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Miller MM, Wideman B, Khan M, Henninger N. Hypoperfusion Intensity Ratio Is Associated with Early Neurologic Deficit Severity and Deterioration after Mechanical Thrombectomy in Large-Vessel Occlusion Ischemic Stroke. AJNR Am J Neuroradiol 2024; 45:879-886. [PMID: 38816020 DOI: 10.3174/ajnr.a8234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/09/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND AND PURPOSE The hypoperfusion intensity ratio is a surrogate marker for collateral status and a predictor of infarct growth, malignant cerebral edema, and hemorrhagic transformation. Its utility to predict a poor NIHSS score and early neurologic deterioration after mechanical thrombectomy for large vessel (LVO) versus distal and medium vessel occlusions (DMVO) has not been investigated. The objective of this study was to determine whether the higher hypoperfusion intensity ratio is associated with a worse NIHSS score at 24 hours post-mechanical thrombectomy and early neurologic deterioration in LVO versus DMVO acute ischemic stroke. MATERIALS AND METHODS This was a retrospective study of 231 patients with acute ischemic stroke with LVO or DMVO amenable for mechanical thrombectomy and available CTP for hypoperfusion intensity ratio assessment pre-mechanical thrombectomy. Clinical and imaging characteristics were abstracted from the medical records. The primary outcome was the NIHSS score at 24 hours post-mechanical thrombectomy. The secondary outcome was early neurologic deterioration, defined as a >4-point increase in the NIHSS score between the initial assessment and 24 hours post-mechanical thrombectomy. All analyses were first conducted in the entire cohort and then separately for the LVO versus DMVO groups. RESULTS The optimal hypoperfusion intensity ratio threshold to detect early neurologic deterioration was 0.54. A hypoperfusion intensity ratio ≥ 0.54 was more frequently present in LVO versus DMVO (n = 37 [77.1%] versus n = 11 [22.9%]; P < .001). On multivariable linear regression, the hypoperfusion intensity ratio ≥ 0.54 was independently associated with a worse NIHSS score at 24 hours post-mechanical thrombectomy in the entire cohort (β = 0.163; P = .002) and the LVO group (β = 0.210; P = .005), but not in the DMVO group. The early neurologic deterioration occurred in 26 (11.3%) subjects. On multivariable logistic regression, there was no association of the hypoperfusion intensity ratio ≥ 0.54 with early neurologic deterioration in the entire cohort. However, when analyzed separately, a hypoperfusion intensity ratio ≥ 0.54 significantly increased the odds of early neurologic deterioration in subjects with LVO (OR = 5.263; 95% CI, 1.170-23.674; P = .030) but not in the DMVO group. CONCLUSIONS The hypoperfusion intensity ratio ≥ 0.54 was independently associated with a worse 24-hour post-mechanical thrombectomy NIHSS score and early neurologic deterioration in LVO, but not in DMVO acute ischemic stroke. Pending confirmation in future, prospective studies assessing the hypoperfusion intensity ratio may help identify patients at risk of secondary decline to improve peri-thrombectomy care and clinical decision-making.
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Affiliation(s)
- Małgorzata M Miller
- From the Department of Neurosciences (M.M.M., B.W.), Corewell Health West, Grand Rapids, Michigan
- College of Human Medicine (M.M.M.), Michigan State University, Grand Rapids, Michigan
| | - Brian Wideman
- From the Department of Neurosciences (M.M.M., B.W.), Corewell Health West, Grand Rapids, Michigan
| | - Muhib Khan
- Department of Neurology (M.K.), Mayo Clinic, Rochester, Minnesota
| | - Nils Henninger
- Department of Neurology (N.H.), University of Massachusetts, Chan Medical School Worcester, Massachusetts
- Department of Psychiatry (N.H.), University of Massachusetts, Chan Medical School Worcester, Massachusetts
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Faizy TD, Heit JJ. Cerebral Venous Outflow in Acute Ischemic Stroke Patients - Out Through the Middle! Acad Radiol 2024; 31:1558-1559. [PMID: 38519300 DOI: 10.1016/j.acra.2024.02.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 02/27/2024] [Indexed: 03/24/2024]
Affiliation(s)
- Tobias D Faizy
- Neuroendovascular Division, Department of Radiology, University Medical Center Münster, Münster, Germany.
| | - Jeremy J Heit
- Department of Radiology, Division of Neuroradiology, Stanford University, CA
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Heitkamp C, Winkelmeier L, Heit JJ, Albers GW, Lansberg MG, Kniep H, Broocks G, Stracke CP, Schell M, Guenego A, Paech D, Wintermark M, Fiehler J, Faizy TD. Early neurological deterioration in patients with acute ischemic stroke is linked to unfavorable cerebral venous outflow. Eur Stroke J 2024; 9:162-171. [PMID: 38069665 PMCID: PMC10916832 DOI: 10.1177/23969873231208277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/29/2023] [Indexed: 03/06/2024] Open
Abstract
INTRODUCTION Early neurological deterioration (END) is associated with poor outcomes in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). Causes of END after mechanical thrombectomy (MT) include unsuccessful recanalization and reperfusion hemorrhages. However, little is known about END excluding the aforementioned causes. We aimed to investigate factors associated with unexplained END (ENDunexplained) with regard to the cerebral collateral status. PATIENTS AND METHODS Multicenter retrospective study of AIS-LVO patients with successful MT (mTICI 2b-3). On admission CT angiography (CTA), pial arterial collaterals and venous outflow (VO) were assessed using the modified Tan-Scale and the Cortical Vein Opacification Score (COVES), respectively. ENDunexplained was defined as an increase in NIHSS score of ⩾ 4 within the first 24 hours after MT without parenchymal hemorrhage on follow-up imaging. Multivariable regression analyses were performed to examine factors of ENDunexplained and unfavorable functional outcome (modified Rankin Scale score 3-6). RESULTS A total of 620 patients met the inclusion criteria. ENDunexplained occurred in 10% of patients. While there was no significant difference in pial arterial collaterals, patients with ENDunexplained exhibited more often unfavorable VO (81% vs. 53%; P < 0.001). Unfavorable VO (aOR [95% CI]; 2.56 [1.02-6.40]; P = 0.045) was an independent predictor of ENDunexplained. ENDunexplained was independently associated with unfavorable functional outcomes at 90 days (aOR [95% CI]; 6.25 [2.06-18.94]; P = 0.001). DISCUSSION AND CONCLUSION Unfavorable VO on admission CTA was associated with ENDunexplained. ENDunexplained was independently linked to unfavorable functional outcomes at 90 days. Identifying AIS-LVO patients at risk of ENDunexplained may help to select patients for intensified monitoring and guide to optimal treatment regimes.
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Affiliation(s)
- Christian Heitkamp
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Gregory W Albers
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Maarten G Lansberg
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Helge Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Christian Paul Stracke
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
- Department of Neuroradiology, University Hospital Muenster, Muenster, Germany
| | - Maximilian Schell
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany
| | - Adrien Guenego
- Department of Neuroradiology, Erasme Medical Center, Brussels, Belgium
| | - Daniel Paech
- Clinic for Neuroradiology, University Hospital Bonn, Germany
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson, Houston, TX, USA
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
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Chen W, Wang X, Liu J, Wang M, Yang S, Yang L, Gong Z, Hu W. Association Between Hypoperfusion Intensity Ratio and Postthrombectomy Malignant Brain Edema for Acute Ischemic Stroke. Neurocrit Care 2024; 40:196-204. [PMID: 38148437 DOI: 10.1007/s12028-023-01900-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 11/22/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND Malignant brain edema (MBE) is a life-threatening complication that can occur after mechanical thrombectomy (MT) for acute ischemic stroke. The hypoperfusion intensity ratio (HIR) reflects the tissue-level perfusion status within the ischemic territory. This study investigated the association between HIR and MBE occurrence after MT in patients with anterior circulation large artery occlusion. METHODS We conducted a retrospective cohort study of patients who received MT at a comprehensive stroke center from February 2020 to June 2022. Using computed tomography perfusion, the HIR was derived from the ratio of tissue volume with a time to maximum (Tmax) > 10 s to that with a Tmax > 6 s. We dichotomized patients based on the occurrence of MBE following MT. The primary outcome, assessed using a multivariable logistic regression model, was the MBE occurrence post MT. The secondary outcome focused on favorable outcomes, defined as achieving a modified Rankin Scale score of 0-2 at 90 days. RESULTS Of the 603 included patients, 90 (14.9%) developed MBE after MT. The median HIR exhibited a significantly higher value in the MBE group compared with the non-MBE group (0.5 vs. 0.3; P < 0.001). Multivariable logistic regression analysis indicated that a higher HIR (adjusted odds ratio [aOR] 8.98; 95% confidence interval [CI] 2.85-28.25; P < 0.001), baseline large infarction (Alberta Stroke Program Early Computed Tomography Score < 6; aOR 1.77; 95% CI 1.04-3.01; P = 0.035), internal carotid artery occlusion (aOR 1.80; 95% CI 1.07-3.01; P = 0.028), and unsuccessful recanalization (aOR 8.45; 95% CI 4.75-15.03; P < 0.001) were independently associated with MBE post MT. Among those with successful recanalization, a higher HIR (P = 0.017) and baseline large infarction (P = 0.032) remained as predictors of MBE occurrence. Furthermore, a higher HIR (P = 0.001) and the occurrence of MBE (P < 0.001) both correlated with reduced odds of achieving favorable outcomes. CONCLUSIONS The presence of a higher HIR on pretreatment perfusion imaging serves as a robust predictor for MBE occurrence after MT, irrespective of successful recanalization.
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Affiliation(s)
- Wang Chen
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang, Beijing, 100020, China
| | - Xianjun Wang
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | - Ji Liu
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | - Mengen Wang
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | - Shuna Yang
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang, Beijing, 100020, China
| | - Lei Yang
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang, Beijing, 100020, China
| | - Zixiang Gong
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | - Wenli Hu
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang, Beijing, 100020, China.
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Zhang Y, Du J, Jin W, Yang J, Ding Z, He Y, Wan H, Yu L. Uncovering Mechanism and Efficacy of Salvia Miltiorrhiza-Safflower in Cerebral Ischemia-Reperfusion Injury. Neuroscience 2024; 537:1-11. [PMID: 38036060 DOI: 10.1016/j.neuroscience.2023.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 11/15/2023] [Accepted: 11/17/2023] [Indexed: 12/02/2023]
Abstract
Cerebral ischemia (CI) is the main cause of stroke morbidity and disability. This study aims to identify the early molecular regulation responsible for the therapeutic effectiveness of the Herb pair Danshen-Honghua (DH) for CI. The major targets of DH were identified by searching the public database of traditional Chinese medicine (TCM). In addition, GeneCards, Disgenet, and GeneMap databases in OMIM were used to determine the disease targets of CI. A total of 88 common targets of DH and CI were selected, a protein-protein interaction (PPI) network was established by Cytoscape, and 19 core targets were screened. These genes were primarily enriched in biological processes including wound healing, reaction to oxidative stress, and response to peptides, lipid and atherosclerosis, Age-rage signaling pathway, and TNF signaling pathway by KEGG and GO enrichments. The effective components of DH had stable binding to these key targets by molecular docking. Finally, it was verified that the mechanism of DH on CI treatment may be related to the activation of the TNF-α/JNK signaling pathway by establishing the middle cerebral artery occlusion (MCAO) rat model.
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Affiliation(s)
- Yangyang Zhang
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China; Key Laboratory of TCM Encephalopathy of Zhejiang Province, Hangzhou, Zhejiang, China.
| | - Jiayin Du
- The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
| | - Weifeng Jin
- Key Laboratory of TCM Encephalopathy of Zhejiang Province, Hangzhou, Zhejiang, China; School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
| | - Jiehong Yang
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China; Key Laboratory of TCM Encephalopathy of Zhejiang Province, Hangzhou, Zhejiang, China.
| | - Zhishan Ding
- School of Medical Technology and Information Engineering, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
| | - Yu He
- Key Laboratory of TCM Encephalopathy of Zhejiang Province, Hangzhou, Zhejiang, China; School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
| | - Haitong Wan
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China; Key Laboratory of TCM Encephalopathy of Zhejiang Province, Hangzhou, Zhejiang, China.
| | - Li Yu
- School of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China; Center of Safety Evaluation and Research, Hangzhou Medical College, Hangzhou, Zhejiang, China; Zhejiang Academy of Medical Sciences, Hangzhou, Zhejiang, China.
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Li X, Lin L, Zhang J, Fan Y, Xing S, Jiang L, Yang Z, Zhao J, Li J. Microvascular dysfunction associated with unfavorable venous outflow in acute ischemic stroke patients. J Cereb Blood Flow Metab 2023; 43:106-115. [PMID: 36967711 PMCID: PMC10638995 DOI: 10.1177/0271678x231165606] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 02/23/2023] [Accepted: 03/05/2023] [Indexed: 06/18/2023]
Abstract
Unfavorable venous outflow (VO) is associated with cerebral edema, which represents microvascular dysfunction. This study estimated the relationship between VO and microvascular function in acute ischemic stroke patients. We retrospectively included 102 MCA/ICA occluded patients with anterior circulation infarction who underwent reperfusion therapy between July 2017 and April 2022. Unfavorable VO was defined as a cortical vein opacification score of 0-3 and favorable VO as that of 4-6. The clinical characteristics, collateral status, microvascular integrity, and outcomes were compared between patients with favorable and unfavorable VO. Multivariate analysis and receiver operator characteristic (ROC) analysis were used. The patients with unfavorable VO had higher extravascular-extracellular volume fraction (Ve) in the infarct core and a lower percentage of robust arterial collateral circulation. ROC analysis revealed that Ve in the infarct core predicts unfavorable VO (AUC = 0.67, sensitivity = 65.08%, specificity = 69.23%). The higher Ve in the infarct core (odds ratio = 1.011, 95% CI = 1.000-1.021, P = 0.046) and poor arterial collateral flow (odds ratio = 0.102, 95% CI = 0.032-0.327, P < 0.001) were independent predictors of unfavorable VO. This suggests that microvascular dysfunction may be one of the mechanisms underlying impaired VO.
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Affiliation(s)
- Xiaoshuang Li
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Liping Lin
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jian Zhang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Yuhua Fan
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Shihui Xing
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
| | - Li Jiang
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Zhiyun Yang
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jing Zhao
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jingjing Li
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, National Key Clinical Department and Key Discipline of Neurology, Guangzhou, China
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Chen S, Su T, Wang Y, Li Z, Li Y, Ge Y, Mi D. Automatic cerebral computed tomography venographic imaging based on the prior knowledge of cerebral blood circulation. J Neuroradiol 2023; 50:556-561. [PMID: 36773846 DOI: 10.1016/j.neurad.2023.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND AND PURPOSE Current clinical computed tomography venographic (cCTV) images present limited cerebral venous profiles. Therefore, this study aimed to develop an automatic cerebral CTV imaging technique using computed tomographic perfusion (CTP) images in a cohort of patients with stroke. MATERIALS AND METHODS We retrospectively evaluated 10 (intracerebral hemorrhage) and 2 (acute ischemic stroke) patients who underwent institutional CTP imaging. CTV images were processed with the proposed CTV (pCTV) technique, and pCTV and cCTV images were then independently evaluated by two experienced neuroradiologists blinded to all clinical information using a novel scoring method that considered overall image quality, venous visibility, and arterial mis-segmentation. Venous visibility was separately evaluated for the dural sinus, superficial vein, and deep vein. Then, statistical analysis was performed to determine whether the pCTV technique was superior to the cCTV technique. RESULTS In total, 14 sets of pCTV images were generated and compared with cCTV images. The overall image quality and venous visibility scores of pCTV images were significantly higher than those of cCTV images (all values of p<0.05), especially for the dural sinus (median [25th, 75th percentiles], 14.00 [13.63, 15.50] vs. 7.50 [7.00, 10.88]), and superficial vein (9.00 [8.88, 10.00] vs. 3.25 [1.63, 8.25]), while the difference in arterial mis-segmentation was not statistically significant (p= 0.164). CONCLUSIONS This study proposed an automatic cerebral CTV imaging technique to eliminate residual bone and soft tissues, minimize the impact of the cerebral arterial system, and present a relatively comprehensive cerebral venous system, which would help physicians assess cerebral venous outflow profiles after stroke and seek imaging markers associated with clinical outcomes.
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Affiliation(s)
- Siqi Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Ting Su
- Research Center for Medical Artificial Intelligence, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China
| | - Yicong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Yinsheng Li
- Research Center for Medical Artificial Intelligence, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China..
| | - Yongshuai Ge
- Research Center for Medical Artificial Intelligence, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China.; Paul C Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China..
| | - Donghua Mi
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China.
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Broocks G, Meyer L, Bechstein M, Hanning U, Kniep HC, Schlemm E, Kyselyova AA, Winkelmeier L, Schön G, Fiehler J, Kemmling A. Investigating Neurologic Improvement After IV Thrombolysis: The Effect of Time From Stroke Onset vs Imaging-Based Tissue Clock. Neurology 2023; 101:e1678-e1686. [PMID: 37657940 PMCID: PMC10624495 DOI: 10.1212/wnl.0000000000207714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/12/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Time from stroke onset is associated with clinical response to intravenous thrombolysis (IVT) with alteplase and is therefore used to select patients for treatment. Alternatively, neuroimaging may be used for treatment in the uncertain or extended time window. We hypothesized that the patient-specific imaging indicator of ischemic lesion progression ("tissue clock") using CT perfusion (CTP) or quantitative net water uptake (NWU) is a predictor of early neurologic improvement (ENI) independent of time. METHODS Observational study of anterior circulation ischemic stroke patients with proximal vessel occlusion and known time from symptom onset triaged by multimodal CT undergoing endovascular treatment. Quantitative NWU using an established threshold (11.5%) or CTP lesion core mismatch (EXTEND criteria) was used to estimate ischemic lesion progression. The treatment effect of IVT depending on lesion progression defined by tissue clock vs time clock was assessed by inverse probability weighting (IPW). End points were binarized ENI and functional independence at day 90. RESULTS Four hundred nine patients were included, of which 223 (54.5%) received IVT. The proportion of patients within an early time window (<4.5 hours), low NWU, and CTP mismatch were 45.0%, 86.5%, and 80.3%. In IPW, IVT was associated with higher rates of ENI (%-difference: 7.3%, p = 0.02). For patients with CTP mismatch or low NWU, IVT was associated with a 9.6% or 7.2% higher rate of ENI, which was different than the effect of IVT in patients without CTP mismatch or high NWU (-9.3%/-7.3%; p = 0.004/p = 0.03), whereas early treatment window did not modify the effect of IVT. DISCUSSION CT-based measures of the "tissue clock" might identify patients who benefit from IVT more accurately than conventional time windows. Considering the high number of patients with early "tissue clock" (low NWU/CTP mismatch) within an extended time window, considerable benefit from IVT using imaging indicators of the "tissue clock" may be achieved.
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Affiliation(s)
- Gabriel Broocks
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany.
| | - Lukas Meyer
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Matthias Bechstein
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Uta Hanning
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Helge C Kniep
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Eckhard Schlemm
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Anna A Kyselyova
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Laurens Winkelmeier
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Gerhard Schön
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Jens Fiehler
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Andre Kemmling
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
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Li J, Long L, Zhang H, Zhang J, Abulimiti A, Abulajiang N, Lu Q, Yan W, Nguyen TN, Cai X. Impact of lipid profiles on parenchymal hemorrhage and early outcome after mechanical thrombectomy. Ann Clin Transl Neurol 2023; 10:1714-1724. [PMID: 37533211 PMCID: PMC10578899 DOI: 10.1002/acn3.51861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/12/2023] [Accepted: 07/13/2023] [Indexed: 08/04/2023] Open
Abstract
OBJECTIVE We aimed to investigate the association of lipid parameters with parenchymal hemorrhage (PH) and early neurological improvement (ENI) after mechanical thrombectomy (MT) in stroke patients. METHODS We retrospectively analyzed consecutive patients who underwent MT between January 2019 and February 2022 at a tertiary stroke center. PH was diagnosed and classified as PH-1 and PH-2 according to the European Cooperative Acute Stroke Study definition. ENI was defined as a decrease in the National Institutes of Health Stroke Scale (NIHSS) score by ≥8 or an NIHSS score of ≤1 at 24 h after MT. RESULTS Among 155 patients, PH occurred in 41 (26.5%) patients, and 34 (21.9%) patients achieved ENI. In multivariate analysis, lower triglyceride to high-density lipoprotein cholesterol ratio (TG/HDL-C) value (OR = 0.51; 95% CI 0.30-0.89; p = 0.017) and higher HDL-C level (OR = 5.83; 95% CI 1.26-26.99; p = 0.024) were independently associated with PH. The combination of TG <0.77 mmol/L and HDL-C ≥ 0.85 mmol/L was the strongest predictor of PH (OR = 10.73; 95% CI 2.89-39.87; p < 0.001). A low HDL-C level was an independent predictor of ENI (OR 0.13; 95% CI 0.02-0.95; p = 0.045), and PH partially accounts for the failure of ENI in patients with higher HDL-C levels (estimate: -0.05; 95% CI: -0.11 to -0.01; p = 0.016). INTERPRETATION The combination of lower TG level and higher HDL-C level can predict PH after MT. Postprocedural PH partially accounts for the failure of ENI in patients with higher HDL-C levels. Further studies into the pathophysiological mechanisms underlying this observation are of interest.
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Affiliation(s)
- Jie Li
- Department of NeurologyThe Sixth Affiliated Hospital, Sun Yat‐Sen UniversityGuangzhouChina
- Department of NeurologyThe First People's Hospital of Kashi PrefectureKashiChina
- Biomedical Innovation CenterThe Sixth Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
| | - Ling Long
- Department of NeurologyThe Third Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
| | - Heng Zhang
- Department of NeurologyThe Sixth Affiliated Hospital, Sun Yat‐Sen UniversityGuangzhouChina
- Department of NeurologyThe First People's Hospital of Kashi PrefectureKashiChina
- Biomedical Innovation CenterThe Sixth Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
| | - Junliu Zhang
- Department of NeurologyThe Sixth Affiliated Hospital, Sun Yat‐Sen UniversityGuangzhouChina
- Department of NeurologyThe First People's Hospital of Kashi PrefectureKashiChina
- Biomedical Innovation CenterThe Sixth Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
| | - Adilijiang Abulimiti
- Department of NeurologyThe First People's Hospital of Kashi PrefectureKashiChina
| | - Nuerbiya Abulajiang
- Department of NeurologyThe First People's Hospital of Kashi PrefectureKashiChina
| | - Qingbo Lu
- Department of NeurologyThe First People's Hospital of Kashi PrefectureKashiChina
| | - Wei Yan
- Department of NeurologyThe First People's Hospital of Kashi PrefectureKashiChina
| | - Thanh N. Nguyen
- Department of Neurology, Radiology, Boston Medical CenterBoston University Chobanian and Avedisian School of MedicineBostonMassachusettsUSA
| | - Xiaodong Cai
- Department of NeurologyThe Sixth Affiliated Hospital, Sun Yat‐Sen UniversityGuangzhouChina
- Biomedical Innovation CenterThe Sixth Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
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10
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Tang T, Li D, Fan TP, Thomas AM, Zhao MH, Li S. Impact of volemia at admission on the effect of collateral status on functional outcomes in patients undergoing endovascular thrombectomy. Eur J Neurol 2023; 30:2693-2699. [PMID: 37255377 DOI: 10.1111/ene.15901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/23/2023] [Accepted: 05/29/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND AND PURPOSE Having good collaterals is associated with better clinical outcomes in patients undergoing endovascular thrombectomy. This study aims to evaluate whether the effect of collateral status on functional outcomes is modified by volemia at admission. METHODS This is a single-center, retrospective analysis of patients who had acute proximal anterior circulation occlusion and underwent endovascular thrombectomy between January 2019 and June 2022. Volemia at admission, evaluated by blood urea nitrogen-to-creatinine ratio, was used to dichotomize patients into dehydrated and hydrated groups. The primary outcome was functional independence (90-day modified Rankin Scale score = 0-2). Secondary outcomes were the rates of successful reperfusion, 24-h symptomatic intracranial hemorrhage, and 90-day all-cause mortality. Multivariable logistic regression analysis was used to assess the interaction between collateral status and volemia at admission on outcomes. RESULTS A total of 290 patients were enrolled, among whom having good collaterals was associated with functional independence (adjusted odds ratio [OR] = 2.71, 95% confidence interval [CI] = 1.41-5.22, p = 0.003). Having good collaterals benefited dehydrated patients (adjusted OR = 3.33, 95% CI = 1.45-7.63, p = 0.004) but not hydrated patients (adjusted OR = 2.21, 95% CI = 0.73-6.68, p = 0.161). However, an interaction between collaterals and volemia at admission on functional independence was not observed (p = 0.319). The rates of successful reperfusion, symptomatic intracerebral hemorrhage, and all-cause mortality were similar between those with good and poor collaterals in both dehydrated and hydrated patients. CONCLUSIONS The effect of collateral status on the functional independence of patients undergoing thrombectomy is not modified by volemia at admission.
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Affiliation(s)
- Tao Tang
- Department of Neurology and Psychiatry, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Di Li
- Department of Neurointervention, Dalian Municipal Central Hospital affiliated with Dalian Medical University, Dalian, China
| | - Tie-Ping Fan
- Department of Neurointervention, Dalian Municipal Central Hospital affiliated with Dalian Medical University, Dalian, China
| | - Aline M Thomas
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Man-Hong Zhao
- Department of Neurointervention, Dalian Municipal Central Hospital affiliated with Dalian Medical University, Dalian, China
| | - Shen Li
- Department of Neurology and Psychiatry, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
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11
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Adusumilli G, Christensen S, Yuen N, Mlynash M, Faizy TD, Albers GW, Lansberg MG, Fiehler J, Heit JJ. CT perfusion to measure venous outflow in acute ischemic stroke in patients with a large vessel occlusion. J Neurointerv Surg 2023:jnis-2023-020727. [PMID: 37643804 DOI: 10.1136/jnis-2023-020727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 08/18/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Robust venous outflow (VO) profiles, measured by degree of venous opacification on pre-thrombectomy CT angiography (CTA) studies, are strongly correlated with favorable outcomes in patients with large vessel occlusion acute ischemic stroke treated by thrombectomy. However, VO measurements are laborious and require neuroimaging expertise. OBJECTIVE To develop a semi-automated method to measure VO using CTA and CT perfusion imaging studies. METHODS We developed a graphical interface using The Visualization Toolkit, allowing for voxel selection at the confluence and bilateral internal cerebral veins on CTA along with arterial input functions (AIFs) from both internal carotid arteries. We extracted concentration-time curves from the CT perfusion study at the corresponding locations associated with AIF and venous output function (VOF). Outcome analyses were primarily conducted by the Mann-Whitney U and Jonckheere-Terpstra tests. RESULTS Segmentation at the pre-selected AIF and VOF locations was performed on a sample of 97 patients. 65 patients had favorable VO (VO+) and 32 patients had unfavorable VO (VO-). VO+ patients were found to have a significantly shorter VOF time to peak (8.26; 95% CI 7.07 to 10.34) than VO- patients (9.44; 95% CI 8.61 to 10.91), P=0.007. No significant difference was found in VOF curve width and the difference in time between AIF and VOF peaks. CONCLUSIONS Time to peak of VOF at the confluence of sinuses was significantly associated with manually scored venous outflow. Further studies should aim to understand better the association between arterial inflow and venous outflow, and capture quantitative metrics of venous outflow at other locations.
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Affiliation(s)
- Gautam Adusumilli
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Nicole Yuen
- Stanford Stroke Center, Stanford University, Stanford, California, USA
| | - Michael Mlynash
- Stanford Stroke Center, Stanford University, Stanford, California, USA
| | - Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gregory W Albers
- Stanford Stroke Center, Stanford University, Stanford, California, USA
| | | | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
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12
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Dolotova DD, Blagosklonova ER, Muslimov RS, Ramazanov GR, Zagryazkina TA, Stepanov VN, Gavrilov AV. Inter-Rater Reliability of Collateral Status Assessment Based on CT Angiography: A Retrospective Study of Middle Cerebral Artery Ischaemic Stroke. J Clin Med 2023; 12:5470. [PMID: 37685536 PMCID: PMC10487547 DOI: 10.3390/jcm12175470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/12/2023] [Accepted: 08/15/2023] [Indexed: 09/10/2023] Open
Abstract
The importance of assessing the collateral status (CS) in patients with ischaemic stroke (IS) has repeatedly been emphasised in clinical guidelines. Various publications offer qualitative or semiquantitative scales with gradations corresponding to the different extents of the collaterals, visualised mostly on the basis of CTA images. However, information on their inter-rater reliability is limited. Therefore, the aim of this study is to investigate the inter-rater reliability of the scales for collateral assessment. CTA images of 158 patients in the acute period of IS were used in the study. The assessment of CS was performed by two experts using three methodologies: the modified Tan scale, the Miteff scale, and the Rosenthal scale. Cohen's kappa, weighted kappa and Krippendorff's alpha were used as reliability measures. For the modified Tan scale and the Miteff and Rosenthal scales, the weighted kappa values were 0.72, 0.49 and 0.59, respectively. Although the best measure of consistency was found for the modified Tan scale, no statistically significant differences were revealed among the scales. The impact of the CS on the degree of neurological deficit at discharge was shown for the modified Tan and Rosenthal scales. In conclusion, the analysis showed a moderate inter-rater reliability of the three scales, but was not able to distinguish the best one among them.
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Affiliation(s)
- Daria D. Dolotova
- Department of Bioinformatics, Department of Pediatric Surgery, Pirogov Russian National Research Medical University, Russian Ministry of Health, 117997 Moscow, Russia
- Research Department, Gammamed-Soft, Ltd., 127473 Moscow, Russia
| | | | - Rustam Sh. Muslimov
- Department of Radiology, Scientific Department of Emergency Neurology and Rehabilitation Treatment, N.V. Sklifosovsky Research Institute for Emergency Medicine, Moscow Health Department, 129090 Moscow, Russia
| | - Ganipa R. Ramazanov
- Department of Radiology, Scientific Department of Emergency Neurology and Rehabilitation Treatment, N.V. Sklifosovsky Research Institute for Emergency Medicine, Moscow Health Department, 129090 Moscow, Russia
| | | | - Valentin N. Stepanov
- Department of Radiology, Scientific Department of Emergency Neurology and Rehabilitation Treatment, N.V. Sklifosovsky Research Institute for Emergency Medicine, Moscow Health Department, 129090 Moscow, Russia
| | - Andrey V. Gavrilov
- Research Department, Gammamed-Soft, Ltd., 127473 Moscow, Russia
- Scobeltsyn Nuclear Physics Research Institute, Lomonosov Moscow State University, 119991 Moscow, Russia
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13
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Adusumilli G, Kobeissi H, Ghozy S, Kallmes KM, Brinjikji W, Kallmes D, Heit JJ. Hypoperfusion intensity ratio as a predictor of outcomes after thrombectomy triage: A call for data homogeneity. Interv Neuroradiol 2023. [DOI: 10.1177/15910199231188763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
Abstract
Background Collateral blood flow markers have been associated with outcomes after thrombectomy in patients presenting with acute ischemic stroke due to large vessel occlusion (AIS-LVO). Hypoperfusion intensity ratio (HIR), a metric reflecting tissue level collaterals, is one such marker with the potential to delineate patients who do and do not do well after thrombectomy. We determined if HIR correlated with successful reperfusion after thrombectomy. Methods Using Nested Knowledge, we screened literature for studies comparing patients with favorable versus unfavorable HIR, distinguished by a cutoff of 0.4, who underwent thrombectomy triage. The primary outcome was reperfusion success, as measured by thrombolysis in cerebral infarction ≥2b and secondary outcomes included rate of symptomatic intracranial hemorrhage, mortality at 90 days, and modified Rankin scale scores 0–2 at 90 days. A random effects model was used to compute pooled prevalence rates and their corresponding 95% confidence intervals (CI). Results Three studies with 973 patients, 496 with favorable HIR, and 477 with unfavorable HIR were included in this meta-analysis. The odds of reperfusion success were not significantly different between patients who had favorable versus unfavorable HIR (OR 0.96, 95% CI: 0.31–3.04) across two of the studies. Analysis of the remaining outcome variables was precluded by significant heterogeneity in data element reporting. Conclusions This meta-analysis was considerably limited by heterogeneity. Future meta-analyses on this topic, and other topics in the field of neurointervention would benefit from improved harmonization of study design and data element reporting.
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Affiliation(s)
- Gautam Adusumilli
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | | | - David Kallmes
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Jeremy J. Heit
- Department of Radiology and Neurosurgery, Stanford University, Stanford, CA, USA
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14
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Gao J, Zhang L, Lin J, Yang J, Yao M, Cheng Z, Cai X, Huang L. Stroke recurrence is associated with unfavorable intracranial venous outflow in patients with symptomatic intracranial atherosclerotic large vessel severe stenosis or occlusion. Front Neurol 2023; 14:1156315. [PMID: 37228413 PMCID: PMC10203233 DOI: 10.3389/fneur.2023.1156315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/20/2023] [Indexed: 05/27/2023] Open
Abstract
Objective The purpose of this study was to investigate the predictive value of intracranial venous outflow for recurrent cerebral ischemic events (RCIE) in patients with symptomatic intracranial atherosclerotic large-vessel severe stenosis or occlusion (sICAS-S/O). Methods This retrospective study included sICAS-S/O patients with anterior circulation who underwent dynamic computed tomography angiography (dCTA) and computed tomography perfusion (CTP). Arterial collaterals were evaluated using the pial arterial filling score for dCTA data, tissue-level collaterals (TLC) were assessed using the high-perfusion intensity ratio (HIR, Tmax >10 s/Tmax >6 s), and cortical veins were evaluated using the multi-phase venous score (MVS) for the vein of Labbé (VOL), sphenoparietal sinus (SPS), and superficial cerebral middle vein (SCMV). The relationships between multi-phase venous outflow (mVO), TLC, and 1-year RCIE were analyzed. Results Ninety-nine patients were included, 37 of whom had unfavorable mVO (mVO-) and 62 of whom had favorable mVO (mVO+). Compared with the mVO+ patients, mVO- patients had a higher admission National Institutes of Health Stroke Scale (NIHSS) score (median, 4 [interquartile range (IQR), 0-9] vs. 1 [IQR, 0-4]; p = 0.048), larger ischemic volume (median, 74.3 [IQR, 10.1-177.9] vs. 20.9 [IQR, 5-86.4] mL; p = 0.042), and worse tissue perfusion (median, 0.04 [IQR, 0-0.17] vs. 0 [IQR, 0-0.03]; p = 0.007). Multivariate regression analysis showed that mVO- was an independent predictor of 1-year RCIE. Conclusion For patients with sICAS-S/O of the anterior circulation, unfavorable intracranial venous outflow is a potential imaging indicator for predicting higher 1-year RCIE risk.
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Affiliation(s)
- Jiali Gao
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Liang Zhang
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jiaxin Lin
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jiajie Yang
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Mingzheng Yao
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Zhongyuan Cheng
- Medical Imaging Center, First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Xiangran Cai
- Medical Imaging Center, First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Li’an Huang
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
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15
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Winkelmeier L, Heit JJ, Adusumilli G, Geest V, Christensen S, Kniep H, van Horn N, Steffen P, Bechstein M, Sporns P, Lansberg MG, Albers GW, Wintermark M, Fiehler J, Faizy TD. Hypoperfusion Intensity Ratio Is Correlated With the Risk of Parenchymal Hematoma After Endovascular Stroke Treatment. Stroke 2023; 54:135-143. [PMID: 36416127 DOI: 10.1161/strokeaha.122.040540] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Parenchymal hematoma (PH) is a major complication after endovascular treatment (EVT) for ischemic stroke. The hypoperfusion intensity ratio (HIR) represents a perfusion parameter reflecting arterial collateralization and cerebral microperfusion in ischemic brain tissue. We hypothesized that HIR correlates with the risk of PH after EVT. METHODS Retrospective multicenter cohort study of patients with large vessel occlusion who underwent EVT between 2013 and 2021 at one of the 2 comprehensive stroke centers (University Medical Center Hamburg-Eppendorf, Germany and Stanford University School of Medicine, CA). HIR was automatically calculated on computed tomography perfusion studies as the ratio of brain volume with time-to-max (Tmax) delay >10 s over volume with Tmax >6 s. Reperfusion hemorrhages were assessed according to the Heidelberg Bleeding Classification. Primary outcome was PH occurrence (PH+) or absence (PH-) on follow-up imaging. Secondary outcome was good clinical outcome defined as a 90-day modified Rankin Scale score of 0 to 2. RESULTS A total of 624 patients met the inclusion criteria. We observed PH in 91 (14.6%) patients after EVT. PH+ patients had higher HIR on admission compared with PH- patients (median, 0.6 versus 0.4; P<0.001). In multivariable regression, higher admission blood glucose (adjusted odds ratio [aOR], 1.08 [95% CI, 1.04-1.13]; P<0.001), extensive baseline infarct defined as Alberta Stroke Program Early CT Score ≤5 (aOR, 2.48 [1.37-4.42]; P=0.002), and higher HIR (aOR, 1.22 [1.09-1.38]; P<0.001) were independent determinants of PH after EVT. Both higher HIR (aOR, 0.83 [0.75-0.92]; P<0.001) and PH on follow-up imaging (aOR, 0.39 [0.18-0.80]; P=0.013) were independently associated with lower odds of achieving good clinical outcome. CONCLUSIONS Poorer (higher) HIR on admission perfusion imaging was strongly associated with PH occurrence after EVT. HIR as a surrogate for cerebral microperfusion might reflect tissue vulnerability for reperfusion hemorrhages. This automated and quickly available perfusion parameter might help to assess the need for intensive medical care after EVT.
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Affiliation(s)
- Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (L.W., V.G., H.K., N.v.H., P.S., M.B., P.S., J.F., T.D.F.)
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, CA (J.J.H., G.A.)
| | - Gautam Adusumilli
- Department of Radiology, Stanford University School of Medicine, CA (J.J.H., G.A.)
| | - Vincent Geest
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (L.W., V.G., H.K., N.v.H., P.S., M.B., P.S., J.F., T.D.F.)
| | - Soren Christensen
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (S.C., M.G.L., G.W.A.)
| | - Helge Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (L.W., V.G., H.K., N.v.H., P.S., M.B., P.S., J.F., T.D.F.)
| | - Noel van Horn
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (L.W., V.G., H.K., N.v.H., P.S., M.B., P.S., J.F., T.D.F.)
| | - Paul Steffen
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (L.W., V.G., H.K., N.v.H., P.S., M.B., P.S., J.F., T.D.F.)
| | - Matthias Bechstein
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (L.W., V.G., H.K., N.v.H., P.S., M.B., P.S., J.F., T.D.F.)
| | - Peter Sporns
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (L.W., V.G., H.K., N.v.H., P.S., M.B., P.S., J.F., T.D.F.).,Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Switzerland (P.S.)
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (S.C., M.G.L., G.W.A.)
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (S.C., M.G.L., G.W.A.)
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson, Houston, TX (M.W.)
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (L.W., V.G., H.K., N.v.H., P.S., M.B., P.S., J.F., T.D.F.)
| | - Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (L.W., V.G., H.K., N.v.H., P.S., M.B., P.S., J.F., T.D.F.)
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