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Faizy TD, Mlynash M, Kabiri R, Christensen S, Kuraitis GM, Mader MM, Flottmann F, Broocks G, Lansberg MG, Albers GW, Marks MP, Fiehler J, Wintermark M, Heit JJ. The Cerebral Collateral Cascade: Comprehensive Blood Flow in Ischemic Stroke. Neurology 2022; 98:e2296-e2306. [PMID: 35483902 DOI: 10.1212/wnl.0000000000200340] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 02/21/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Robust cerebral collaterals are associated with favorable outcomes in patients with acute ischemic stroke due to large vessel occlusion treated by thrombectomy. However, collateral status assessment mostly relies on single imaging biomarkers and a more comprehensive holistic approach may provide deeper insights into the biology of collateral perfusion on medical imaging. Comprehensive collateralization is defined as blood flow of cerebral arteries through the brain tissue and into draining veins. We hypothesized that a comprehensive analysis of the cerebral collateral cascade (CCC) on an arterial, tissue, and venous level would predict clinical and radiologic outcomes. METHODS This was a multicenter retrospective cohort study of patients with acute stroke undergoing thrombectomy triage. CCC was determined by quantifying pial arterial collaterals, tissue-level collaterals, and venous outflow (VO). Pial arterial collaterals were determined by CT angiography; tissue-level collaterals were assessed on CT perfusion. VO was assessed on CT angiography using the cortical vein opacification score. Three groups were defined: CCC+ (good pial collaterals, tissue-level collaterals, and VO), CCC- (poor pial collaterals, tissue-level collaterals, and VO), and CCCmixed (the remainder of the patients). Primary outcome was functional independence (modified Rankin Scale score 0-2) at 90 days. Secondary outcome was final infarct volume. RESULTS A total of 647 patients met inclusion criteria: 176 CCC+, 345 CCCmixed, and 126 CCC-. Multivariable ordinal logistic regression showed that CCC+ predicted good functional outcomes (odds ratio [OR] 18.9 [95% CI 8-44.5]; p < 0.001) compared with CCC- and CCCmixed. CCCmixed patients likely had better functional outcomes compared with CCC- patients (OR 2.5 [95% CI 1.2-5.4]; p = 0.014). Quantile regression analysis (50th percentile) showed that CCC+ (β -78.5, 95% CI -96.0 to -61.1; p < 0.001) and CCCmixed (β -64.0, 95% CI -82.4 to -45.6; p < 0.001) profiles were associated with considerably lower final infarct volumes compared with CCC- profiles. DISCUSSION Comprehensive assessment of the collateral blood flow cascade in patients with acute stroke is a strong predictor of clinical and radiologic outcomes in patients treated by thrombectomy.
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Affiliation(s)
- Tobias Djamsched Faizy
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Michael Mlynash
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Reza Kabiri
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Soren Christensen
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Gabriella Marie Kuraitis
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Marius M Mader
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Fabian Flottmann
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Gabriel Broocks
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Maarten G Lansberg
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Gregory W Albers
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Michael P Marks
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Jens Fiehler
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Max Wintermark
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Jeremy J Heit
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany.
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Faizy TD, Kabiri R, Christensen S, Mlynash M, Kuraitis G, Mader MMD, Albers GW, Lansberg MG, Fiehler J, Wintermark M, Marks MP, Heit JJ. Association of Venous Outflow Profiles and Successful Vessel Reperfusion After Thrombectomy. Neurology 2021; 96:e2903-e2911. [PMID: 33952649 PMCID: PMC8253568 DOI: 10.1212/wnl.0000000000012106] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 03/17/2021] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Robust arterial collaterals are associated with successful reperfusion after thrombectomy treatment of acute ischemic stroke due to large vessel occlusion (AIS-LVO). Excellent venous outflow (VO) reflects excellent tissue perfusion and collateral status in patients with AIS-LVO. The goal of this study was to determine whether favorable VO profiles assessed on pretreatment CT angiography (CTA) images correlate with successful vessel reperfusion after thrombectomy in patients with AIS-LVO. METHODS This was a multicenter retrospective cohort study of consecutive patients with AIS-LVO treated by thrombectomy. Baseline CTA was used to assess collateral status (Tan scale) and VO using the Cortical Vein Opacification Score (COVES). Favorable VO was defined as COVES ≥3. Primary outcome was excellent vessel reperfusion status (modified Thrombolysis in Cerebral Infarction 2c/3). Secondary outcome was good functional outcome defined as a score of 0 to 2 on the modified Rankin Scale after 90 days. RESULTS Five hundred sixty-five patients met the inclusion criteria. Multivariable logistic regression analysis showed that favorable VO (odds ratio [OR] 2.10 [95% confidence interval (CI) 1.39-3.16]; p < 0.001) was associated with excellent vessel reperfusion during thrombectomy, regardless of good CTA collateral status (OR 0.87 [95% CI 0.58-1.34]; p = 0.48). A favorable VO profile (OR 8.9 [95%CI 5.3-14.9]; p < 0.001) and excellent vessel reperfusion status (OR 2.7 [95%CI 1.7-4.4]; p < 0.001) were independently associated with good functional outcome adjusted for age, sex, glucose, tissue plasminogen activator administration, good CTA collateral status, and presentation NIH Stroke Scale score. CONCLUSION A favorable VO profile is associated with reperfusion success and good functional outcomes in patients with AIS-LVO treated by endovascular thrombectomy. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that a favorable VO profile is associated with reperfusion success and good functional outcomes in patients with AIS-LVO treated by endovascular thrombectomy.
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Affiliation(s)
- Tobias Djamsched Faizy
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Reza Kabiri
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Soren Christensen
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Mlynash
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriella Kuraitis
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marius Marc-Daniel Mader
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gregory W Albers
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maarten G Lansberg
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Max Wintermark
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael P Marks
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Liebeskind DS, Hinman JD, Kaneko N, Kitajima H, Honda T, De Havenon AH, Feldmann E, Nogueira RG, Prabhakaran S, Romano JG, Callas PW, Schneider DJ. Endothelial Shear Stress and Platelet FcγRIIa Expression in Intracranial Atherosclerotic Disease. Front Neurol 2021; 12:646309. [PMID: 33716947 PMCID: PMC7947292 DOI: 10.3389/fneur.2021.646309] [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: 12/26/2020] [Accepted: 02/05/2021] [Indexed: 11/13/2022] Open
Abstract
Intracranial atherosclerotic disease (ICAD) has been characterized by the degree of arterial stenosis and downstream hypoperfusion, yet microscopic derangements of endothelial shear stress at the luminal wall may be key determinants of plaque growth, vascular remodeling and thrombosis that culminate in recurrent stroke. Platelet interactions have similarly been a principal focus of treatment, however, the mechanistic basis of anti-platelet strategies is largely extrapolated rather than directly investigated in ICAD. Platelet FcγRIIa expression has been identified as a potent risk factor in cardiovascular disease, as elevated expression markedly increases the risk of recurrent events. Differential activation of the platelet FcγRIIa receptor may also explain the variable response of individual patients to anti-platelet medications. We review existing data on endothelial shear stress and potential interactions with the platelet FcγRIIa receptor that may alter the evolving impact of ICAD, based on local pathophysiology at the site of arterial stenosis. Current methods for quantification of endothelial shear stress and platelet activation are described, including tools that may be readily adapted to the clinical realm for further understanding of ICAD.
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Affiliation(s)
- David S Liebeskind
- Department of Neurology, Neurovascular Imaging Research Core and UCLA Stroke Center, University of California, Los Angeles, Los Angeles, CA, United States
| | - Jason D Hinman
- Department of Neurology, Neurovascular Imaging Research Core and UCLA Stroke Center, University of California, Los Angeles, Los Angeles, CA, United States
| | - Naoki Kaneko
- Department of Neurology, Neurovascular Imaging Research Core and UCLA Stroke Center, University of California, Los Angeles, Los Angeles, CA, United States
| | - Hiroaki Kitajima
- Department of Neurology, Neurovascular Imaging Research Core and UCLA Stroke Center, University of California, Los Angeles, Los Angeles, CA, United States
| | - Tristan Honda
- Department of Neurology, Neurovascular Imaging Research Core and UCLA Stroke Center, University of California, Los Angeles, Los Angeles, CA, United States
| | - Adam H De Havenon
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
| | - Edward Feldmann
- Department of Neurology, The University of Massachusetts Medical School-Baystate, Springfield, MA, United States
| | - Raul G Nogueira
- Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine, Atlanta, GA, United States
| | - Shyam Prabhakaran
- Department of Neurology, The University of Chicago, Chicago, IL, United States
| | - Jose G Romano
- Department of Neurology, University of Miami, Miami, FL, United States
| | - Peter W Callas
- Department of Biostatistics, University of Vermont, Burlington, VT, United States
| | - David J Schneider
- Department of Medicine, Cardiovascular Research Institute, University of Vermont, Burlington, VT, United States
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Liebeskind DS. Precision Medicine for Intracranial Atherosclerotic Disease. Front Neurol 2021; 12:646734. [PMID: 33679595 PMCID: PMC7928351 DOI: 10.3389/fneur.2021.646734] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 01/21/2021] [Indexed: 11/13/2022] Open
Abstract
Diagnostic and therapeutic strategies for intracranial atherosclerotic disease (ICAD) have vastly expanded within the last several years. Challenges and concrete initiatives have emerged in the implementation of precision medicine for ICAD, focusing personalized treatment for the prevention of stroke and cognitive impairment around pathophysiology. Theranostics for ICAD incorporates an integrated diagnostic and therapeutic approach tailored to a specific individual. The ICAS 2019 meeting provided a roadmap for accelerating global innovation, underscoring the epidemiology, prior scientific evidence from trials, diagnostic tools or imaging, novel biomarkers, management approaches, and a broad range of treatments including many new medications, endovascular, and surgical strategies. This thematic overview provides perspective on current definitions for arterial stenosis, symptomatic lesions and outcomes or endpoints in clinical trials. Imaging correlates are reviewed, from routine multimodal CT or MRI to advanced angiographic techniques. The temporal features of ICAD and longitudinal observation are considered with respect to management and risk factor modification. The evolving science of multivariable interactions in ICAD and use of big data are explored, followed by an overview of recently launched clinical trials.
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Affiliation(s)
- David S Liebeskind
- Department of Neurology, Neurovascular Imaging Research Core & UCLA Stroke Center, University of California, Los Angeles, Los Angeles, CA, United States
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Liebeskind DS. Mapping the collaterome for precision cerebrovascular health: Theranostics in the continuum of stroke and dementia. J Cereb Blood Flow Metab 2018; 38:1449-1460. [PMID: 28555527 PMCID: PMC6125977 DOI: 10.1177/0271678x17711625] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 04/04/2017] [Accepted: 04/29/2017] [Indexed: 01/10/2023]
Abstract
Precision cerebrovascular health or individualized long-term preservation of the brain and associated blood vessels, is predicated on understanding, diagnosing, and tailoring therapies for people at risk of ischemic injury associated with stroke and vascular dementia. The associated imaging patterns are sculpted by the protective effect of the collaterome, the innate compensatory ability of the brain and vasculature to offset hypoperfusion when antegrade or normal arterial inflow pathways are compromised. Theranostics or rational and synchronous use of diagnostic studies in tandem with specific therapies to optimally guide patient outcomes in ischemic brain disorders may capitalize on the pivotal role of the collaterome. Understanding the functional impact of the collaterome across populations of individuals would advance translational science on the brain, while questions with immediate clinical implications may be prioritized. Big data and systematic analyses are necessary to develop normative standards, multimodal imaging atlases, and delineation of specific patterns to guide clinical management. Large-scale, systematic imaging analyses of the collaterome provide a platform for translational work on cerebral collateral circulation and hemodynamics and a theranostic framework with direct clinical implications. This article frames incipient research objectives to guide precision stroke medicine in coming years, building upon the collaterome concept in brain health.
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Affiliation(s)
- David S Liebeskind
- Neurovascular Imaging Research Core and UCLA Stroke Center, Los Angeles, CA, USA
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Tong LS, Guo ZN, Ou YB, Yu YN, Zhang XC, Tang J, Zhang JH, Lou M. Cerebral venous collaterals: A new fort for fighting ischemic stroke? Prog Neurobiol 2017; 163-164:172-193. [PMID: 29199136 DOI: 10.1016/j.pneurobio.2017.11.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 09/03/2017] [Accepted: 11/28/2017] [Indexed: 12/13/2022]
Abstract
Stroke therapy has entered a new era highlighted by the use of endovascular therapy in addition to intravenous thrombolysis. However, the efficacy of current therapeutic regimens might be reduced by their associated adverse events. For example, over-reperfusion and futile recanalization may lead to large infarct, brain swelling, hemorrhagic complication and neurological deterioration. The traditional pathophysiological understanding on ischemic stroke can hardly address these occurrences. Accumulating evidence suggests that a functional cerebral venous drainage, the major blood reservoir and drainage system in brain, may be as critical as arterial infusion for stroke evolution and clinical sequelae. Further exploration of the multi-faceted function of cerebral venous system may add new implications for stroke outcome prediction and future therapeutic decision-making. In this review, we emphasize the anatomical and functional characteristics of the cerebral venous system and illustrate its necessity in facilitating the arterial infusion and maintaining the cerebral perfusion in the pathological stroke content. We then summarize the recent critical clinical studies that underscore the associations between cerebral venous collateral and outcome of ischemic stroke with advanced imaging techniques. A novel three-level venous system classification is proposed to demonstrate the distinct characteristics of venous collaterals in the setting of ischemic stroke. Finally, we discuss the current directions for assessment of cerebral venous collaterals and provide future challenges and opportunities for therapeutic strategies in the light of these new concepts.
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Affiliation(s)
- Lu-Sha Tong
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China; Departments of Physiology, Loma Linda University, School of Medicine, CA, USA
| | - Zhen-Ni Guo
- Department of Neurology, The First Affiliated Hospital of Jilin University, Changchun, China; Departments of Physiology, Loma Linda University, School of Medicine, CA, USA
| | - Yi-Bo Ou
- Department of Neurosurgery, Tong-ji Hospital, Wuhan, China; Departments of Physiology, Loma Linda University, School of Medicine, CA, USA
| | - Yan-Nan Yu
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Xiao-Cheng Zhang
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Jiping Tang
- Department of Anesthesiology, Loma Linda University, School of Medicine, CA, USA
| | - John H Zhang
- Departments of Physiology, Loma Linda University, School of Medicine, CA, USA.
| | - Min Lou
- Department of Neurology, The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China.
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Liebeskind DS, Woolf GW, Shuaib A. Collaterals 2016: Translating the collaterome around the globe. Int J Stroke 2017; 12:338-342. [PMID: 28345431 DOI: 10.1177/1747493017701942] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Collaterals 2016 (third International Symposium on Collaterals to the Brain) was a multidisciplinary scientific conference focused on collateral circulation in acute ischemic stroke. Decisive challenges include generalizability of optimal triage and selection paradigms based on collateral status for definitive treatment of acute ischemic stroke, rapid dissemination of expert methods, and the urgent need to leverage networking opportunities for stroke science related to the hemodynamics of collaterals. The collaterome, or individual capacity to offset ischemia in the brain, and determination of a favorable collateral profile have become pivotal factors in consideration of the precision medicine of stroke decision-making. The conference convened over 50 invited faculty from around the world to connect on-site participants at a state-of-the-art facility with remote audiences in more than 22 countries and regions. The 2½-day program was structured into 40-min sessions devoted to key issues in translating the collaterome in acute stroke therapy across the globe. This unique forum of expertise emphasized the timely impact of collaterals on a monumental scale, encouraging maximal participation, rapid diffusion and added value of a diverse networking resource. The meeting format established a model geographical framework and innovative videoconferencing platform for future scientific conferences.
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Affiliation(s)
- David S Liebeskind
- 1 Neurovascular Imaging Research Core and UCLA Stroke Center, University of California, Los Angeles, CA, USA
| | - Graham W Woolf
- 1 Neurovascular Imaging Research Core and UCLA Stroke Center, University of California, Los Angeles, CA, USA
| | - Ashfaq Shuaib
- 2 Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
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Hinman JD, Rost NS, Leung TW, Montaner J, Muir KW, Brown S, Arenillas JF, Feldmann E, Liebeskind DS. Principles of precision medicine in stroke. J Neurol Neurosurg Psychiatry 2017; 88:54-61. [PMID: 27919057 DOI: 10.1136/jnnp-2016-314587] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 09/30/2016] [Accepted: 10/03/2016] [Indexed: 01/22/2023]
Abstract
The era of precision medicine has arrived and conveys tremendous potential, particularly for stroke neurology. The diagnosis of stroke, its underlying aetiology, theranostic strategies, recurrence risk and path to recovery are populated by a series of highly individualised questions. Moreover, the phenotypic complexity of a clinical diagnosis of stroke makes a simple genetic risk assessment only partially informative on an individual basis. The guiding principles of precision medicine in stroke underscore the need to identify, value, organise and analyse the multitude of variables obtained from each individual to generate a precise approach to optimise cerebrovascular health. Existing data may be leveraged with novel technologies, informatics and practical clinical paradigms to apply these principles in stroke and realise the promise of precision medicine. Importantly, precision medicine in stroke will only be realised once efforts to collect, value and synthesise the wealth of data collected in clinical trials and routine care starts. Stroke theranostics, the ultimate vision of synchronising tailored therapeutic strategies based on specific diagnostic data, demand cerebrovascular expertise on big data approaches to clinically relevant paradigms. This review considers such challenges and delineates the principles on a roadmap for rational application of precision medicine to stroke and cerebrovascular health.
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Affiliation(s)
- Jason D Hinman
- Department of Neurology, Neurovascular Imaging Research Core and the UCLA Stroke Center, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Natalia S Rost
- Department of Neurology, Philip Kistler Stroke Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas W Leung
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Research Institute (VHIR), Barcelona & IBIS Stroke Programme, Hospital Virgen Macarena-Rocio, Sevilla, Spain
| | - Keith W Muir
- Institute of Neuroscience & Psychology, Glasgow, UK
| | - Scott Brown
- Altair Biostatistics, St. Louis Park, Minnesota, USA
| | - Juan F Arenillas
- Stroke Unit, Department of Neurology and Medicine, Hospital Clínico Universitario, Universidad de Valladolid, Valladolid, Spain
| | | | - David S Liebeskind
- Department of Neurology, Neurovascular Imaging Research Core and the UCLA Stroke Center, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
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Liebeskind DS. Crowdsourcing Precision Cerebrovascular Health: Imaging and Cloud Seeding A Million Brains Initiative™. Front Med (Lausanne) 2016; 3:62. [PMID: 27921034 PMCID: PMC5118427 DOI: 10.3389/fmed.2016.00062] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 11/10/2016] [Indexed: 11/13/2022] Open
Abstract
Crowdsourcing, an unorthodox approach in medicine, creates an unusual paradigm to study precision cerebrovascular health, eliminating the relative isolation and non-standardized nature of current imaging data infrastructure, while shifting emphasis to the astounding capacity of big data in the cloud. This perspective envisions the use of imaging data of the brain and vessels to orient and seed A Million Brains Initiative™ that may leapfrog incremental advances in stroke and rapidly provide useful data to the sizable population around the globe prone to the devastating effects of stroke and vascular substrates of dementia. Despite such variability in the type of data available and other limitations, the data hierarchy logically starts with imaging and can be enriched with almost endless types and amounts of other clinical and biological data. Crowdsourcing allows an individual to contribute to aggregated data on a population, while preserving their right to specific information about their own brain health. The cloud now offers endless storage, computing prowess, and neuroimaging applications for postprocessing that is searchable and scalable. Collective expertise is a windfall of the crowd in the cloud and particularly valuable in an area such as cerebrovascular health. The rise of precision medicine, rapidly evolving technological capabilities of cloud computing and the global imperative to limit the public health impact of cerebrovascular disease converge in the imaging of A Million Brains Initiative™. Crowdsourcing secure data on brain health may provide ultimate generalizability, enable focused analyses, facilitate clinical practice, and accelerate research efforts.
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Affiliation(s)
- David S Liebeskind
- Department of Neurology, Neurovascular Imaging Research Core and UCLA Stroke Center, University of California Los Angeles , Los Angeles, CA , USA
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Liebeskind DS. Editorial commentary: Beyond the guidelines to expertise in precision stroke medicine. Trends Cardiovasc Med 2016; 27:67-68. [PMID: 27591800 DOI: 10.1016/j.tcm.2016.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 08/02/2016] [Indexed: 11/30/2022]
Affiliation(s)
- David S Liebeskind
- Neurovascular Imaging Research Core, University of California, Los Angeles, CA; Department of Neurology, Comprehensive Stroke Center, Geffen School of Medicine, University of California, Los Angeles, CA.
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12
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Tan L, Jiang T, Tan L, Yu JT. Toward precision medicine in neurological diseases. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:104. [PMID: 27127757 DOI: 10.21037/atm.2016.03.26] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Technological development has paved the way for accelerated genomic discovery and is bringing precision medicine into view. The goal of precision medicine is to deliver optimally targeted and timed interventions tailored to an individual's molecular drivers of disease. Neurological diseases are promisingly suited models for precision medicine because of the rapidly expanding genetic knowledge base, phenotypic classification, the development of biomarkers and the potential modifying treatments. Moving forward, it is crucial that through these integrated research platforms to provide analysis both for accurate personal genome analysis and gene and drug discovery. Here we describe our vision of how precision medicine can bring greater clarity to the clinical and biological complexity of neurological diseases.
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Affiliation(s)
- Lin Tan
- 1 College of Medicine and Pharmaceutics, Ocean University of China, Qingdao 266071, China ; 2 Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210029, China ; 3 Memory and Aging Center, Department of Neurology, University of California, San Francisco, CA, USA ; 4 Department of Neurology, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao 266071, China
| | - Teng Jiang
- 1 College of Medicine and Pharmaceutics, Ocean University of China, Qingdao 266071, China ; 2 Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210029, China ; 3 Memory and Aging Center, Department of Neurology, University of California, San Francisco, CA, USA ; 4 Department of Neurology, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao 266071, China
| | - Lan Tan
- 1 College of Medicine and Pharmaceutics, Ocean University of China, Qingdao 266071, China ; 2 Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210029, China ; 3 Memory and Aging Center, Department of Neurology, University of California, San Francisco, CA, USA ; 4 Department of Neurology, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao 266071, China
| | - Jin-Tai Yu
- 1 College of Medicine and Pharmaceutics, Ocean University of China, Qingdao 266071, China ; 2 Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210029, China ; 3 Memory and Aging Center, Department of Neurology, University of California, San Francisco, CA, USA ; 4 Department of Neurology, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao 266071, China
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Belle A, Thiagarajan R, Soroushmehr SMR, Navidi F, Beard DA, Najarian K. Big Data Analytics in Healthcare. BIOMED RESEARCH INTERNATIONAL 2015; 2015:370194. [PMID: 26229957 PMCID: PMC4503556 DOI: 10.1155/2015/370194] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 05/26/2015] [Accepted: 06/16/2015] [Indexed: 02/06/2023]
Abstract
The rapidly expanding field of big data analytics has started to play a pivotal role in the evolution of healthcare practices and research. It has provided tools to accumulate, manage, analyze, and assimilate large volumes of disparate, structured, and unstructured data produced by current healthcare systems. Big data analytics has been recently applied towards aiding the process of care delivery and disease exploration. However, the adoption rate and research development in this space is still hindered by some fundamental problems inherent within the big data paradigm. In this paper, we discuss some of these major challenges with a focus on three upcoming and promising areas of medical research: image, signal, and genomics based analytics. Recent research which targets utilization of large volumes of medical data while combining multimodal data from disparate sources is discussed. Potential areas of research within this field which have the ability to provide meaningful impact on healthcare delivery are also examined.
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Affiliation(s)
- Ashwin Belle
- Emergency Medicine Department, University of Michigan, Ann Arbor, MI 48109, USA
- University of Michigan Center for Integrative Research in Critical Care (MCIRCC), Ann Arbor, MI 48109, USA
| | - Raghuram Thiagarajan
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - S. M. Reza Soroushmehr
- Emergency Medicine Department, University of Michigan, Ann Arbor, MI 48109, USA
- University of Michigan Center for Integrative Research in Critical Care (MCIRCC), Ann Arbor, MI 48109, USA
| | - Fatemeh Navidi
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Daniel A. Beard
- University of Michigan Center for Integrative Research in Critical Care (MCIRCC), Ann Arbor, MI 48109, USA
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Kayvan Najarian
- Emergency Medicine Department, University of Michigan, Ann Arbor, MI 48109, USA
- University of Michigan Center for Integrative Research in Critical Care (MCIRCC), Ann Arbor, MI 48109, USA
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