (OR 9.3 95%CI 2.2–41; p = 0.003, adjusted for age and clinical severity). Inter-rater agreement was substantial for cerebral blood volume pc-ASPECTS (intraclass correlation coefficient 0.82 95%CI 0.71–0.90 versus 0.67 for CTA-SI 95%CI 0.43–0.81). Conclusions Cerebral blood volume pc-ASPECTS may identify VBAO patients at higher risk of disability.
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Affiliation(s)
- Fana Alemseged
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
- Department of Neuroscience, University Hospital of “Tor Vergata”, Rome, Italy
| | - Darshan G Shah
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Andrew Bivard
- Department of Neurology, John Hunter Hospital, University of Newcastle, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia
| | - Nawaf Yassi
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Marina Diomedi
- Department of Neuroscience, University Hospital of “Tor Vergata”, Rome, Italy
- I.R.C.C.S., Santa Lucia Foundation, Rome, Italy
| | - Francesca Di Giuliano
- Department of Biomedicine and Prevention, University Hospital of “Tor Vergata”, Rome, Italy
| | - Gagan Sharma
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Roy Drew
- Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Richard J Dowling
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Steven Bush
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Fabrizio Sallustio
- Department of Neuroscience, University Hospital of “Tor Vergata”, Rome, Italy
| | - Carlo Caltagirone
- Department of Neuroscience, University Hospital of “Tor Vergata”, Rome, Italy
- I.R.C.C.S., Santa Lucia Foundation, Rome, Italy
| | - Nicola B Mercuri
- Department of Neuroscience, University Hospital of “Tor Vergata”, Rome, Italy
| | - Roberto Floris
- Department of Biomedicine and Prevention, University Hospital of “Tor Vergata”, Rome, Italy
| | - Mark W Parsons
- Department of Neurology, John Hunter Hospital, University of Newcastle, Australia
| | - Christopher R Levi
- Department of Neurology, John Hunter Hospital, University of Newcastle, Australia
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Bruce CV Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
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22
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Naylor J, Churilov L, Chen Z, Koome M, Rane N, Campbell BCV. Reliability, Reproducibility and Prognostic Accuracy of the Alberta Stroke Program Early CT Score on CT Perfusion and Non-Contrast CT in Hyperacute Stroke. Cerebrovasc Dis 2017; 44:195-202. [DOI: 10.1159/000479707] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 07/23/2017] [Indexed: 11/19/2022] Open
Abstract
Background: Alberta Stroke Program Early CT Score (ASPECTS) assesses early ischemic change on non-contrast CT (NCCT). We hypothesised that assessing ASPECTS regions on CT Perfusion (CTP) rather than NCCT would improve inter-rater agreement and prognostic accuracy, particularly in patients presenting early after stroke onset. Methods: Ischemic stroke patients treated with intravenous alteplase from 2009 to 2014 at our institution were included in this study. Inter-rater agreement and prognostic accuracy of ASPECTS across modalities were analysed by the time between stroke onset and initial NCCT, dichotomized 1st quartile versus quartiles 2-4, referred to as epochs. ASPECTS was assessed by 2 independent raters, blinded to stroke onset time, with agreement determined by weighted kappa (κw). Prognostic accuracy for favourable outcome (modified Rankin Scale 0-2) was assessed using the receiver-operating characteristic analysis. Results: A total of 227 participants were included. There was significant time-by-CT modality interaction for ASPECTS, p < 0.0001. The inter-rater agreement of ASPECTS on NCCT significantly increased as onset to CT time increased (κw epoch 1 = 0.76 vs. κw epoch 2-4 = 0.89, p = 0.04), whereas agreement using CTP parameters was stable across epochs. Inter-rater agreement for CTP-ASPECTS was significantly higher than NCCT in early epoch: Tmax κw = 0.96, p = 0.002; cerebral blood volume (CBV) κw = 0.95, p = 0.003; cerebral blood flow (CBF) κw = 0.94, p = 0.006, with no differences in the later epochs. Prognostic accuracy of ASPECTS on NCCT in epoch 1 were (area under the ROC curves [AUC] = 0.52, 95% CI 0.48-0.56), CBV (AUC = 0.55, 95% CI 0.42-0.69, CBF (AUC = 0.58, 95% CI 0.46-0.71) and Tmax (AUC = 0.62, 95% CI 0.49-0.75), p = 0.46 between modalities. Conclusions: CTP can improve reliability when assessing the extent of ischemic changes, particularly in patients imaged early after stroke onset.
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Affiliation(s)
- Jillian Naylor
- Melbourne Brain Centre, Royal Melbourne Hospital and Department of Medicine, University of Melbourne, Parkville, VIC, Australia
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23
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Lee WJ, Jung KH, Ryu YJ, Kim JM, Lee ST, Chu K, Kim M, Lee SK, Roh JK. Utility of digital subtraction angiography-based collateral evaluation in medically treated acute symptomatic basilar artery stenosis. Eur J Neurol 2017; 24:1148-1155. [PMID: 28707434 DOI: 10.1111/ene.13351] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 06/01/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Although a stroke from atherosclerosis in the basilar artery (BA) often presents with mild initial stroke severity, it has heterogeneous clinical courses. We investigated the efficacy of digital subtraction angiography (DSA)-based collateral perfusion evaluation in association with long-term outcomes of medically treated symptomatic basilar artery stenosis. METHODS From a registry database of all consecutive patients with stroke, we included 98 medically treated patients (due to mild initial stroke severity) [National Institute of Health Stroke Scale (NIHSS) scores ≤ 4; symptomatic basilar artery stenosis, 70-99%] with available initial diagnostic DSA. Basilar collateral scoring was performed via the DSA, using a modified version of the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology grading system in both the superior cerebellar artery and anterior/posterior-inferior cerebellar artery territories (score 0-8). The outcomes were designated as the 90-day modified Rankin Scale (mRS90) score (poor, 3-6). Student's t-test, chi-square test and logistic regression analyses were used to identify factors associated with a poor outcome. RESULTS The median initial NIHSS score was 2 [interquartile range (IQR), 0-3], median posterior circulation Alberta Stroke Program Early CT Score was 8 (IQR, 7-10), median collateral score was 7 (IQR, 7-8) and 20 (20.4%) had poor mRS90 scores. In multivariate analysis, poorer collateral scores (P = 0.003), higher NIHSS scores (P = 0.005) and lower posterior circulation Alberta Stroke Program Early CT Score (P = 0.017) were independently associated with a poor mRS90 score. CONCLUSIONS The DSA-based collateral scoring of the BA large branches might predict long-term outcome in medically treated symptomatic basilar artery stenosis with mild initial severity. Evaluation of BA collateral perfusion status might be useful to determine appropriate treatment strategies.
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Affiliation(s)
- W-J Lee
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - K-H Jung
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea.,Program in Neuroscience, Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University, Seoul, South Korea
| | - Y J Ryu
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea
| | - J-M Kim
- Department of Neurology, Chung-Ang University Hospital, Seoul, South Korea
| | - S-T Lee
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea.,Program in Neuroscience, Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University, Seoul, South Korea
| | - K Chu
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea.,Program in Neuroscience, Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University, Seoul, South Korea
| | - M Kim
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea.,Program in Neuroscience, Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University, Seoul, South Korea
| | - S K Lee
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea.,Program in Neuroscience, Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University, Seoul, South Korea
| | - J-K Roh
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea.,Department of Neurology, The Armed Forces Capital Hospital, Sungnam, South Korea
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24
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Lin L, Cheng X, Bivard A, Levi CR, Dong Q, Parsons MW. Quantifying reperfusion of the ischemic region on whole-brain computed tomography perfusion. J Cereb Blood Flow Metab 2017; 37:2125-2136. [PMID: 27461903 PMCID: PMC5464706 DOI: 10.1177/0271678x16661338] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To derive the reperfusion index best predicting clinical outcome of ischemic stroke patients, we retrospectively analysed the acute and 24-h computed tomography perfusion data of 116 patients, collected from two centres equipped with whole-brain computed tomography perfusion. Reperfusion index was defined by the percentage of the ischemic region reperfused from acute to 24-h computed tomography perfusion. Recanalization was graded by arterial occlusive lesion system. Receiver operator characteristic analysis was performed to assess the prognostic value of reperfusion and recanalization in predicting good clinical outcome, defined as modified Rankin Score of 0-2 at 90 days. Among previous reported reperfusion measurements, reperfusion of the Tmax>6 s region resulted in higher prognostic value than recanalization at predicting good clinical outcome (area under the curve = 0.88 and 0.74, respectively, p = 0.002). Successful reperfusion of the Tmax>6 s region (≥60%) had 89% sensitivity and 78% specificity in predicting good clinical outcome. A reperfusion index defined by Tmax>2 s or by mean transit time>145% had much lower area under the curve in comparison to Tmax>6 s measurement (p < 0.001 and p = 0.003, respectively), and had no significant difference to recanalization at predicting clinical outcome (p = 0.58 and 0.63, respectively). In conclusion, reperfusion index calculated by Tmax>6 s is a stronger predictor of clinical outcome than recanalization or other reperfusion measures.
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Affiliation(s)
- Longting Lin
- 1 School of Medicine and Public health, University of Newcastle, Newcastle, Australia
| | - Xin Cheng
- 3 Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Andrew Bivard
- 1 School of Medicine and Public health, University of Newcastle, Newcastle, Australia
| | - Christopher R Levi
- 1 School of Medicine and Public health, University of Newcastle, Newcastle, Australia.,2 Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - Qiang Dong
- 3 Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Mark W Parsons
- 1 School of Medicine and Public health, University of Newcastle, Newcastle, Australia.,2 Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
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25
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Demeestere J, Garcia-Esperon C, Garcia-Bermejo P, Ombelet F, McElduff P, Bivard A, Parsons M, Levi C. Evaluation of hyperacute infarct volume using ASPECTS and brain CT perfusion core volume. Neurology 2017; 88:2248-2253. [PMID: 28515270 PMCID: PMC5567320 DOI: 10.1212/wnl.0000000000004028] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 03/16/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare the accuracy of Alberta Stroke Program Early Computed Tomography Score (ASPECTS) and CT perfusion to detect established infarction in acute anterior circulation stroke. METHODS We performed an observational study in 59 acute anterior circulation ischemic stroke patients who underwent brain noncontrast CT, CT perfusion, and MRI within 100 minutes from CT imaging. ASPECTS scores were calculated by 4 blinded vascular neurologists. The accuracy of ASPECTS and CT perfusion core volume to detect an acute MRI diffusion lesion of ≥70 mL was evaluated using receiver operating characteristics analysis and optimum cutoff values were calculated using Youden J. RESULTS Median ASPECTS score was 8 (interquartile range [IQR] 5-9). Median CT perfusion core volume was 22 mL (IQR 10.4-71.9). Median MRI diffusion lesion volume was 24.5 mL (IQR 10-63.9). No significant difference was found between the accuracy of CT perfusion and ASPECTS (c statistic 0.95 vs 0.87, p value for difference = 0.17). The optimum ASPECTS cutoff score to detect a diffusion-weighted imaging lesion ≥70 mL was <7 (sensitivity 0.74, specificity 0.86, Youden J = 0.60) and the optimum CT perfusion core volume cutoff was ≥50 mL (sensitivity 0.86, specificity 0.97, Youden J = 0.84). The CT perfusion core lesion covered a median of 100% (IQR 86%-100%) of the acute MRI lesion volume (Pearson R = 0.88; R2 = 0.77). CONCLUSIONS We found no significant difference between the accuracy of CT perfusion and ASPECTS to predict hyperacute MRI lesion volume in ischemic stroke.
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Affiliation(s)
- Jelle Demeestere
- From the Acute Stroke Service (J.D., C.G.-E., F.O., M.P., C.L.), John Hunter Hospital, Newcastle, Australia; Hamad Medical Corporation (P.G.-B.), Doha, Qatar; Hunter Medical Research Institute (P.M., A.B.), Newcastle; and University of Newcastle (P.M., M.P., C.L.), Callaghan, Australia
| | - Carlos Garcia-Esperon
- From the Acute Stroke Service (J.D., C.G.-E., F.O., M.P., C.L.), John Hunter Hospital, Newcastle, Australia; Hamad Medical Corporation (P.G.-B.), Doha, Qatar; Hunter Medical Research Institute (P.M., A.B.), Newcastle; and University of Newcastle (P.M., M.P., C.L.), Callaghan, Australia
| | - Pablo Garcia-Bermejo
- From the Acute Stroke Service (J.D., C.G.-E., F.O., M.P., C.L.), John Hunter Hospital, Newcastle, Australia; Hamad Medical Corporation (P.G.-B.), Doha, Qatar; Hunter Medical Research Institute (P.M., A.B.), Newcastle; and University of Newcastle (P.M., M.P., C.L.), Callaghan, Australia
| | - Fouke Ombelet
- From the Acute Stroke Service (J.D., C.G.-E., F.O., M.P., C.L.), John Hunter Hospital, Newcastle, Australia; Hamad Medical Corporation (P.G.-B.), Doha, Qatar; Hunter Medical Research Institute (P.M., A.B.), Newcastle; and University of Newcastle (P.M., M.P., C.L.), Callaghan, Australia
| | - Patrick McElduff
- From the Acute Stroke Service (J.D., C.G.-E., F.O., M.P., C.L.), John Hunter Hospital, Newcastle, Australia; Hamad Medical Corporation (P.G.-B.), Doha, Qatar; Hunter Medical Research Institute (P.M., A.B.), Newcastle; and University of Newcastle (P.M., M.P., C.L.), Callaghan, Australia
| | - Andrew Bivard
- From the Acute Stroke Service (J.D., C.G.-E., F.O., M.P., C.L.), John Hunter Hospital, Newcastle, Australia; Hamad Medical Corporation (P.G.-B.), Doha, Qatar; Hunter Medical Research Institute (P.M., A.B.), Newcastle; and University of Newcastle (P.M., M.P., C.L.), Callaghan, Australia
| | - Mark Parsons
- From the Acute Stroke Service (J.D., C.G.-E., F.O., M.P., C.L.), John Hunter Hospital, Newcastle, Australia; Hamad Medical Corporation (P.G.-B.), Doha, Qatar; Hunter Medical Research Institute (P.M., A.B.), Newcastle; and University of Newcastle (P.M., M.P., C.L.), Callaghan, Australia
| | - Christopher Levi
- From the Acute Stroke Service (J.D., C.G.-E., F.O., M.P., C.L.), John Hunter Hospital, Newcastle, Australia; Hamad Medical Corporation (P.G.-B.), Doha, Qatar; Hunter Medical Research Institute (P.M., A.B.), Newcastle; and University of Newcastle (P.M., M.P., C.L.), Callaghan, Australia.
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26
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Abdelgawad EA, Higazi MM, Abdelbaky AO, Abdelghany HS. Diagnostic performance of CT cerebral blood volume colour maps for evaluation of acute infarcts; comparison with diffusion-weighted MRI within 12hours of major stroke onset. J Neuroradiol 2017; 44:10-16. [DOI: 10.1016/j.neurad.2016.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 08/10/2016] [Accepted: 10/17/2016] [Indexed: 01/19/2023]
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27
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Shao GL, Zheng JP, Guo LW, Chen YT, Zeng H, Yao Z. Evaluation of efficacy of transcatheter arterial chemoembolization combined with computed tomography-guided radiofrequency ablation for hepatocellular carcinoma using magnetic resonance diffusion weighted imaging and computed tomography perfusion imaging: A prospective study. Medicine (Baltimore) 2017; 96:e5518. [PMID: 28099329 PMCID: PMC5279074 DOI: 10.1097/md.0000000000005518] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The purpose of this study is to evaluate the efficacy of transcatheter arterial chemoembolization (TACE) combined with computed tomography-guided radiofrequency ablation (CT-RFA) in the treatment of hepatocellular carcinoma (HCC) using magnetic resonance diffusion weighted imaging (MR-DWI) and CT perfusion imaging (CT-PI). METHODS From January 2008 to January 2014, a total of 522 HCC patients receiving TACE combined with CT-RFA were included in this study. All patients underwent TACE followed by CT-RFA, and 1 day before treatment and 1 month after treatment they received MR-DWI and CT-PI. Enzyme-linked immunosorbent assay (ELISA) was performed to detect the concentration of alpha-fetoprotein (AFP). Tumor response was evaluated using the revised RECIST criteria. One-year follow-up was conducted on all patients. Receiver-operating characteristic (ROC) curve was drawn to evaluate the efficacy of TACE combined with CT-RFA for HCC using MR-DWI and CT-PI. RESULTS Total effective rate (complete remission [CR] + partial remission [PR]) of TACE combined with CT-RFA for HCC was 82.95%. HCC patients of CR + PR had lower hepatic blood flow (HBF), hepatic blood volume (HBV), permeability surface (PS), hepatic arterial perfusion (HAP), and hepatic perfusion index (HPI) levels than those of SD + PD, but HCC patients of CR + PR had higher mean transit time (MTT) level than those of SD + PD. The patients of PR + CR had higher apparent diffusion coefficient (ADC) values than those of SD + PD. The patients of PR + CR showed lower AFP concentration than those of SD + PD. ROC curve analysis indicated that the area under the curve (AUC) of AFP, HBV, PS, HAP, HPI, and ADC was more than 0.7, but the AUC of HBF, MTT, and PVP were less than 0.7. After treatment, the AFP, HBF, HBV, PS, HAP, and HPI in the HCC patients with recurrence were higher than those in the HCC patients without, but MTT and ADC in the HCC patients with recurrence were lower than those in the HCC patients without. CONCLUSION These findings indicate that MR-DWI and CT-PI can effectively evaluate the efficacy of TACE combined with CT-RFA and postoperative recurrence of HCC.
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Diagnostic accuracy of whole-brain CT perfusion in the detection of acute infratentorial infarctions. Neuroradiology 2016; 58:1077-1085. [DOI: 10.1007/s00234-016-1743-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 08/17/2016] [Indexed: 10/21/2022]
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Lin L, Bivard A, Krishnamurthy V, Levi CR, Parsons MW. Whole-Brain CT Perfusion to Quantify Acute Ischemic Penumbra and Core. Radiology 2016; 279:876-87. [DOI: 10.1148/radiol.2015150319] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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30
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Yu Y, Han Q, Ding X, Chen Q, Ye K, Zhang S, Yan S, Campbell BCV, Parsons MW, Wang S, Lou M. Defining Core and Penumbra in Ischemic Stroke: A Voxel- and Volume-Based Analysis of Whole Brain CT Perfusion. Sci Rep 2016; 6:20932. [PMID: 26860196 PMCID: PMC4748242 DOI: 10.1038/srep20932] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 01/13/2016] [Indexed: 12/02/2022] Open
Abstract
Whole brain computed tomography perfusion (CTP) has the potential to select eligible patients for reperfusion therapy. We aimed to find the optimal thresholds on baseline CTP for ischemic core and penumbra in acute ischemic stroke. We reviewed patients with acute ischemic stroke in the anterior circulation, who underwent baseline whole brain CTP, followed by intravenous thrombolysis and perfusion imaging at 24 hours. Patients were divided into those with major reperfusion (to define the ischemic core) and minimal reperfusion (to define the extent of penumbra). Receiver operating characteristic (ROC) analysis and volumetric consistency analysis were performed separately to determine the optimal threshold by Youden’s Index and mean magnitude of volume difference, respectively. From a series of 103 patients, 22 patients with minimal-reperfusion and 47 with major reperfusion were included. Analysis revealed delay time ≥ 3 s most accurately defined penumbra (AUC = 0.813; 95% CI, 0.812-0.814, mean magnitude of volume difference = 29.1 ml). The optimal threshold for ischemic core was rCBF ≤ 30% within delay time ≥ 3 s (AUC = 0.758; 95% CI, 0.757-0.760, mean magnitude of volume difference = 10.8 ml). In conclusion, delay time ≥ 3 s and rCBF ≤ 30% within delay time ≥ 3 s are the optimal thresholds for penumbra and core, respectively. These results may allow the application of the mismatch on CTP to reperfusion therapy.
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Affiliation(s)
- Yannan Yu
- Department of Neurology, Second Affiliated Hospital of Zhejiang University, Hangzhou, Zhejiang, China
| | - Quan Han
- Department of Neurology, Second Affiliated Hospital of Zhejiang University, Hangzhou, Zhejiang, China
| | - Xinfa Ding
- Department of Radiology, Second Affiliated Hospital of Zhejiang University, Hangzhou, Zhejiang, China
| | - Qingmeng Chen
- Department of Neurology, Second Affiliated Hospital of Zhejiang University, Hangzhou, Zhejiang, China
| | - Keqi Ye
- Department of Neurology, Second Affiliated Hospital of Zhejiang University, Hangzhou, Zhejiang, China
| | - Sheng Zhang
- Department of Neurology, Second Affiliated Hospital of Zhejiang University, Hangzhou, Zhejiang, China
| | - Shenqiang Yan
- Department of Neurology, Second Affiliated Hospital of Zhejiang University, Hangzhou, Zhejiang, China
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Mark W Parsons
- Department of Neurology, John Hunter Hospital, and Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Shaoshi Wang
- Department of Neurology, Shanghai Jiaotong University Affiliated Branch of People's No. 1 Hospital, Shanghai, China
| | - Min Lou
- Department of Neurology, Second Affiliated Hospital of Zhejiang University, Hangzhou, Zhejiang, China
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Xu B, Qiao Q, Chen M, Rastogi R, Luo D, Bi Q. Relationship between neurological complications, cerebrovascular and cerebral perfusion following off-pump coronary artery bypass grafting. Neurol Res 2015; 37:421-6. [DOI: 10.1179/1743132815y.0000000030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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32
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Agarwal S, Matys T, Marrapu ST, Scoffings DJ, Mitchell J, Jones PS, Baron JC, Warburton EA. Is CT-Based Perfusion and Collateral Imaging Sensitive to Time Since Stroke Onset? Front Neurol 2015; 6:70. [PMID: 25914673 PMCID: PMC4391339 DOI: 10.3389/fneur.2015.00070] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 03/15/2015] [Indexed: 12/12/2022] Open
Abstract
Purpose CT-based perfusion and collateral imaging is increasingly used in the assessment of patients with acute stroke. Time of stroke onset is a critical factor in determining eligibility for and benefit from thrombolysis. Animal studies predict that the volume of ischemic penumbra decreases with time. Here, we evaluate if CT is able to detect a relationship between perfusion or collateral status, as assessed by CT, and time since stroke onset. Materials and methods We studied 53 consecutive patients with proximal vessel occlusions, mean (SD) age of 71.3 (14.9) years, at a mean (SD) of 125.2 (55.3) minutes from onset, using whole-brain CT perfusion (CTp) imaging. Penumbra was defined using voxel-based thresholds for cerebral blood flow (CBF) and mean transit time (MTT); core was defined by cerebral blood volume (CBV). Normalized penumbra fraction was calculated as Penumbra volume/(Penumbra volume + Core volume) for both CBF and MTT (PenCBF and PenMTT, respectively). Collaterals were assessed on CT angiography (CTA). CTp ASPECTS score was applied visually, lower scores indicating larger lesions. ASPECTS ratios were calculated corresponding to penumbra fractions. Results Both PenCBF and PenMTT showed decremental trends with increasing time since onset (Kendall’s tau-b = −0.196, p = 0.055, and −0.187, p = 0.068, respectively). The CBF/CBV ASPECTS ratio, which showed a relationship to PenCBF (Kendall’s tau-b = 0.190, p = 0.070), decreased with increasing time since onset (Kendall’s tau-b = −0.265, p = 0.006). Collateral response did not relate to time (Kendall’s tau-b = −0.039, p = 0.724). Conclusion Even within 4.5 h since stroke onset, a decremental relationship between penumbra and time, but not between collateral status and time, may be detected using perfusion CT imaging. The trends that we demonstrate merit evaluation in larger datasets to confirm our results, which may have potential wider applications, e.g., in the setting of strokes of unknown onset time.
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Affiliation(s)
- Smriti Agarwal
- Clinical Neurosciences, University of Cambridge , Cambridge , UK
| | - Tomasz Matys
- Department of Radiology, Addenbrooke's Hospital , Cambridge , UK
| | - S Tulasi Marrapu
- Clinical Neurosciences, University of Cambridge , Cambridge , UK
| | | | | | - P Simon Jones
- Clinical Neurosciences, University of Cambridge , Cambridge , UK
| | - Jean-Claude Baron
- University of Cambridge , Cambridge , UK ; Centre de Psychiatrie et Neurosciences, INSERM U894, Hôpital Sainte-Anne, Université Paris 5 , Paris , France
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Rosenkrantz AB, Mendiratta-Lala M, Bartholmai BJ, Ganeshan D, Abramson RG, Burton KR, Yu JPJ, Scalzetti EM, Yankeelov TE, Subramaniam RM, Lenchik L. Clinical utility of quantitative imaging. Acad Radiol 2015; 22:33-49. [PMID: 25442800 PMCID: PMC4259826 DOI: 10.1016/j.acra.2014.08.011] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 08/25/2014] [Accepted: 08/25/2014] [Indexed: 12/24/2022]
Abstract
Quantitative imaging (QI) is increasingly applied in modern radiology practice, assisting in the clinical assessment of many patients and providing a source of biomarkers for a spectrum of diseases. QI is commonly used to inform patient diagnosis or prognosis, determine the choice of therapy, or monitor therapy response. Because most radiologists will likely implement some QI tools to meet the patient care needs of their referring clinicians, it is important for all radiologists to become familiar with the strengths and limitations of QI. The Association of University Radiologists Radiology Research Alliance Quantitative Imaging Task Force has explored the clinical application of QI and summarizes its work in this review. We provide an overview of the clinical use of QI by discussing QI tools that are currently used in clinical practice, clinical applications of these tools, approaches to reporting of QI, and challenges to implementing QI. It is hoped that these insights will help radiologists recognize the tangible benefits of QI to their patients, their referring clinicians, and their own radiology practice.
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Affiliation(s)
- Andrew B Rosenkrantz
- Department of Radiology, NYU Langone Medical Center, 550 First Avenue, New York, NY 10016.
| | - Mishal Mendiratta-Lala
- Henry Ford Hospital, Abdominal and Cross-sectional Interventional Radiology, Detroit, Michigan
| | - Brian J Bartholmai
- Division of Radiology Informatics, Mayo Clinic in Rochester, Rochester, Minnesota
| | | | - Richard G Abramson
- Department of Radiology and Radiological Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Kirsteen R Burton
- Department of Medical Imaging and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - John-Paul J Yu
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Ernest M Scalzetti
- Department of Radiology, SUNY Upstate Medical University, Syracuse New York
| | - Thomas E Yankeelov
- Institute of Imaging Science, Vanderbilt University, Nashville, Tennessee
| | - Rathan M Subramaniam
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, and Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Leon Lenchik
- Department of Radiology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
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Abstract
In acute ischemic stroke, the volume of threatened but potentially salvageable tissue, i.e. the ischemic penumbra, is critical to the success of all acute therapeutic interventions, most notably thrombolysis. Despite the availability of both CT and MRI based techniques to detect and assess the penumbra, advanced imaging of this type remains under-utilized. Although the optimal selection criteria are still being refined and technical improvements are ongoing, rapid imaging of the penumbra appears to be the most promising approach to expanding the acute thrombolysis population, as well as tailoring treatment based on specific pathophysiological findings. This second article in a two-part series reviews current evidence for penumbral-based treatment selection and discusses the barriers to implementation of these advanced imaging techniques in acute stroke management protocols.
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Burton KR, Dhanoa D, Aviv RI, Moody AR, Kapral MK, Laupacis A. Perfusion CT for selecting patients with acute ischemic stroke for intravenous thrombolytic therapy. Radiology 2014; 274:103-14. [PMID: 25243539 DOI: 10.1148/radiol.14140728] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine rates of death, disability, and symptomatic intracranial hemorrhage ( SICH symptomatic ICH ) among patients with acute ischemic stroke selected for thrombolytic therapy by using perfusion computed tomography (CT) by conducting a systematic review and meta-analysis. MATERIALS AND METHODS A search of the literature up to July 2012 was performed by using MEDLINE, EMBASE, the Cochrane Library, PubMed, and Google Scholar on terms including "brain ischemia" and "perfusion imaging." The search was unrestricted by language of publication. Two reviewers extracted study data and independently assessed the risk of study bias. Outcomes of patients selected by using perfusion CT, including case-fatality rate, favorable outcome (modified Rankin Scale [ mRS modified Rankin Scale ] score, ≤2), and rates of SICH symptomatic ICH , were estimated. RESULTS Thirteen experimental or observational studies that included patients who received intravenous thrombolytic treatment after perfusion CT were identified. The methodologic quality of the small studies was generally good. Overall, 90-day mortality was 10.0% (95% confidence interval [ CI confidence interval ]: 5.4%, 15.9%). Among patients treated within 3 hours of symptom onset, mortality was 12.5% (95% CI confidence interval : 6.7%, 19.7%), a favorable outcome ( mRS modified Rankin Scale score, ≤2) was seen in 42.5% of patients (95% CI confidence interval : 16.6%, 70.9%), and the SICH symptomatic ICH rate was 3.3% (95% CI confidence interval : 0.7%, 7.7%). Among patients treated more than 3 hours after symptom onset, mortality was 2.9% (95% CI confidence interval : 0.0%, 12.7%), 69.9% of patients (95% CI confidence interval : 0%, 83.5%) had a favorable outcome, and the SICH symptomatic ICH rate was 3.9% (95% CI confidence interval : 0.8%, 9.2%). CONCLUSION The outcomes (mortality, morbidity, and SICH symptomatic ICH rates) for patients selected with perfusion CT to receive intravenous thrombolytic treatment more than 3 hours after symptom onset appear favorable.
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Affiliation(s)
- Kirsteen R Burton
- From the Institute for Health Policy, Management and Evaluation (K.R.B., M.K.K., A.L.), Department of Medical Imaging (K.R.B., R.I.A., A.R.M.), Institute of Medical Sciences (R.I.A., A.R.M.), and Department of Medicine (M.K.K., A.L.), University of Toronto, 263 McCaul St, 4th Floor, Toronto, ON, Canada M5T 1W7; Department of Medical Imaging, Fraser Health Authority, Vancouver, British Columbia, Canada (D.D.); Department of Medical Imaging, University of British Columbia, Vancouver, British Columbia, Canada (D.D.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (M.K.K.); and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (A.L.)
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Barlinn K, Seibt J, Engellandt K, Gerber J, Puetz V, Kepplinger J, Wunderlich O, Pallesen LP, Bodechtel U, Koch R, von Kummer R, Dzialowski I. Multimodal Computed Tomography Based Definition of Cerebral Imaging Profiles for Acute Stroke Reperfusion Therapy (CT-DEFINE): Results of a Prospective Observational Study. Clin Neuroradiol 2014; 25:403-10. [PMID: 25150187 DOI: 10.1007/s00062-014-0320-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 06/17/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE To prospectively evaluate the prognostic impact of multimodal computed tomography-based imaging in ischemic stroke patients potentially eligible for reperfusion therapy. METHODS Anterior circulation stroke patients underwent non-contrast CT (NCCT), CT-angiography, and CT-perfusion within 12 h from symptom-onset. Patients could be treated with intravenous-tissue plasminogen activator (IV-tPA), endovascular or combined reperfusion therapies. Cerebral imaging profiles (IP) were NCCT-Alberta Stroke Program Early CT Score (ASPECTS) > 7 (IP1); NCCT-ASPECTS > 5 and proximal occlusion on CT-angiography (IP2); CT-perfusion mismatch between cerebral blood volume (CBV)-ASPECTS, and cerebral blood flow (CBF)-ASPECTS ≥ 2 (IP3). Favorable outcome was defined as modified Rankin Scale ≤ 2 at 3 months. RESULTS Of 102 included patients, 62 (61%) received any reperfusion therapy. In IP2 and IP3, favorable outcome was more frequent in patients with reperfusion therapy than in those without; however, this did not reach statistical significance (IP2: 39% vs 15%, p = 0.26; IP3: 50% vs 17 %; p = 0.31). No difference was seen in IP1 (58% vs 58%, p = 1.0). In IP2, patients with IV-tPA alone achieved better functional outcome (50% vs 11%, p = 0.03) and lower mortality (0% vs 28%, p = 0.045) than those without. CONCLUSIONS Our results suggest a benefit with imaging profile selection based upon the combination of a small-to-moderate-sized infarction and a visible intracranial occlusion in patients receiving IV-tPA. Reperfusion therapy may be futile in patients without proven vessel occlusion.
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Affiliation(s)
- K Barlinn
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - J Seibt
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - K Engellandt
- Division of Neuroradiology, University Hospital Dresden, Dresden, Germany
| | - J Gerber
- Division of Neuroradiology, University Hospital Dresden, Dresden, Germany
| | - V Puetz
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - J Kepplinger
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - O Wunderlich
- Division of Neuroradiology, University Hospital Dresden, Dresden, Germany
| | - L-P Pallesen
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - U Bodechtel
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - R Koch
- Institute for Medical Informatics and Biometry, University Hospital Dresden, Dresden, Germany
| | - R von Kummer
- Division of Neuroradiology, University Hospital Dresden, Dresden, Germany
| | - I Dzialowski
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- Elblandklinikum Meissen, Department of Neurology, Academic Teaching Hospital of the University of Technology Dresden, Meissen, Germany
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Penumbra pattern assessment in acute stroke patients: comparison of quantitative and non-quantitative methods in whole brain CT perfusion. PLoS One 2014; 9:e105413. [PMID: 25144396 PMCID: PMC4140765 DOI: 10.1371/journal.pone.0105413] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 07/21/2014] [Indexed: 11/19/2022] Open
Abstract
Background And Purpose While penumbra assessment has become an important part of the clinical decision making for acute stroke patients, there is a lack of studies measuring the reliability and reproducibility of defined assessment techniques in the clinical setting. Our aim was to determine reliability and reproducibility of different types of three-dimensional penumbra assessment methods in stroke patients who underwent whole brain CT perfusion imaging (WB-CTP). Materials And Methods We included 29 patients with a confirmed MCA infarction who underwent initial WB-CTP with a scan coverage of 100 mm in the z-axis. Two blinded and experienced readers assessed the flow-volume-mismatch twice and in two quantitative ways: Performing a volumetric mismatch analysis using OsiriX imaging software (MMVOL) and visual estimation of mismatch (MMEST). Complementarily, the semiquantitative Alberta Stroke Programme Early CT Score for CT perfusion was used to define mismatch (MMASPECTS). A favorable penumbral pattern was defined by a mismatch of ≥30% in combination with a cerebral blood flow deficit of ≤90 ml and an MMASPECTS score of ≥1, respectively. Inter- and intrareader agreement was determined by Kappa-values and ICCs. Results Overall, MMVOL showed considerably higher inter-/intrareader agreement (ICCs: 0.751/0.843) compared to MMEST (0.292/0.749). In the subgroup of large (≥50 mL) perfusion deficits, inter- and intrareader agreement of MMVOL was excellent (ICCs: 0.961/0.942), while MMEST interreader agreement was poor (0.415) and intrareader agreement was good (0.919). With respect to penumbra classification, MMVOL showed the highest agreement (interreader agreement: 25 agreements/4 non-agreements/κ: 0.595; intrareader agreement 27/2/0.833), followed by MMEST (22/7/0.471; 23/6/0.577), and MMASPECTS (18/11/0.133; 21/8/0.340). Conclusion The evaluated approach of volumetric mismatch assessment is superior to pure visual and ASPECTS penumbra pattern assessment in WB-CTP and helps to precisely judge the extent of 3-dimensional mismatch in acute stroke patients.
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McVerry F, Dani KA, MacDougall NJ, MacLeod MJ, Wardlaw J, Muir KW. Derivation and Evaluation of Thresholds for Core and Tissue at Risk of Infarction Using CT Perfusion. J Neuroimaging 2014; 24:562-568. [DOI: 10.1111/jon.12134] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 02/06/2014] [Accepted: 03/31/2014] [Indexed: 11/25/2022] Open
Affiliation(s)
- Ferghal McVerry
- Institute of Neuroscience and Psychology; University of Glasgow; Glasgow United Kingdom
| | - Krishna Ashok Dani
- Institute of Neuroscience and Psychology; University of Glasgow; Glasgow United Kingdom
| | - Niall J.J. MacDougall
- Institute of Neuroscience and Psychology; University of Glasgow; Glasgow United Kingdom
| | - Mary Joan MacLeod
- Department of Medicine and Therapeutics; University of Aberdeen; United Kingdom
| | - Joanna Wardlaw
- Division of Clinical Neurosciences; Western General Hospital; Edinburgh United Kingdom
| | - Keith W Muir
- Institute of Neuroscience and Psychology; University of Glasgow; Glasgow United Kingdom
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Pallesen LP, Gerber J, Dzialowski I, van der Hoeven EJRJ, Michel P, Pfefferkorn T, Ozdoba C, Kappelle LJ, Wiedemann B, Khomenko A, Algra A, Hill MD, von Kummer R, Demchuk AM, Schonewille WJ, Puetz V. Diagnostic and Prognostic Impact of pc-ASPECTS Applied to Perfusion CT in the Basilar Artery International Cooperation Study. J Neuroimaging 2014; 25:384-9. [PMID: 24942473 DOI: 10.1111/jon.12130] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Revised: 02/20/2014] [Accepted: 03/31/2014] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE The posterior circulation Acute Stroke Prognosis Early CT Score (pc-APECTS) applied to CT angiography source images (CTA-SI) predicts the functional outcome of patients in the Basilar Artery International Cooperation Study (BASICS). We assessed the diagnostic and prognostic impact of pc-ASPECTS applied to perfusion CT (CTP) in the BASICS registry population. METHODS We applied pc-ASPECTS to CTA-SI and cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT) parameter maps of BASICS patients with CTA and CTP studies performed. Hypoattenuation on CTA-SI, relative reduction in CBV or CBF, or relative increase in MTT were rated as abnormal. RESULTS CTA and CTP were available in 27/592 BASICS patients (4.6%). The proportion of patients with any perfusion abnormality was highest for MTT (93%; 95% confidence interval [CI], 76%-99%), compared with 78% (58%-91%) for CTA-SI and CBF, and 46% (27%-67%) for CBV (P < .001). All 3 patients with a CBV pc-ASPECTS < 8 compared to 6/23 patients with a CBV pc-ASPECTS ≥ 8 had died at 1 month (RR 3.8; 95% CI, 1.9-7.6). CONCLUSION CTP was performed in a minority of the BASICS registry population. Perfusion disturbances in the posterior circulation were most pronounced on MTT parameter maps. CBV pc-ASPECTS < 8 may indicate patients with high case fatality.
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Affiliation(s)
- Lars-Peder Pallesen
- Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany
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Wu TC, Sitton C, Potter A, Bowry R, Sahota P, Cai C, Hui P, Chen Z, Gonzales N, Barreto A, Lopez G, Grotta JC, Savitz SI. CTP infarct core may predict poor outcome in stroke patients treated with IV t-PA. J Neurol Sci 2014; 340:165-9. [PMID: 24694764 DOI: 10.1016/j.jns.2014.03.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 03/03/2014] [Accepted: 03/12/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Computerized tomography perfusion (CTP) has been widely studied in assessing physiological brain tissue parameters in patients with acute ischemic stroke (AIS). The utility of CTP to predict clinical outcome in patients with AIS treated with intravenous tissue plasminogen activator (IV t-PA) is controversial. We reviewed CTP data in AIS patients treated with IV t-PA to uncover potential predictors of clinical outcome. METHODS We retrospectively identified AIS patients from our stroke registry (7/07 to 2/10) who underwent CTP on arrival and then received IV t-PA. A neuroradiologist blinded to outcome performed all CTP parameter measurements on a commercially available Siemens Neuro PCT workstation. Tissue at risk (TAR) was defined as the area of infarct territory with a relative time to peak (rTTP) greater than 4s. Non-viable tissue (NVT) was defined as the area of infarct territory with absolute cerebral blood volume (CBV) less than 2 ml/100g and cerebral blood flow (CBF) less than 12.7 ml/100g/min. Penumbra was defined as the area of (TAR) minus the area of (NVT). Excellent clinical outcome was defined as mRS (0-1), good clinical outcome was defined as mRS (0-2), and poor clinical outcome was defined as mRS (4-6), all measured at hospital discharge and 90 days if available. Recanalization data was obtained when available by comparing pre-thrombolytic CTA data and post-treatment MRA/CTA images by a single blinded radiologist. RESULTS We identified 61 patients that met our inclusion criteria with a mean age of 68 (29-94), median NIHSS on admission of 13 (1-40), and median discharge mRS of 4 (0-6). Using multivariate logistic regression and ordinal logistic regression controlling for age and admission NIHSS, none of the CTP parameters were statistically associated with excellent or good clinical outcome (mRS<2). Using multivariate analysis controlling for age and admission NIHSS, NVT area>30 cm(2) (OR=5.12, CI: 0.95-27, p=0.05) was statistically associated with poor clinical outcome at discharge. NVT area ≥ 30 cm(2) was a potential predictor of poor outcome at discharge even when controlling for age and NIHSS. CONCLUSION CTP parameters derived from commercially available software and published thresholds yield little predictive value for good clinical outcomes for AIS patients treated with IV t-PA but may be useful in predicting poor clinical outcome especially if the area of non-viable tissue is greater than 30 cm(2).
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Affiliation(s)
- Tzu-Ching Wu
- Department of Neurology, University of Texas-Houston Medical School, Houston, TX, USA.
| | - Clark Sitton
- Department of Neurology, University of Texas-Houston Medical School, Houston, TX, USA
| | - Andrew Potter
- Department of Neurology, University of Texas-Houston Medical School, Houston, TX, USA
| | - Ritvij Bowry
- Department of Neurology, University of Texas-Houston Medical School, Houston, TX, USA
| | - Preeti Sahota
- Department of Neurology, University of Texas-Houston Medical School, Houston, TX, USA
| | - Chunyan Cai
- Department of Neurology, University of Texas-Houston Medical School, Houston, TX, USA
| | - Peng Hui
- Department of Neurology, University of Texas-Houston Medical School, Houston, TX, USA
| | - Zhongxue Chen
- Department of Neurology, University of Texas-Houston Medical School, Houston, TX, USA
| | - Nicole Gonzales
- Department of Neurology, University of Texas-Houston Medical School, Houston, TX, USA
| | - Andrew Barreto
- Department of Neurology, University of Texas-Houston Medical School, Houston, TX, USA
| | - George Lopez
- Department of Neurology, University of Texas-Houston Medical School, Houston, TX, USA
| | - James C Grotta
- Department of Neurology, University of Texas-Houston Medical School, Houston, TX, USA
| | - Sean I Savitz
- Department of Neurology, University of Texas-Houston Medical School, Houston, TX, USA
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Lin L, Bivard A, Parsons MW. Perfusion patterns of ischemic stroke on computed tomography perfusion. J Stroke 2013; 15:164-73. [PMID: 24396810 PMCID: PMC3859000 DOI: 10.5853/jos.2013.15.3.164] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 08/19/2013] [Accepted: 08/19/2013] [Indexed: 11/11/2022] Open
Abstract
CT perfusion (CTP) has been applied increasingly in research of ischemic stroke. However, in clinical practice, it is still a relatively new technology. For neurologists and radiologists, the challenge is to interpret CTP results properly in the context of the clinical presentation. In this article, we will illustrate common CTP patterns in acute ischemic stroke using a case-based approach. The aim is to get clinicians more familiar with the information provided by CTP with a view towards inspiring them to incorporate CTP in their routine imaging workup of acute stroke patients.
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Affiliation(s)
- Longting Lin
- Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, the University of Newcastle, Newcastle, Australia
| | - Andrew Bivard
- Department of Neurology and Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Mark W Parsons
- Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, the University of Newcastle, Newcastle, Australia
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Bendinelli C, Bivard A, Nebauer S, Parsons MW, Balogh ZJ. Brain CT perfusion provides additional useful information in severe traumatic brain injury. Injury 2013; 44:1208-12. [PMID: 23642628 DOI: 10.1016/j.injury.2013.03.039] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 03/10/2013] [Accepted: 03/29/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND The role of brain CT perfusion (CTP) imaging in severe traumatic brain injury (STBI) is unclear. We hypothesised that in STBI early CTP may provide additional information beyond the non contrast CT (NCCT). METHODS Subset analysis of an ongoing prospective observational study on trauma patients with STBI who did not require craniectomy and deteriorated or failed to improve neurologically during the first 48h from trauma. Subsequently to follow-up NCCT, a CTP was obtained. Additional findings were defined as an area of altered perfusion on CTP larger than the abnormal area detected by the simultaneous NCCT. Patients who had additional finding (A-CTP) were compared with patients who did not have additional findings (NA-CTP). RESULTS Study population was 30 patients [male: 90%, mean age: 38.6 (SD 16.9), blunt trauma: 100%; prehospital intubation: 6 (20%); lowest GCS before intubation: 5.1 (SD 2.0); mean ISS: 30.5 (SD 8.3); mean head and neck AIS: 4.4 (SD 0.8). Days in ICU: 10.2 (SD 6.3). Intracranial pressure (ICP) monitored in 12 (40%). Mean highest ICP in mmHg: 30.1 (SD14.1). There were five (17%) deaths. Findings of NCCT: primarily diffuse axonal injury (DAI) pattern in seven (23%), primarily haematoma in ten (33%), and primarily intracerebral contusion in nine (30%). CTP was performed 24.9 (SD 13) hours from trauma. There were 18 (60%) patients in the A-CTP group and 12 (40.0%) in NA-CTP. The A-CTP group was older (41.7 (SD16.9) vs 27.7 (SD 12.8): P<0.02) and showed on admission NCCT presence of cerebral contusion and absence of DAI. The degree of hypoperfusion was found to be severe enough to be in the ischaemic range in eight patients (27%). CTP altered clinical management in three patients (10%), who were diagnosed with massive and unsurvivable strokes despite minimal changes on NCCT. CONCLUSION When compared to NCCT, CTP provided additional diagnostic information in 60% of patients with STBI. CTP altered clinical management in 10% of patients.
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Li JJ, Chen XY, Soo Y, Abrigo JM, Leung TW, Wong E, Mok V, Cheung JSW, Ahuja AT, Zeng JS, Wong KS. Persistent benign oligemia causes CT perfusion mismatch in patients with intracranial large artery occlusive disease during subacute stroke. CNS Neurosci Ther 2013; 19:635-7. [PMID: 23876019 DOI: 10.1111/cns.12133] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 04/21/2013] [Accepted: 04/22/2013] [Indexed: 10/26/2022] Open
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Wang XC, Gao PY, Xue J, Liu GR, Ma L, Wang C, Sui BB, Wang CJ, Liao XL, Wang YJ. Computed tomography perfusion source images assessment of infarct core and penumbra in acute stroke. Neurol Res 2013; 31:351-4. [DOI: 10.1179/174313209x444080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Wang XC, Gao PY, Lin Y, Ma L, Guan-ruiLiu, Xue J, Sui BB, Wang CJ, Wang YJ. Clinical value of computed tomography perfusion source images in acute stroke. Neurol Res 2013; 31:1079-83. [DOI: 10.1179/174313209x389820] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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46
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Bivard A, Levi C, Spratt N, Parsons M. Perfusion CT in Acute Stroke: A Comprehensive Analysis of Infarct and Penumbra. Radiology 2013; 267:543-50. [DOI: 10.1148/radiol.12120971] [Citation(s) in RCA: 191] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Mousa AE, Elrakhawy MM, Zaher AA. Multimodal CT assessment of acute ischemic stroke. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2013. [DOI: 10.1016/j.ejrnm.2012.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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O'Brien B, Parsons MW, Anderson CS. Sudden limb weakness. Med J Aust 2012; 196:572-7. [DOI: 10.5694/mja12.10441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Bill O'Brien
- Department of Neurology, John Hunter Hospital, Newcastle, NSW
| | - Mark W Parsons
- Department of Neurology, John Hunter Hospital, Newcastle, NSW
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Zhao L, Barlinn K, Bag AK, Kesani M, Cava LF, Balucani C, Alexandrov AW, Horton JA, Patterson DE, Harrigan MR, Albright KC, Alexandrov AV. Computed Tomography Perfusion Prognostic Maps Do Not Predict Reversible and Irreversible Neurological Dysfunction following Reperfusion Therapies. Int J Stroke 2011; 6:544-6. [DOI: 10.1111/j.1747-4949.2011.00681.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background We aimed to evaluate the ability of commercially available computed tomography perfusion (CTP) prognostic maps software to identify reversibly and irreversibly damaged brain functions in the best case scenario: patients who achieved early and complete tissue reperfusion. Methods Consecutive ischemic stroke patients who received reperfusion therapies, those with early (less than two-hours from treatment initiation) and complete Thrombolysis in Myocardial Infarction grade III or equivalent reperfusion were included in the analysis. Computed tomography perfusion prognostic maps were assigned as ‘red,’ or irreversible if cerebral blood volume declined below 2 ml/100 g and ‘green,’ or recoverable if the affected/unaffected mean transit time ratio was >1·45. Only patients with middle cerebral artery territory affected were included and subcomponents of the National Institutes of Health Stroke Scale scale pre- and posttreatment were analyzed based on anatomical correlation of the affected CTP areas and corresponding neurological functions. Results Among 109 consecutive patients who had intra-arterial reperfusion procedures, 16 (age 60±17 years, 56% men, median National Institutes of Health Stroke Scale 13·5, interquartile range 7–18) had pretreatment CTP and had early complete reperfusion. We identified 44 affected areas on CTP (red 12 (27%), green 32 (73%)) with corresponding measurable neurological deficits including aphasia, arm, face weakness, and inattention. Red areas correctly identified 5/12 (42%) of functions that did not recover despite early reperfusion. Green areas correctly identified 18/32 (56%) of functions that recover after early reperfusion (OR 0·92, 95% CI 0·25–3·39, P=1·0). Conclusions In-patients achieving early and complete reperfusion, pretreatment CTP prognostic maps were not predictive for irreversibly or reversibly lost neurologic functions.
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Affiliation(s)
- Limin Zhao
- Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, AL, USA
| | - Kristian Barlinn
- Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, AL, USA
- Dresden University Stroke Center, Department of Neurology, University of Technology Dresden, Dresden, Germany
| | - Asim K. Bag
- Radiology Department, University of Alabama Hospital, Birmingham, AL, USA
| | - Maruthi Kesani
- Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, AL, USA
| | - Luis F. Cava
- Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, AL, USA
| | - Clotilde Balucani
- Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, AL, USA
| | - Anne W. Alexandrov
- Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, AL, USA
| | - Joseph A. Horton
- Radiology Department, University of Alabama Hospital, Birmingham, AL, USA
| | - Damon E. Patterson
- Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, AL, USA
| | - Mark R. Harrigan
- Division of Neurosurgery, University of Alabama Hospital, Birmingham, AL, USA
| | - Karen C. Albright
- Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, AL, USA
| | - Andrei V. Alexandrov
- Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, AL, USA
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Bivard A, Spratt N, Levi C, Parsons M. Perfusion computer tomography: imaging and clinical validation in acute ischaemic stroke. Brain 2011; 134:3408-16. [DOI: 10.1093/brain/awr257] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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