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Avula A, Bui Q, Kumar A, Chen Y, Hamzehloo A, Cifarelli J, Heitsch L, Slowik A, Strbian D, Lee JM, Dhar R. Evaluating the interaction between hemorrhagic transformation and cerebral edema on functional outcome after ischemic stroke. J Stroke Cerebrovasc Dis 2024; 33:107913. [PMID: 39098362 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107913] [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: 05/16/2024] [Revised: 07/12/2024] [Accepted: 08/01/2024] [Indexed: 08/06/2024] Open
Abstract
BACKGROUND Hemorrhagic transformation (HT) and cerebral edema (CED) are both major complications following ischemic stroke, but few studies have evaluated their overlap. We evaluated the frequency and predictors of CED/HT overlap and whether their co-occurrence impacts functional outcome more than each in isolation. METHODS 892 stroke patients enrolled in a prospective study had follow-up CT imaging evaluated for HT and CED; the latter was quantified using the ratio of hemispheric CSF volumes (with hemispheric CSF ratio < 0.90 used as the CED threshold). The interaction between HT and CED on functional outcome (using modified Rankin Scale at 3 months) was compared to that for each condition separately. RESULTS Among the 275 (31%) who developed HT, 233 (85%) manifested hemispheric CSF ratio < 0.9 (CED/HT), with this overlap group representing half of the 475 with measurable CED. Higher baseline NIHSS scores and larger infarct volumes were observed in the CED/HT group compared with those with CED or HT alone. Functional outcome was worse in those with CED/HT [median mRS 3 (IQR 2-5)] than those with CED [median 2 (IQR 1-4)] or HT alone [median 1 (IQR 0-2), p < 0.0001]. Overlap of CED/HT independently predicted worse outcome [OR 1.89 (95% CI: 1.12-3.18), p = 0.02] while HT did not; however, CED/HT was no longer associated with worse outcome after adjusting for severity of CED [adjusted OR 0.35 (95% CI: 0.23, 0.51) per 0.21 lower hemispheric CSF ratio, p < 0.001]. CONCLUSIONS Most stroke patients with HT also have measurable CED. The co-occurrence of CED and HT occurs in larger and more severe strokes and is associated with worse functional outcome, although this is driven by greater severity of stroke-related edema in those with HT.
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Affiliation(s)
- Amrit Avula
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA
| | - Quoc Bui
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA
| | - Atul Kumar
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA
| | - Yasheng Chen
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA
| | - Ali Hamzehloo
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA
| | - Julien Cifarelli
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA
| | - Laura Heitsch
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA; Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Jin-Moo Lee
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA
| | - Rajat Dhar
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA.
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Favilla CG, Patel H, Abassi MH, Thon J, Mullen MT, Kasner SE, Song JW, Cummings S, Messé SR. Infarct density defined by ADC threshold is associated with long-term functional outcome after endovascular thrombectomy. J Stroke Cerebrovasc Dis 2024; 33:107857. [PMID: 38997048 PMCID: PMC11380574 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107857] [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: 08/24/2023] [Revised: 07/03/2024] [Accepted: 07/10/2024] [Indexed: 07/14/2024] Open
Abstract
OBJECTIVES Endovascular thrombectomy (EVT) dramatically improves clinical outcomes, but the reduction in final infarct volume only accounts for 10-15 % of the treatment benefit. We aimed to develop a novel MRI-ADC-based metric that quantify the degree of tissue injury to test the hypothesis that it outperforms infarct volume in predicting long-term outcome. MATERIALS AND METHODS A single-center cohort consisted of consecutive acute stroke patients with anterior circulation large vessel occlusion, successful recanalization via EVT (mTICI ≥2b), and MRI of the brain between 12 h and 7 days post-EVT. Imaging was processed via RAPID software. Final infarct volume was based on the traditional ADC <620 threshold. Logistic regression quantified the association of lesion volumes and good outcome (90-day modified Rankin Scale ≤2) at a range of lower ADC thresholds (<570, <520, and <470). Infarct density was calculated as the percentage of the final infarct volume below the ADC threshold with the greatest effect size. Univariate and multivariate logistic regression quantified the association between imaging/clinical metrics and functional outcome. RESULTS 120 patients underwent MRI after successful EVT. Lesion volume based on the ADC threshold <470 had the strongest association with good outcome (OR: 0.81 per 10 mL; 95 % CI: 0.66-0.99). In a multivariate model, infarct density (<470/<620 * 100) was independently associated with good outcome (aOR 0.68 per 10 %; 95 % CI: 0.49-0.95), but final infarct volume was not (aOR 0.98 per 10 mL; 95 % CI: 0.85-1.14). CONCLUSIONS Infarct density after EVT is more strongly associated with long-term clinical outcome than infarct volume.
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Affiliation(s)
| | - Heta Patel
- University of Pennsylvania, Department of Neurology, Philadelphia, PA, USA
| | | | - Jesse Thon
- Cooper University, Department of Neurology, Camden, NJ, USA
| | - Michael T Mullen
- Temple University, Department of Neurology, Philadelphia, PA, USA
| | - Scott E Kasner
- University of Pennsylvania, Department of Neurology, Philadelphia, PA, USA
| | - Jae W Song
- University of Pennsylvania, Department of Radiology, Philadelphia, PA, USA
| | - Stephanie Cummings
- University of Pennsylvania, Department of Neurology, Philadelphia, PA, USA
| | - Steven R Messé
- University of Pennsylvania, Department of Neurology, Philadelphia, PA, USA
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3
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Yedavalli V, Salim HA, Musmar B, Adeeb N, El Naamani K, Henninger N, Sundararajan SH, Kühn AL, Khalife J, Ghozy S, Scarcia L, Tan BY, Regenhardt RW, Heit JJ, Cancelliere NM, Bernstock JD, Rouchaud A, Fiehler J, Sheth S, Puri AS, Dyzmann C, Colasurdo M, Barreau X, Renieri L, Filipe JP, Harker P, Radu RA, Abdalkader M, Klein P, Marotta TR, Spears J, Ota T, Mowla A, Jabbour P, Biswas A, Clarençon F, Siegler JE, Nguyen TN, Varela R, Baker A, Essibayi MA, Altschul D, Gonzalez NR, Möhlenbruch MA, Costalat V, Gory B, Stracke CP, Aziz-Sultan MA, Hecker C, Shaikh H, Liebeskind DS, Pedicelli A, Alexandre AM, Tancredi I, Faizy TD, Kalsoum E, Lubicz B, Patel AB, Pereira VM, Guenego A, Dmytriw AA. Predictive value of follow-up infarct volume on functional outcomes in middle cerebral artery M2 segment vessel occlusion stroke treated with mechanical thrombectomy. Eur Stroke J 2024:23969873241275531. [PMID: 39269154 DOI: 10.1177/23969873241275531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2024] Open
Abstract
BACKGROUND Medium vessel occlusion (MeVO) strokes, particularly affecting the M2 segment of the middle cerebral artery, represent a critical proportion of acute ischemic strokes, posing significant challenges in management and outcome prediction. The efficacy of mechanical thrombectomy (MT) in MeVO stroke may warrant reliable predictors of functional outcomes. This study aimed to investigate the prognostic value of follow-up infarct volume (FIV) for predicting 90-day functional outcomes in MeVO stroke patients undergoing MT. METHODS This multicenter, retrospective cohort study analyzed data from the Multicenter Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy (MAD-MT) registry, covering patients with acute ischemic stroke due to M2 segment occlusion treated with MT. We examined the relationship between 90-day functional outcomes, measured by the modified Rankin Scale (mRS), and follow-up infarct volume (FIV), assessed through CT or MRI within 12-36 h post-MT. RESULTS Among 130 participants, specific FIV thresholds were identified with high specificity and sensitivity for predicting outcomes. A FIV ⩽5 ml was highly specific for predicting favorable and excellent outcomes. The optimal cut-off for both prognostications was identified at ⩽15 ml by the Youden Index, with significant reductions in the likelihood of favorable outcomes observed above a 40 ml threshold. Receiver Operator Curve (ROC) analyses confirmed FIV as a superior predictor of functional outcomes compared to traditional recanalization scores, such as final modified thrombolysis in cerebral infarction score (mTICI). Multivariable analysis further highlighted the inverse relationship between FIV and positive functional outcomes. CONCLUSIONS FIV within 36 h post-MT serves as a potent predictor of 90-day functional outcomes in patients with M2 segment MeVO strokes. Establishing FIV thresholds may aid in the prognostication of stroke outcomes, suggesting a role for FIV in guiding post intervention treatment decisions and informing clinical practice. Future research should focus on validating these findings across diverse patient populations and exploring the integration of FIV measurements with other clinical and imaging markers to enhance outcome prediction accuracy.
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Affiliation(s)
- Vivek Yedavalli
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA
| | - Hamza Adel Salim
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neuroradiology, MD Anderson Medical Center, Houston, TX, USA
| | - Basel Musmar
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, LA, USA
| | - Nimer Adeeb
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, LA, USA
| | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | - Anna Luisa Kühn
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Jane Khalife
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | - Sherief Ghozy
- Departments of Neurological Surgery & Radiology, Mayo Clinic, Rochester, MN, USA
| | - Luca Scarcia
- Department of Neuroradiology, Henri Mondor Hospital, Creteil, France
| | - Benjamin Yq Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Robert W Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeremy J Heit
- Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA, USA
| | - Nicole M Cancelliere
- Divisions of Therapeutic Neuroradiology and Neurosurgery, Neurovascular Centre, St. Michael Hospital, University of Toronto, Toronto, ON, Canada
| | - Joshua D Bernstock
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aymeric Rouchaud
- Neuroradiology Department, University Hospital of Limoges, Dupuytren, Université de Limoges, XLIM CNRS, UMR, France
| | - Jens Fiehler
- Departments of Neurological Surgery & Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sunil Sheth
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX, USA
| | - Ajit S Puri
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Christian Dyzmann
- Neuroradiology Department, Sana Kliniken, Lübeck GmbH, Lübeck, Germany
| | - Marco Colasurdo
- Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA
| | - Xavier Barreau
- Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France
| | - Leonardo Renieri
- Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy
| | - João Pedro Filipe
- Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Pablo Harker
- Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Răzvan Alexandru Radu
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, France
| | - Mohamad Abdalkader
- Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA
| | - Piers Klein
- Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA
| | - Thomas R Marotta
- Divisions of Therapeutic Neuroradiology and Neurosurgery, Neurovascular Centre, St. Michael Hospital, University of Toronto, Toronto, ON, Canada
| | - Julian Spears
- Divisions of Therapeutic Neuroradiology and Neurosurgery, Neurovascular Centre, St. Michael Hospital, University of Toronto, Toronto, ON, Canada
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Arundhati Biswas
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Frédéric Clarençon
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
- GRC BioFast., Sorbonne University, Paris VI, France
| | - James E Siegler
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | - Thanh N Nguyen
- Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA
| | - Ricardo Varela
- Department of Neurology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Amanda Baker
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Muhammed Amir Essibayi
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - David Altschul
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Nestor R Gonzalez
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Markus A Möhlenbruch
- Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Vincent Costalat
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, France
| | - Benjamin Gory
- Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France
- INSERM U1254, IADI, Université de Lorraine, Vandoeuvre-les-Nancy, France
| | - Christian Paul Stracke
- Department of Radiology, Interventional Neuroradiology Section, University Medical Center Münster, Münster, Germany
| | - Mohammad Ali Aziz-Sultan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Constantin Hecker
- Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Hamza Shaikh
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | | | - Alessandro Pedicelli
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Roma, Italy
| | - Andrea M Alexandre
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Roma, Italy
| | - Illario Tancredi
- Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium
| | - Tobias D Faizy
- Department of Radiology, Neuroendovascular Program, University Medical Center Münster, Germany
| | - Erwah Kalsoum
- Department of Neuroradiology, Henri Mondor Hospital, Creteil, France
| | - Boris Lubicz
- Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Vitor Mendes Pereira
- Divisions of Therapeutic Neuroradiology and Neurosurgery, Neurovascular Centre, St. Michael Hospital, University of Toronto, Toronto, ON, Canada
| | - Adrien Guenego
- Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Divisions of Therapeutic Neuroradiology and Neurosurgery, Neurovascular Centre, St. Michael Hospital, University of Toronto, Toronto, ON, Canada
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Lu J, Lu Z, Li Y, Li F, Feng Y, Dang M, Yang Y, Tang F, Li T, Zhao L, Jian Y, Wang X, Zhang L, Fan H, Zhang G. Association between ASPECTS region of infarction and clinical outcome in non-acute large vessel occlusion ischaemic stroke after endovascular recanalisation. Stroke Vasc Neurol 2024:svn-2024-003355. [PMID: 39266208 DOI: 10.1136/svn-2024-003355] [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: 04/26/2024] [Accepted: 09/04/2024] [Indexed: 09/14/2024] Open
Abstract
PURPOSE This study retrospectively investigated whether infarction in specific Alberta Stroke Program Early CT Score (ASPECTS) regions is associated with clinical outcome in patients with symptomatic non-acute internal carotid or middle cerebral artery occlusion who underwent endovascular recanalisation (ER). METHODS Preoperative ASPECTS and region of infarction were recorded before recanalisation. Clinical outcome was evaluated 90 days after the procedure using the modified Rankin Scale; a score>2 was defined as poor outcome. Secondary outcomes included postprocedural cerebral oedema, intracranial haemorrhage (ICH) and symptomatic ICH. RESULTS Among the 86 patients included, 90-day outcome was poor in 30 (34.9%) and 40 experienced cerebral oedema (46.5%). Multivariate logistic regression models showed that lenticular nucleus infarction (OR 19.61-26.00, p<0.05), admission diastolic blood pressure (OR 1.07-1.08, p<0.05), preprocedural National Institutes of Health Stroke Scale (OR 1.96-2.05, p<0.001) and haemorrhagic transformation (OR 14.99-18.81, p<0.05) were independent predictors of poor 90-day outcome. The area under the receiver operating characteristic curve for lenticular nucleus infarction as a predictor of poor outcome was 0.73. M2 region infarction (OR 26.07, p<0.001) and low American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology collateral circulation grade (OR 0.16, p=0.001) were independent predictors of postprocedural cerebral oedema. The area under the receiver operating characteristic curve for M2 region infarction as a predictor of cerebral oedema was 0.64. Region of infarction did not significantly differ between patients with and without postprocedural ICH or symptomatic ICH. CONCLUSIONS Lenticular nucleus and M2 region infarction were independent predictors of poor 90-day outcome and postprocedural cerebral oedema, respectively, in patients with non-acute anterior circulation large artery occlusion who underwent ER.
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Affiliation(s)
- Jialiang Lu
- Neurology, Xi'an Jiaotong University Second Affiliated Hospital, Xi'an, Shaanxi, China
| | - Ziwei Lu
- Neurology, Xi'an Jiaotong University Second Affiliated Hospital, Xi'an, Shaanxi, China
| | - Ye Li
- Neurology, Xi'an Jiaotong University Second Affiliated Hospital, Xi'an, Shaanxi, China
| | - Fangcun Li
- Neurology, Xi'an Jiaotong University Second Affiliated Hospital, Xi'an, Shaanxi, China
| | - Yuxuan Feng
- Neurology, Xi'an Jiaotong University Second Affiliated Hospital, Xi'an, Shaanxi, China
| | - Meijuan Dang
- Neurology, Xi'an Jiaotong University Second Affiliated Hospital, Xi'an, Shaanxi, China
| | - Yang Yang
- Neurology, Xi'an Jiaotong University Second Affiliated Hospital, Xi'an, Shaanxi, China
| | - Fan Tang
- Neurology, Xi'an Jiaotong University Second Affiliated Hospital, Xi'an, Shaanxi, China
| | - Tao Li
- Neurology, Xi'an Jiaotong University Second Affiliated Hospital, Xi'an, Shaanxi, China
| | - Lili Zhao
- Neurology, Xi'an Jiaotong University Second Affiliated Hospital, Xi'an, Shaanxi, China
| | - Yating Jian
- Neurology, Xi'an Jiaotong University Second Affiliated Hospital, Xi'an, Shaanxi, China
| | - Xiaoya Wang
- Neurology, Xi'an Jiaotong University Second Affiliated Hospital, Xi'an, Shaanxi, China
| | - Lei Zhang
- Neurology, Xi'an Jiaotong University Second Affiliated Hospital, Xi'an, Shaanxi, China
| | - Hong Fan
- Neurology, Xi'an Jiaotong University Second Affiliated Hospital, Xi'an, Shaanxi, China
| | - Guilian Zhang
- Neurology, Xi'an Jiaotong University Second Affiliated Hospital, Xi'an, Shaanxi, China
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5
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Gillani SA, Ma X, Huang Y, Bains NK, Fakih R, Siddiq F, French BR, Gomez CR, Lyden PD, Qureshi AI. Effect of post thrombolytic intracerebral hemorrhage volume on 90-day outcomes in acute ischemic stroke patients. J Stroke Cerebrovasc Dis 2024; 33:107962. [PMID: 39191317 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107962] [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: 03/26/2024] [Revised: 08/16/2024] [Accepted: 08/19/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND AND PURPOSE Post thrombolytic intracerebral hemorrhage (ICH) is associated with higher rate of death or disability in acute ischemic stroke patients. We investigated the relationship between post thrombolytic ICH volume and change in volume and death or disability at 90 days in acute ischemic stroke patients. METHODS We analyzed 110 patents recruited in the Safety Evaluation of 3K3A-APC in Ischemic Stroke (RHAPSODY) trial who received intravenous tissue plasminogen activator (tPA) followed by mechanical thrombectomy (if indicated) and 3K3A-APC or placebo. ICH volume was measured at Day 2 and Day 7 using susceptibility weighted sequence (SWI) on magnetic resonance imaging (MRI). We also calculated the post thrombolytic ICH volume change between Day 2 and Day 7. Outcomes were determined by using utility weighted modified Rankin scale (UW-mRs) at 90-days, Outcomes were determined by using utility weighted modified Rankin scale (UW-mRS) at 90 days. To minimize interpretation bias, outcome assessors were blinded to the treatment allocation and clinical data.We adjusted for age, gender, National Institutes of Health Stroke Scale (NIHSS) score (<10,10-19 and ≥20), location of hemorrhage (single basal ganglia hemorrhage, single lobar, single cerebellum, and multiple sites) in multivariate regression analysis. RESULTS A total of 88 (80%) of 110 patients had post thrombolytic ICH (mean volume 28.3 ml ± SD 62 ml). The strata of ICH volume were not associated with UW-mRs at 90 days: <20 cc (regression coefficient (RC)-0.05, p= 0.58), 20-39 cc (RC-0.22, p=0.17), or ≥40 cc (RC-0.34, p= 0.083) compared with no ICH after adjusting for potential confounders. Change in ICH mean volume 26.78 ml ±59.68, 52 had increase in volume) between Day 2 and day 7 was not associated with UW-mRS at 90 days (RC -67.71, p= 0.06). CONCLUSIONS We did not observe any independent effect of post thrombolytic ICH volume on death or disability in acute ischemic stroke patients. Although further studies must be done, our data suggest that strategies to prevent ICH expansion such as antifibrinolytic medications and reduction in ICH volume such as surgical evacuation may not reduce death or disability in acute ischemic stroke patients with post thrombolytic ICH.
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Affiliation(s)
- Syed A Gillani
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA.
| | - Xiaoyu Ma
- Department of Statistics, University of Missouri, Columbia, MO, USA.
| | - Yilun Huang
- Department of Statistics, University of Missouri, Columbia, MO, USA.
| | - Navpreet K Bains
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA.
| | - Rami Fakih
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA.
| | - Farhan Siddiq
- Department of Neurosurgery, University of Missouri, Columbia, MO, USA.
| | - Brandi R French
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA.
| | - Camilo R Gomez
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA.
| | - Patrick D Lyden
- Department of Physiology and Neuroscience and the Department of Neurology, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA.
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA.
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6
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Elawady SS, Abo Kasem R, Mulpur B, Cunningham C, Matsukawa H, Sowlat MM, Orscelik A, Nawabi NLA, Isidor J, Maier I, Jabbour P, Kim JT, Wolfe SQ, Rai A, Starke RM, Psychogios MN, Samaniego EA, Yoshimura S, Cuellar H, Howard BM, Alawieh A, Alaraj A, Ezzeldin M, Romano DG, Tanweer O, Mascitelli JR, Fragata I, Polifka AJ, Siddiqui F, Osbun JW, Grandhi R, Crosa RJ, Matouk C, Park MS, Brinjikji W, Moss M, Daglioglu E, Williamson R, Navia P, Kan P, De Leacy RA, Chowdhry SA, Altschul D, Spiotta AM, Levitt MR, Goyal N. Comparison of combined intravenous and intra-arterial thrombolysis with intravenous thrombolysis alone in stroke patients undergoing mechanical thrombectomy: a propensity-matched analysis. J Neurointerv Surg 2024:jnis-2024-021975. [PMID: 39179373 DOI: 10.1136/jnis-2024-021975] [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: 05/16/2024] [Accepted: 08/01/2024] [Indexed: 08/26/2024]
Abstract
BACKGROUND A combination of intravenous (IVT) or intra-arterial (IAT) thrombolysis with mechanical thrombectomy (MT) for acute ischemic stroke due to large vessel occlusion (AIS-LVO) has been investigated. However, there is limited data on patients who receive both IVT and IAT compared with IVT alone before MT. METHODS STAR data from 2013 to 2023 was utilized. We performed propensity score matching between the two groups. The primary outcomes were symptomatic intracranial hemorrhage (sICH) and 90-day modified Rankin Scale (mRS) score 0-2. Secondary outcomes included successful recanalization (modified treatment in cerebral infarction (mTICI) ≥2B, ≥2C), early neurological improvement, any intracranial hemorrhage (ICH), and 90-day mortality. RESULTS A total of 2454 AIS-LVO patients were included. Propensity matching yielded 190 well-matched patients in each group. No significant differences were observed between the groups in either ICH or sICH (odds ratio (OR): 0.80, 95% confidence interval (CI) 0.51-1.24, P=0.37; OR: 0.60, 95% CI 0.29 to 1.24, P=0.21, respectively). Rates of successful recanalization and early neurological improvement (ENI) were significantly lower in MT+IVT + IAT. mRS 0-1 and mortality were not significantly different between the two groups. However, the MT+IVT + IAT group demonstrated superior rates of good functional outcomes (90-day mRS 0-1) compared with patients in the MT+IVT group who had mTICI ≤2B, (OR: 2.18, 95% CI 1.05 to 3.99, P=0.04). CONCLUSION The combined use of IAT and IVT thrombolysis in AIS-LVO patients undergoing MT is safe. Although the MT+IVT+ IAT group demonstrated lower rates of recanalization and early neurological improvement, long-term functional outcomes were favorable in this group suggesting a potential delayed benefit of IAT.
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Affiliation(s)
- Sameh Samir Elawady
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Rahim Abo Kasem
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Bhageeradh Mulpur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Conor Cunningham
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Hidetoshi Matsukawa
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Mohammad-Mahdi Sowlat
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Atakan Orscelik
- Department of Neurosurgery, UCSF School of Medicine, San Francisco, California, USA
| | - Noah L A Nawabi
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Julio Isidor
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ilko Maier
- Department of Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Pascal Jabbour
- Department of Neurological surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Medical School, Gwangju, Gwangju, Korea (the Republic of)
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Ansaar Rai
- Department of Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Edgar A Samaniego
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hugo Cuellar
- Department of Neurosurgery, LSUHSC, Shreveport, Louisiana, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ali Alawieh
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Mohamad Ezzeldin
- Department of Clinical Sciences, College of Medicine, University of Houston, Houston, Texas, USA
- Department of Neuroendovascular surgery, HCA Houston, Houston, Texas, USA
| | - Daniele G Romano
- Department of Neurordiology, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Justin R Mascitelli
- Deparment of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Fazeel Siddiqui
- Department of Neuroscience, University of Michigan Health-West, Wyoming, Wyoming, USA
| | - Joshua W Osbun
- Department of Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Roberto Javier Crosa
- Department of Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay
| | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Min S Park
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Mark Moss
- Department of Neuroradiology, Washington Regional J.B. Hunt Transport Services Neuroscience Institute, Fayetteville, Arizona, USA
| | - Ergun Daglioglu
- Department of Neurosurgery, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Richard Williamson
- Department of Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Pedro Navia
- Department of Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
| | - Peter Kan
- Department of Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Reade Andrew De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shakeel A Chowdhry
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - David Altschul
- Department of Neurosurgery, Montefiore Medical Center, Bronx, New York, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Nitin Goyal
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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7
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Viticchi G, Falsetti L, Altamura C, Di Felice C, Vernieri F, Bartolini M, Silvestrini M. Impact of carotid stenosis on the outcome of stroke patients submitted to reperfusion treatments: a narrative review. Rev Neurosci 2024; 35:575-583. [PMID: 38459676 DOI: 10.1515/revneuro-2024-0002] [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: 01/04/2024] [Accepted: 02/18/2024] [Indexed: 03/10/2024]
Abstract
Intravenous thrombolysis (IT) and mechanical thrombectomy (MD) are the two interventional approaches that have changed the outcome of patients with acute ischemic stroke (AIS). Ipsilateral and contralateral carotid stenosis (ICS, CCS) play an important role in regulating cerebral hemodynamics, both in chronic and acute situations such as AIS. Several studies have explored their role in the incidence and severity of stroke, but very few have investigated the possible impact of ICS and CCS on the efficacy of interventional procedures. The purpose of this review was to I) highlight the incidence and prevalence of carotid stenosis (CS); II) assess the impact of ICS and CCS on cerebral hemodynamics; III) evaluate the effect of carotid stenosis on the efficacy of interventional therapies (IT and MT) for AIS; and IV) report therapeutic complications related to CS. We searched PubMed/Medline for case reports, reviews, and original research articles on English-language review topics during the period from January 1, 2000 to October 1, 2023. CS is associated with 15-20 % of the total number of AIS. ICS and CCS had a negative influence on both cerebral hemodynamics before AIS and outcome after interventional procedures (IT, MT alone or in bridging). Available data on cerebral hemodynamics and efficacy of interventional therapies for AIS suggest a negative role of CS. Therefore, early diagnosis of CS may be considered relevant to preventive and post-stroke treatment strategies.
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Affiliation(s)
- Giovanna Viticchi
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Lorenzo Falsetti
- Clinica Medica, Clinical and Molecular Sciences Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Claudia Altamura
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, via Álvaro del Portillo n.200, 00128, Rome, Italy
| | - Chiara Di Felice
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Fabrizio Vernieri
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, via Álvaro del Portillo n.200, 00128, Rome, Italy
| | - Marco Bartolini
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Mauro Silvestrini
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
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8
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van der Sluijs PM, Su R, Cornelissen S, van Es ACGM, Lycklama A Nijeholt GJ, van Doormaal PJ, van Zwam WH, Dippel DWJ, van Walsum T, van der Lugt A. Assessment of automated TICI scoring during endovascular treatment in patients with an ischemic stroke. J Neurointerv Surg 2024:jnis-2024-021892. [PMID: 39019506 DOI: 10.1136/jnis-2024-021892] [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: 04/24/2024] [Accepted: 06/18/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND The extended Thrombolysis in Cerebral Infarction (eTICI) score is used in digital subtraction angiography (DSA) to quantify reperfusion grade in patients with an ischemic stroke who undergo endovascular thrombectomy (EVT). A previously developed automatic TICI score (autoTICI), which quantifies the ratio of reperfused pixels after EVT, demonstrates good correlation with eTICI. OBJECTIVE To evaluate the autoTICI model in a large multicenter registry of patients with an ischemic stroke, investigate the association with visual eTICI, and compare prediction of functional outcome between autoTICI and eTICI. METHODS Patients in the MR CLEAN Registry with an internal carotid artery, M1, and M2 occlusion were selected if both anteroposterior and lateral views were present in pre- and post-EVT DSA scans. The autoTICI score was compared with eTICI in predicting favorable functional outcome (modified Rankin Scale score 0-2), using area under the receiver operating characteristics curve (AUC) with a multivariable logistic regression model including known prognostic characteristics. RESULTS In total 421 of 3637 patients were included. AutoTICI was significantly associated with eTICI non-linearly (below 70% cOR=2.3 (95% CI 2.1 to 2.5), above 70% cOR=1.6 (95% CI 1.6 to 1.7) per 10% increment). The AUC of the model predicting favorable functional outcome was similar for autoTICI and eTICI (0.86, 95% CI 0.82 to 0.92 vs 0.86, 95% CI 0.83 to 0.90, P=0.73) and was higher than for a model with prognostic patient characteristics alone (0.86 vs 0.84, P=0.01). CONCLUSION Automatic quantitative assessment of reperfusion after EVT is associated with eTICI, and prediction of functional outcome is similar to that with visual eTICI. Therefore, autoTICI could be used as an alternative or additional review for visual reperfusion assessment to facilitate reproducible and uniform reporting.
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Affiliation(s)
| | - Ruisheng Su
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Sandra Cornelissen
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Adriaan C G M van Es
- Department of Radiology, Leiden Universitair Medisch Centrum, Leiden, Zuid-Holland, The Netherlands
| | | | - Pieter Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Wim H van Zwam
- Department of Radiology, Maastricht UMC+, Maastricht, Limburg, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - T van Walsum
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
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9
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Sun D, Nguyen TN, Pan Y, Wang M, Abdalkader M, Masoud HE, Ma A, Tong X, Ma G, Sun X, Song L, Ma N, Gao F, Mo D, Miao Z, Huo X. Unsuccessful Recanalization versus Medical Management of Patients with Large Ischemic Core : Analysis of the ANGEL-ASPECT Randomized Trial. Clin Neuroradiol 2024; 34:441-450. [PMID: 38319347 DOI: 10.1007/s00062-024-01384-5] [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: 10/17/2023] [Accepted: 01/05/2024] [Indexed: 02/07/2024]
Abstract
PURPOSE The outcomes of patients with large ischemic core who fail to recanalize with endovascular therapy (EVT) compared to medical management (MM) are uncertain. The objective was to evaluate the clinical and safety outcomes of patients who underwent EVT in patients with large ischemic core and unsuccessful recanalization. METHODS This was a post hoc analysis of the ANGEL-ASPECT randomized trial. Unsuccessful recanalization was defined as patients who underwent EVT with eTICI 0-2a. The primary endpoint was 90-day very poor outcome (mRS 5-6). Multivariable logistic regression was conducted controlling for ASPECTS, occlusion location, intravenous thrombolysis, and time to treatment. RESULTS Of 455 patients 225 were treated with MM. Of 230 treated with EVT, 43 (19%) patients had unsuccessful recanalization. There was no difference in 90-day very poor outcomes (39.5% vs. 40%, aOR 0.93, 95% confidence interval, CI 0.47-1.85, p = 0.95), sICH (7.0% vs. 2.7%, aOR 2.81, 95% CI 0.6-13.29, p = 0.19), or mortality (30% vs. 20%, aOR 1.65, 95% CI 0.89-3.06, p = 0.11) between the unsuccessful EVT and MM groups, respectively. There were higher rates of ICH (55.8% vs. 17.3%, p < 0.001), infarct core volume growth (142.7 ml vs. 90.5 ml, β = 47.77, 95% CI 20.97-74.57 ml, p < 0.001), and decompressive craniectomy (18.6% vs. 3.6%, p < 0.001) in the unsuccessful EVT versus MM groups. CONCLUSION In a randomized trial of patients with large ischemic core undergoing EVT with unsuccessful recanalization, there was no difference in very poor outcomes, sICH or death versus medically managed patients. In the unsuccessful EVT group, there were higher rates of any ICH, volume of infarct core growth, and decompressive craniectomy.
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Affiliation(s)
- Dapeng Sun
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
| | - Thanh N Nguyen
- Neurology, Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, USA
| | - Yuesong Pan
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Mengxing Wang
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Mohamad Abdalkader
- Neurology, Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, USA
| | - Hesham E Masoud
- Neurology, SUNY Upstate Medical University Hospital, Syracuse, NY, USA
| | - Alice Ma
- Neurosurgery, Royal North Shore Hospital, Sydney, Australia
| | - Xu Tong
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
| | - Gaoting Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xuan Sun
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
| | - Ligang Song
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
| | - Feng Gao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
| | - Dapeng Mo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
| | - Zhongrong Miao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China.
| | - Xiaochuan Huo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China.
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
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10
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Joundi RA, Smith EE, Mandzia J, Ganesh A, Menon BK, Rempel JL, Thornton J, Roy D, Jovin TG, Dowlatshahi D, Frei DF, Bharatha A, Poppe A, Silver FL, Shuaib A, Teitelbaum JS, Williams D, Bang OY, Sapkota BL, Burns P, Choe H, Heo JH, Kelly ME, Linares G, Shankar JJ, Sohn SI, Swartz RH, Barber P, Coutts SB, Demchuk A, Goyal M, Hill MD. Effect of Endovascular Thrombectomy for Acute Ischemic Stroke on Cognitive Outcomes: A Secondary Analysis of the ESCAPE Trial. Neurology 2024; 102:e209270. [PMID: 38739880 PMCID: PMC11177593 DOI: 10.1212/wnl.0000000000209270] [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: 06/27/2023] [Accepted: 02/14/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The effect of endovascular therapy (EVT) for large vessel occlusion stroke on cognitive outcomes is not well understood. We evaluated the effect of EVT on cognitive function in the Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times (ESCAPE) trial. METHODS Patient data from the ESCAPE randomized trial were analyzed. Cognitive assessments completed at 90 days after stroke were the Montreal Cognitive Assessment (MoCA), the Sunnybrook Neglect Assessment Procedure (SNAP), the Boston Naming Test (BNT), Trail-making test A (Trails A), and Trail-making test B (Trails B). We used logistic regression to evaluate the association between EVT and favorable cognitive outcome on the 5 separate tests, adjusting for demographic and clinical factors. We used generalized estimating equations and ordinal regression to determine the odds of favorable outcome with EVT on global cognition incorporating the 5 tests. We added final infarct volume (FIV) to the models to assess the relationship of FIV with cognitive outcome. RESULTS The ESCAPE trial included 315 patients, 165 randomized to EVT and 150 randomized to control. There was higher odds of favorable outcome with EVT for MoCA (adjusted odds ratio [aOR] 2.32, 95% CI 1.30-4.16), SNAP (aOR 3.85, 95% CI 2.00-7.45), BNT (aOR 2.33, 95% CI 1.30-4.17), trails A (aOR 3.50, 95% CI 1.93-6.36), and trails B (aOR 2.56, 95% CI 1.46-4.48). There was higher odds of favorable outcome with EVT on global binary (aOR 2.57, 95% CI 1.67-3.94) and ordinal analyses (aOR 2.83, 95% CI 1.68-4.76) of cognitive function. After adding FIV to the models, both FIV and EVT were significantly associated with cognitive outcome. There was a significant correlation between global cognitive performance and mRS at day 90 (r = -0.78, p < 0.001), with the largest reductions in favorable cognitive outcome from mRS score 4 to 5 and from mRS 2 to 3. DISCUSSION In this secondary analysis of the ESCAPE trial, EVT was associated with favorable outcome on 5 separate cognitive tests and in global analyses of cognitive benefit. These results provide novel evidence for the effect of EVT on cognition and support the global benefit of treatment with EVT. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that in patients with acute ischemic stroke due to intracranial internal carotid artery (ICA) or M1 segment MCA occlusion, including tandem extracranial ICA occlusions, EVT compared with best medical therapy increased odds of favorable cognitive outcome.
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Affiliation(s)
- Raed A Joundi
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Eric E Smith
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Jennifer Mandzia
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Aravind Ganesh
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Bijoy K Menon
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Jeremy L Rempel
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - John Thornton
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Daniel Roy
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Tudor G Jovin
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Dar Dowlatshahi
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Donald F Frei
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Aditya Bharatha
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Alexandre Poppe
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Frank L Silver
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Ashfaq Shuaib
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Jeanne S Teitelbaum
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - David Williams
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Oh Young Bang
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Biggya L Sapkota
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Paul Burns
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Hana Choe
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Jie-Hoe Heo
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Michael E Kelly
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Guillermo Linares
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Jai J Shankar
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Sung-Il Sohn
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Richard H Swartz
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Philip Barber
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Shelagh B Coutts
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Andrew Demchuk
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Mayank Goyal
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Michael D Hill
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada
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Bauer A, Boehme C, Mayer-Suess L, Rudzki D, Knoflach M, Kiechl S, Reindl M. Peripheral inflammatory response in people after acute ischaemic stroke and isolated spontaneous cervical artery dissection. Sci Rep 2024; 14:12063. [PMID: 38802464 PMCID: PMC11130263 DOI: 10.1038/s41598-024-62557-3] [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: 12/15/2023] [Accepted: 05/18/2024] [Indexed: 05/29/2024] Open
Abstract
The systemic inflammatory response following acute ischaemic stroke remains incompletely understood. We characterised the circulating inflammatory profile in 173 acute ischaemic stroke patients by measuring 65 cytokines and chemokines in plasma. Participants were grouped based on their inflammatory response, determined by high-sensitivity C-reactive protein levels in the acute phase. We compared stroke patients' profiles with 42 people experiencing spontaneous cervical artery dissection without stroke. Furthermore, variations in cytokine levels among stroke aetiologies were analysed. Follow-up samples were collected in a subgroup of ischaemic stroke patients at three and twelve months. Ischaemic stroke patients had elevated plasma levels of HGF and SDF-1α, and lower IL-4 levels, compared to spontaneous cervical artery dissection patients without stroke. Aetiology-subgroup analysis revealed reduced levels of nine cytokines/chemokines (HGF, SDF-1α, IL-2R, CD30, TNF-RII, IL-16, MIF, APRIL, SCF), and elevated levels of IL-4 and MIP-1β, in spontaneous cervical artery dissection (with or without ischaemic stroke as levels were comparable between both groups) compared to other aetiologies. The majority of cytokine/chemokine levels remained stable across the study period. Our research indicates that stroke due to large artery atherosclerosis, cardioembolism, and small vessel occlusion triggers a stronger inflammatory response than spontaneous cervical artery dissection.
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Affiliation(s)
- Angelika Bauer
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- VASCage Research Centre on Vascular Ageing and Stroke, Innsbruck, Austria
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Boehme
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Lukas Mayer-Suess
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Dagmar Rudzki
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- VASCage Research Centre on Vascular Ageing and Stroke, Innsbruck, Austria
| | - Michael Knoflach
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- VASCage Research Centre on Vascular Ageing and Stroke, Innsbruck, Austria
| | - Stefan Kiechl
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- VASCage Research Centre on Vascular Ageing and Stroke, Innsbruck, Austria
| | - Markus Reindl
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.
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12
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Jung HS, Lee EJ, Chang DI, Cho HJ, Lee J, Cha JK, Park MS, Yu KH, Jung JM, Ahn SH, Kim DE, Lee JH, Hong KS, Sohn SI, Park KP, Kwon SU, Kim JS, Chang JY, Kim BJ, Kang DW. A Multimodal Ensemble Deep Learning Model for Functional Outcome Prognosis of Stroke Patients. J Stroke 2024; 26:312-320. [PMID: 38836278 PMCID: PMC11164594 DOI: 10.5853/jos.2023.03426] [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: 10/13/2023] [Accepted: 04/23/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND AND PURPOSE The accurate prediction of functional outcomes in patients with acute ischemic stroke (AIS) is crucial for informed clinical decision-making and optimal resource utilization. As such, this study aimed to construct an ensemble deep learning model that integrates multimodal imaging and clinical data to predict the 90-day functional outcomes after AIS. METHODS We used data from the Korean Stroke Neuroimaging Initiative database, a prospective multicenter stroke registry to construct an ensemble model integrated individual 3D convolutional neural networks for diffusion-weighted imaging and fluid-attenuated inversion recovery (FLAIR), along with a deep neural network for clinical data, to predict 90-day functional independence after AIS using a modified Rankin Scale (mRS) of 3-6. To evaluate the performance of the ensemble model, we compared the area under the curve (AUC) of the proposed method with that of individual models trained on each modality to identify patients with AIS with an mRS score of 3-6. RESULTS Of the 2,606 patients with AIS, 993 (38.1%) achieved an mRS score of 3-6 at 90 days post-stroke. Our model achieved AUC values of 0.830 (standard cross-validation [CV]) and 0.779 (time-based CV), which significantly outperformed the other models relying on single modalities: b-value of 1,000 s/mm2 (P<0.001), apparent diffusion coefficient map (P<0.001), FLAIR (P<0.001), and clinical data (P=0.004). CONCLUSION The integration of multimodal imaging and clinical data resulted in superior prediction of the 90-day functional outcomes in AIS patients compared to the use of a single data modality.
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Affiliation(s)
- Hye-Soo Jung
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun-Jae Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae-Il Chang
- Department of Neurology, Kyung Hee University Medical Center, Seoul, Korea
| | - Han Jin Cho
- Department of Neurology, Pusan National University Hospital, Busan, Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Medical Center, Daegu, Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, Korea
| | - Man-Seok Park
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - Kyung Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Jin-Man Jung
- Department of Neurology, Korea University Ansan Hospital, Ansan, Korea
| | - Seong Hwan Ahn
- Department of Neurology, Chosun University Hospital, Gwangju, Korea
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Ilsan, Korea
| | - Ju Hun Lee
- Department of Neurology, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Keun-Sik Hong
- Department of Neurology, Inje University Ilsan Paik Hospital, Ilsan, Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Medical Center, Daegu, Korea
| | - Kyung-Pil Park
- Department of Neurology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sun U Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong S Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun Young Chang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bum Joon Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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13
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Ospel JM, Rinkel L, Ganesh A, Demchuk A, Joshi M, Poppe A, McTaggart R, Nogueira R, Menon B, Tymianski M, Hill MD, Goyal M. Influence of Infarct Morphology and Patterns on Cognitive Outcomes After Endovascular Thrombectomy. Stroke 2024; 55:1349-1358. [PMID: 38511330 DOI: 10.1161/strokeaha.123.045825] [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: 11/12/2023] [Accepted: 02/23/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND To assess the association of qualitative and quantitative infarct characteristics and 3 cognitive outcome tests, namely the Montreal Cognitive Assessment (MOCA) for mild cognitive impairment, the Boston Naming Test for visual confrontation naming, and the Sunnybrook Neglect Assessment Procedure for neglect, in large vessel occlusion stroke. METHODS Secondary observational cohort study using data from the randomized-controlled ESCAPE-NA1 trial (Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke), in which patients with large vessel occlusion undergoing endovascular treatment were randomized to receive either intravenous Nerinetide or placebo. MOCA, Sunnybrook Neglect Assessment Procedure, and 15-item Boston Naming Test were obtained at 90 days. Total infarct volume, gray matter, and white matter infarct volumes were manually measured on 24-hour follow-up imaging. Infarcts were also visually classified as either involving the gray matter only or both the gray and white matter and scattered versus territorial. Associations of infarct variables and cognitive outcomes were analyzed using multivariable ordinal or binary logistic regression models. RESULTS Of 1105 patients enrolled in ESCAPE-NA1, 1026 patients with visible infarcts on 24-hour follow-up imaging were included. MOCA and Sunnybrook Neglect Assessment Procedure were available for 706 (68.8%) patients and the 15-item Boston Naming Test was available for 682 (66.5%) patients. Total infarct volume was associated with worse MOCA scores (adjusted common odds ratio per 10 mL increase, 1.05 [95% CI, 1.04-1.06]). After adjusting for baseline variables and total infarct volume, mixed gray and white matter involvement (versus gray matter-only adjusted common odds ratio, 1.92 [95% CI, 1.37-2.69]), white matter infarct volume (adjusted common odds ratio per 10 mL increase 1.36 [95% CI, 1.18-1.58]) and territorial (versus scattered) infarct pattern (adjusted common odds ratio, 1.65 [95% CI, 1.15-2.38]) were associated with worse MOCA scores. Results for Sunnybrook Neglect Assessment Procedure and 15-item Boston Naming Test were similar, except for the territorial infarct pattern, which did not reach statistical significance in multivariable analysis. CONCLUSIONS Besides total infarct volume, infarcts that involve the white matter and that show a territorial distribution were associated with worse cognitive outcomes, even after adjusting for total infarct volume.
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Affiliation(s)
- Johanna Maria Ospel
- Departments of Diagnostic Imaging (J.M.O., M.J., M.D.H., M.G.), Foothills Medical Center, University of Calgary, AB, Canada
- Neurosciences (J.M.O., L.R., A.G., A.D., M.J., B.M., M.D.H., M.G.), Foothills Medical Center, University of Calgary, AB, Canada
| | - Leon Rinkel
- Neurosciences (J.M.O., L.R., A.G., A.D., M.J., B.M., M.D.H., M.G.), Foothills Medical Center, University of Calgary, AB, Canada
- Department of Neurology, Amsterdam University Medical Centers, Amsterdam, the Netherlands (L.R.)
| | - Aravind Ganesh
- Neurosciences (J.M.O., L.R., A.G., A.D., M.J., B.M., M.D.H., M.G.), Foothills Medical Center, University of Calgary, AB, Canada
| | - Andrew Demchuk
- Neurosciences (J.M.O., L.R., A.G., A.D., M.J., B.M., M.D.H., M.G.), Foothills Medical Center, University of Calgary, AB, Canada
| | - Manish Joshi
- Departments of Diagnostic Imaging (J.M.O., M.J., M.D.H., M.G.), Foothills Medical Center, University of Calgary, AB, Canada
- Neurosciences (J.M.O., L.R., A.G., A.D., M.J., B.M., M.D.H., M.G.), Foothills Medical Center, University of Calgary, AB, Canada
| | - Alexandre Poppe
- Centre Hospitalier de l'Université de Montréal, QC, Canada (A.P.)
| | - Ryan McTaggart
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA (R.N.)
| | - Raul Nogueira
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA (R.N.)
| | - Bijoy Menon
- Departments of Diagnostic Imaging (J.M.O., M.J., M.D.H., M.G.), Foothills Medical Center, University of Calgary, AB, Canada
| | | | - Michael Douglas Hill
- Departments of Diagnostic Imaging (J.M.O., M.J., M.D.H., M.G.), Foothills Medical Center, University of Calgary, AB, Canada
- Neurosciences (J.M.O., L.R., A.G., A.D., M.J., B.M., M.D.H., M.G.), Foothills Medical Center, University of Calgary, AB, Canada
| | - Mayank Goyal
- Departments of Diagnostic Imaging (J.M.O., M.J., M.D.H., M.G.), Foothills Medical Center, University of Calgary, AB, Canada
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14
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Kniep H, Meyer L, Broocks G, Bechstein M, Austein F, McDonough RV, Brekenfeld C, Flottmann F, Deb-Chatterji M, Alegiani A, Hanning U, Thomalla G, Fiehler J, Gellissen S. How much of the outcome improvement after successful recanalization is explained by follow-up infarct volume reduction? J Neurointerv Surg 2024; 16:459-465. [PMID: 37230748 DOI: 10.1136/jnis-2023-020296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/15/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Follow-up infarct volume (FIV) is used as surrogate for treatment efficiency in mechanical thrombectomy (MT). However, previous works suggest that MT-related FIV reduction has only limited association with outcome comparing MT independently of recanalization success versus medical care. It remains unclear to what extent the relationship between successful recanalization versus persistent occlusion and functional outcome is explained by FIV reduction. OBJECTIVE To determine whether FIV mediates the relationship between successful recanalization and functional outcome. METHODS All patients from our institution enrolled in the German Stroke Registry (May 2015-December 2019) with anterior circulation stroke; availability of the relevant clinical data, and follow-up-CT were analyzed. The effect of FIV reduction on functional outcome (90-day modified Rankin Scale (mRS) score ≤2) after successful recanalization (Thrombolysis in Cerebral Infarction ≥2b) was quantified using mediation analysis. RESULTS 429 patients were included, of whom, 309 (72 %) had successful recanalization and 127 (39%) had good functional outcome. Good outcome was associated with age (OR=0.89, P<0.001), pre-stroke mRS score (OR=0.38, P<0.001), FIV (OR=0.98, P<0.001), hypertension (OR=2.08, P<0.05), and successful recanalization (OR=3.57, P<0.01). Using linear regression in the mediator pathway, FIV was associated with Alberta Stroke program Early CT Score (coefficient (Co)=-26.13, P<0.001), admission National Institutes of Health Stroke Scale score (Co=3.69, P<0.001), age (Co=-1.18, P<0.05), and successful recanalization (Co=-85.22, P<0.001). Successful recanalization increased the probability of good outcome by 23 percentage points (pp) (95% CI 16pp to 29pp). 56% (95% CI 38% to 78%) of the improvement in good outcome was explained by FIV reduction. CONCLUSION 56% (95% CI 38% to 78%) of outcome improvement after successful recanalization was explained by FIV reduction. Results corroborate pathophysiological assumptions and confirm the value of FIV as an imaging endpoint in clinical trials. 44% (95% CI 22% to 62%) of the improvement in outcome was not explained by FIV reduction and reflects the remaining mismatch between radiological and clinical outcome measures.
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Affiliation(s)
- Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friederike Austein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie V McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Schleswig-Holstein Campus Kiel, Kiel, Schleswig-Holstein, Germany
| | - Anna Alegiani
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellissen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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15
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Li Q, Guo J, Chen HS, Blauenfeldt RA, Hess DC, Pico F, Khatri P, Campbell BCV, Feng X, Abdalkader M, Saver JL, Nogueira RG, Jiang B, Li B, Yang M, Sang H, Yang Q, Qiu Z, Dai Y, Nguyen TN. Remote Ischemic Conditioning With Medical Management or Reperfusion Therapy for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Neurology 2024; 102:e207983. [PMID: 38457772 PMCID: PMC11033986 DOI: 10.1212/wnl.0000000000207983] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/13/2023] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Remote ischemic conditioning (RIC) is a low-cost, accessible, and noninvasive neuroprotective treatment strategy, but its efficacy and safety in acute ischemic stroke are controversial. With the publication of several randomized controlled trials (RCTs) and the recent results of the RESIST trial, it may be possible to identify the patient population that may (or may not) benefit from RIC. This systematic review and meta-analysis aims to evaluate the effectiveness and safety of RIC in patients with ischemic stroke receiving different treatments by pooling data of all randomized controlled studies to date. METHODS We searched the PubMed, Embase, Cochrane, Elsevier, and Web of Science databases to obtain articles in all languages from inception until May 25, 2023. The primary outcome was the modified Rankin Scale (mRS) score at the specified endpoint time in the trial. The secondary outcomes were change in NIH Stroke Scale (NIHSS) and recurrence of stroke events. The safety outcomes were cardiovascular events, cerebral hemorrhage, and mortality. The quality of articles was evaluated through the Cochrane risk assessment tool. This study was registered in PROSPERO (CRD42023430073). RESULTS There were 7,657 patients from 22 RCTs included. Compared with the control group, patients who received RIC did not have improved mRS functional outcomes, regardless of whether they received medical management, reperfusion therapy with intravenous thrombolysis (IVT), or mechanical thrombectomy (MT). In the medical management group, patients who received RIC had decreased incidence of stroke recurrence (risk ratio 0.63, 95% CI 0.43-0.92, p = 0.02) and lower follow-up NIHSS score by 1.72 points compared with the control group (p < 0.00001). There was no increased risk of adverse events including death or cerebral hemorrhage in the IVT or medical management group. DISCUSSION In patients with ischemic stroke who are not eligible for reperfusion therapy, RIC did not affect mRS functional outcomes but significantly improved the NIHSS score at the follow-up endpoint and reduced stroke recurrence, without increasing the risk of cerebral hemorrhage or death. In patients who received IVT or MT, the benefit of RIC was not observed.
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Affiliation(s)
- Qi Li
- From the Department of Neurology (Q.L., X.F., B.J., B.L., M.Y., Z.Q., Y.D.), The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou; Intensive Care Unit of Department of Neurology (J.G.), Ningbo Medical Center Lihuili Hospital; Department of Neurology (H.-S.C.), General Hospital of Northern Theater Command, Shenyang, China; Department of Neurology (R.A.B.), Aarhus University Hospital, Denmark; Department of Neurology (D.C.H.), Medical College of Georgia, Augusta University, Augusta; Neurology and Stroke Center (F.P.), Versailles Mignot Hospital, Paris, France; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Boston Medical Center (M.A., T.N.N.), Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (J.L.S.), University of California in Los Angeles; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Department of Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; and Department of Neurology (Q.Y.), Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Jinxiu Guo
- From the Department of Neurology (Q.L., X.F., B.J., B.L., M.Y., Z.Q., Y.D.), The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou; Intensive Care Unit of Department of Neurology (J.G.), Ningbo Medical Center Lihuili Hospital; Department of Neurology (H.-S.C.), General Hospital of Northern Theater Command, Shenyang, China; Department of Neurology (R.A.B.), Aarhus University Hospital, Denmark; Department of Neurology (D.C.H.), Medical College of Georgia, Augusta University, Augusta; Neurology and Stroke Center (F.P.), Versailles Mignot Hospital, Paris, France; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Boston Medical Center (M.A., T.N.N.), Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (J.L.S.), University of California in Los Angeles; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Department of Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; and Department of Neurology (Q.Y.), Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Hui-Sheng Chen
- From the Department of Neurology (Q.L., X.F., B.J., B.L., M.Y., Z.Q., Y.D.), The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou; Intensive Care Unit of Department of Neurology (J.G.), Ningbo Medical Center Lihuili Hospital; Department of Neurology (H.-S.C.), General Hospital of Northern Theater Command, Shenyang, China; Department of Neurology (R.A.B.), Aarhus University Hospital, Denmark; Department of Neurology (D.C.H.), Medical College of Georgia, Augusta University, Augusta; Neurology and Stroke Center (F.P.), Versailles Mignot Hospital, Paris, France; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Boston Medical Center (M.A., T.N.N.), Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (J.L.S.), University of California in Los Angeles; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Department of Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; and Department of Neurology (Q.Y.), Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Rolf Ankerlund Blauenfeldt
- From the Department of Neurology (Q.L., X.F., B.J., B.L., M.Y., Z.Q., Y.D.), The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou; Intensive Care Unit of Department of Neurology (J.G.), Ningbo Medical Center Lihuili Hospital; Department of Neurology (H.-S.C.), General Hospital of Northern Theater Command, Shenyang, China; Department of Neurology (R.A.B.), Aarhus University Hospital, Denmark; Department of Neurology (D.C.H.), Medical College of Georgia, Augusta University, Augusta; Neurology and Stroke Center (F.P.), Versailles Mignot Hospital, Paris, France; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Boston Medical Center (M.A., T.N.N.), Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (J.L.S.), University of California in Los Angeles; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Department of Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; and Department of Neurology (Q.Y.), Xinqiao Hospital of Army Medical University, Chongqing, China
| | - David C Hess
- From the Department of Neurology (Q.L., X.F., B.J., B.L., M.Y., Z.Q., Y.D.), The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou; Intensive Care Unit of Department of Neurology (J.G.), Ningbo Medical Center Lihuili Hospital; Department of Neurology (H.-S.C.), General Hospital of Northern Theater Command, Shenyang, China; Department of Neurology (R.A.B.), Aarhus University Hospital, Denmark; Department of Neurology (D.C.H.), Medical College of Georgia, Augusta University, Augusta; Neurology and Stroke Center (F.P.), Versailles Mignot Hospital, Paris, France; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Boston Medical Center (M.A., T.N.N.), Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (J.L.S.), University of California in Los Angeles; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Department of Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; and Department of Neurology (Q.Y.), Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Fernando Pico
- From the Department of Neurology (Q.L., X.F., B.J., B.L., M.Y., Z.Q., Y.D.), The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou; Intensive Care Unit of Department of Neurology (J.G.), Ningbo Medical Center Lihuili Hospital; Department of Neurology (H.-S.C.), General Hospital of Northern Theater Command, Shenyang, China; Department of Neurology (R.A.B.), Aarhus University Hospital, Denmark; Department of Neurology (D.C.H.), Medical College of Georgia, Augusta University, Augusta; Neurology and Stroke Center (F.P.), Versailles Mignot Hospital, Paris, France; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Boston Medical Center (M.A., T.N.N.), Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (J.L.S.), University of California in Los Angeles; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Department of Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; and Department of Neurology (Q.Y.), Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Pooja Khatri
- From the Department of Neurology (Q.L., X.F., B.J., B.L., M.Y., Z.Q., Y.D.), The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou; Intensive Care Unit of Department of Neurology (J.G.), Ningbo Medical Center Lihuili Hospital; Department of Neurology (H.-S.C.), General Hospital of Northern Theater Command, Shenyang, China; Department of Neurology (R.A.B.), Aarhus University Hospital, Denmark; Department of Neurology (D.C.H.), Medical College of Georgia, Augusta University, Augusta; Neurology and Stroke Center (F.P.), Versailles Mignot Hospital, Paris, France; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Boston Medical Center (M.A., T.N.N.), Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (J.L.S.), University of California in Los Angeles; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Department of Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; and Department of Neurology (Q.Y.), Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Bruce C V Campbell
- From the Department of Neurology (Q.L., X.F., B.J., B.L., M.Y., Z.Q., Y.D.), The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou; Intensive Care Unit of Department of Neurology (J.G.), Ningbo Medical Center Lihuili Hospital; Department of Neurology (H.-S.C.), General Hospital of Northern Theater Command, Shenyang, China; Department of Neurology (R.A.B.), Aarhus University Hospital, Denmark; Department of Neurology (D.C.H.), Medical College of Georgia, Augusta University, Augusta; Neurology and Stroke Center (F.P.), Versailles Mignot Hospital, Paris, France; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Boston Medical Center (M.A., T.N.N.), Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (J.L.S.), University of California in Los Angeles; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Department of Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; and Department of Neurology (Q.Y.), Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Xinggang Feng
- From the Department of Neurology (Q.L., X.F., B.J., B.L., M.Y., Z.Q., Y.D.), The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou; Intensive Care Unit of Department of Neurology (J.G.), Ningbo Medical Center Lihuili Hospital; Department of Neurology (H.-S.C.), General Hospital of Northern Theater Command, Shenyang, China; Department of Neurology (R.A.B.), Aarhus University Hospital, Denmark; Department of Neurology (D.C.H.), Medical College of Georgia, Augusta University, Augusta; Neurology and Stroke Center (F.P.), Versailles Mignot Hospital, Paris, France; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Boston Medical Center (M.A., T.N.N.), Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (J.L.S.), University of California in Los Angeles; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Department of Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; and Department of Neurology (Q.Y.), Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Mohamad Abdalkader
- From the Department of Neurology (Q.L., X.F., B.J., B.L., M.Y., Z.Q., Y.D.), The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou; Intensive Care Unit of Department of Neurology (J.G.), Ningbo Medical Center Lihuili Hospital; Department of Neurology (H.-S.C.), General Hospital of Northern Theater Command, Shenyang, China; Department of Neurology (R.A.B.), Aarhus University Hospital, Denmark; Department of Neurology (D.C.H.), Medical College of Georgia, Augusta University, Augusta; Neurology and Stroke Center (F.P.), Versailles Mignot Hospital, Paris, France; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Boston Medical Center (M.A., T.N.N.), Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (J.L.S.), University of California in Los Angeles; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Department of Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; and Department of Neurology (Q.Y.), Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Jeffrey L Saver
- From the Department of Neurology (Q.L., X.F., B.J., B.L., M.Y., Z.Q., Y.D.), The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou; Intensive Care Unit of Department of Neurology (J.G.), Ningbo Medical Center Lihuili Hospital; Department of Neurology (H.-S.C.), General Hospital of Northern Theater Command, Shenyang, China; Department of Neurology (R.A.B.), Aarhus University Hospital, Denmark; Department of Neurology (D.C.H.), Medical College of Georgia, Augusta University, Augusta; Neurology and Stroke Center (F.P.), Versailles Mignot Hospital, Paris, France; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Boston Medical Center (M.A., T.N.N.), Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (J.L.S.), University of California in Los Angeles; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Department of Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; and Department of Neurology (Q.Y.), Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Raul G Nogueira
- From the Department of Neurology (Q.L., X.F., B.J., B.L., M.Y., Z.Q., Y.D.), The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou; Intensive Care Unit of Department of Neurology (J.G.), Ningbo Medical Center Lihuili Hospital; Department of Neurology (H.-S.C.), General Hospital of Northern Theater Command, Shenyang, China; Department of Neurology (R.A.B.), Aarhus University Hospital, Denmark; Department of Neurology (D.C.H.), Medical College of Georgia, Augusta University, Augusta; Neurology and Stroke Center (F.P.), Versailles Mignot Hospital, Paris, France; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Boston Medical Center (M.A., T.N.N.), Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (J.L.S.), University of California in Los Angeles; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Department of Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; and Department of Neurology (Q.Y.), Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Bingwu Jiang
- From the Department of Neurology (Q.L., X.F., B.J., B.L., M.Y., Z.Q., Y.D.), The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou; Intensive Care Unit of Department of Neurology (J.G.), Ningbo Medical Center Lihuili Hospital; Department of Neurology (H.-S.C.), General Hospital of Northern Theater Command, Shenyang, China; Department of Neurology (R.A.B.), Aarhus University Hospital, Denmark; Department of Neurology (D.C.H.), Medical College of Georgia, Augusta University, Augusta; Neurology and Stroke Center (F.P.), Versailles Mignot Hospital, Paris, France; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Boston Medical Center (M.A., T.N.N.), Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (J.L.S.), University of California in Los Angeles; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Department of Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; and Department of Neurology (Q.Y.), Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Bing Li
- From the Department of Neurology (Q.L., X.F., B.J., B.L., M.Y., Z.Q., Y.D.), The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou; Intensive Care Unit of Department of Neurology (J.G.), Ningbo Medical Center Lihuili Hospital; Department of Neurology (H.-S.C.), General Hospital of Northern Theater Command, Shenyang, China; Department of Neurology (R.A.B.), Aarhus University Hospital, Denmark; Department of Neurology (D.C.H.), Medical College of Georgia, Augusta University, Augusta; Neurology and Stroke Center (F.P.), Versailles Mignot Hospital, Paris, France; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Boston Medical Center (M.A., T.N.N.), Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (J.L.S.), University of California in Los Angeles; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Department of Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; and Department of Neurology (Q.Y.), Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Min Yang
- From the Department of Neurology (Q.L., X.F., B.J., B.L., M.Y., Z.Q., Y.D.), The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou; Intensive Care Unit of Department of Neurology (J.G.), Ningbo Medical Center Lihuili Hospital; Department of Neurology (H.-S.C.), General Hospital of Northern Theater Command, Shenyang, China; Department of Neurology (R.A.B.), Aarhus University Hospital, Denmark; Department of Neurology (D.C.H.), Medical College of Georgia, Augusta University, Augusta; Neurology and Stroke Center (F.P.), Versailles Mignot Hospital, Paris, France; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Boston Medical Center (M.A., T.N.N.), Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (J.L.S.), University of California in Los Angeles; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Department of Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; and Department of Neurology (Q.Y.), Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Hongfei Sang
- From the Department of Neurology (Q.L., X.F., B.J., B.L., M.Y., Z.Q., Y.D.), The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou; Intensive Care Unit of Department of Neurology (J.G.), Ningbo Medical Center Lihuili Hospital; Department of Neurology (H.-S.C.), General Hospital of Northern Theater Command, Shenyang, China; Department of Neurology (R.A.B.), Aarhus University Hospital, Denmark; Department of Neurology (D.C.H.), Medical College of Georgia, Augusta University, Augusta; Neurology and Stroke Center (F.P.), Versailles Mignot Hospital, Paris, France; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Boston Medical Center (M.A., T.N.N.), Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (J.L.S.), University of California in Los Angeles; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Department of Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; and Department of Neurology (Q.Y.), Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Qingwu Yang
- From the Department of Neurology (Q.L., X.F., B.J., B.L., M.Y., Z.Q., Y.D.), The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou; Intensive Care Unit of Department of Neurology (J.G.), Ningbo Medical Center Lihuili Hospital; Department of Neurology (H.-S.C.), General Hospital of Northern Theater Command, Shenyang, China; Department of Neurology (R.A.B.), Aarhus University Hospital, Denmark; Department of Neurology (D.C.H.), Medical College of Georgia, Augusta University, Augusta; Neurology and Stroke Center (F.P.), Versailles Mignot Hospital, Paris, France; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Boston Medical Center (M.A., T.N.N.), Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (J.L.S.), University of California in Los Angeles; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Department of Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; and Department of Neurology (Q.Y.), Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Zhongming Qiu
- From the Department of Neurology (Q.L., X.F., B.J., B.L., M.Y., Z.Q., Y.D.), The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou; Intensive Care Unit of Department of Neurology (J.G.), Ningbo Medical Center Lihuili Hospital; Department of Neurology (H.-S.C.), General Hospital of Northern Theater Command, Shenyang, China; Department of Neurology (R.A.B.), Aarhus University Hospital, Denmark; Department of Neurology (D.C.H.), Medical College of Georgia, Augusta University, Augusta; Neurology and Stroke Center (F.P.), Versailles Mignot Hospital, Paris, France; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Boston Medical Center (M.A., T.N.N.), Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (J.L.S.), University of California in Los Angeles; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Department of Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; and Department of Neurology (Q.Y.), Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Yi Dai
- From the Department of Neurology (Q.L., X.F., B.J., B.L., M.Y., Z.Q., Y.D.), The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou; Intensive Care Unit of Department of Neurology (J.G.), Ningbo Medical Center Lihuili Hospital; Department of Neurology (H.-S.C.), General Hospital of Northern Theater Command, Shenyang, China; Department of Neurology (R.A.B.), Aarhus University Hospital, Denmark; Department of Neurology (D.C.H.), Medical College of Georgia, Augusta University, Augusta; Neurology and Stroke Center (F.P.), Versailles Mignot Hospital, Paris, France; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Boston Medical Center (M.A., T.N.N.), Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (J.L.S.), University of California in Los Angeles; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Department of Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; and Department of Neurology (Q.Y.), Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Thanh N Nguyen
- From the Department of Neurology (Q.L., X.F., B.J., B.L., M.Y., Z.Q., Y.D.), The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou; Intensive Care Unit of Department of Neurology (J.G.), Ningbo Medical Center Lihuili Hospital; Department of Neurology (H.-S.C.), General Hospital of Northern Theater Command, Shenyang, China; Department of Neurology (R.A.B.), Aarhus University Hospital, Denmark; Department of Neurology (D.C.H.), Medical College of Georgia, Augusta University, Augusta; Neurology and Stroke Center (F.P.), Versailles Mignot Hospital, Paris, France; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Boston Medical Center (M.A., T.N.N.), Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (J.L.S.), University of California in Los Angeles; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Department of Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; and Department of Neurology (Q.Y.), Xinqiao Hospital of Army Medical University, Chongqing, China
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16
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Palsson F, Forkert ND, Meyer L, Broocks G, Flottmann F, Maros ME, Bechstein M, Winkelmeier L, Schlemm E, Fiehler J, Gellißen S, Kniep HC. Prediction of tissue outcome in acute ischemic stroke based on single-phase CT angiography at admission. Front Neurol 2024; 15:1330497. [PMID: 38566856 PMCID: PMC10985353 DOI: 10.3389/fneur.2024.1330497] [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: 10/30/2023] [Accepted: 03/05/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction In acute ischemic stroke, prediction of the tissue outcome after reperfusion can be used to identify patients that might benefit from mechanical thrombectomy (MT). The aim of this work was to develop a deep learning model that can predict the follow-up infarct location and extent exclusively based on acute single-phase computed tomography angiography (CTA) datasets. In comparison to CT perfusion (CTP), CTA imaging is more widely available, less prone to artifacts, and the established standard of care in acute stroke imaging protocols. Furthermore, recent RCTs have shown that also patients with large established infarctions benefit from MT, which might not have been selected for MT based on CTP core/penumbra mismatch analysis. Methods All patients with acute large vessel occlusion of the anterior circulation treated at our institution between 12/2015 and 12/2020 were screened (N = 404) and 238 patients undergoing MT with successful reperfusion were included for final analysis. Ground truth infarct lesions were segmented on 24 h follow-up CT scans. Pre-processed CTA images were used as input for a U-Net-based convolutional neural network trained for lesion prediction, enhanced with a spatial and channel-wise squeeze-and-excitation block. Post-processing was applied to remove small predicted lesion components. The model was evaluated using a 5-fold cross-validation and a separate test set with Dice similarity coefficient (DSC) as the primary metric and average volume error as the secondary metric. Results The mean ± standard deviation test set DSC over all folds after post-processing was 0.35 ± 0.2 and the mean test set average volume error was 11.5 mL. The performance was relatively uniform across models with the best model according to the DSC achieved a score of 0.37 ± 0.2 after post-processing and the best model in terms of average volume error yielded 3.9 mL. Conclusion 24 h follow-up infarct prediction using acute CTA imaging exclusively is feasible with DSC measures comparable to results of CTP-based algorithms reported in other studies. The proposed method might pave the way to a wider acceptance, feasibility, and applicability of follow-up infarct prediction based on artificial intelligence.
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Affiliation(s)
- Frosti Palsson
- deCODE Genetics Inc., Reykjavik, Iceland
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nils D. Forkert
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Máté E. Maros
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eckhard Schlemm
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge C. Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Yi JS, Ki HJ, Jeon YS, Park JJ, Lee TJ, Kwak JT, Lee SB, Lee HJ, Kim IS, Kim JH, Lee JS, Roh HG, Kim HJ. The collateral map: prediction of lesion growth and penumbra after acute anterior circulation ischemic stroke. Eur Radiol 2024; 34:1411-1421. [PMID: 37646808 PMCID: PMC10873223 DOI: 10.1007/s00330-023-10084-6] [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: 03/26/2023] [Revised: 07/03/2023] [Accepted: 07/15/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVES This study evaluated the collateral map's ability to predict lesion growth and penumbra after acute anterior circulation ischemic strokes. METHODS This was a retrospective analysis of selected data from a prospectively collected database. The lesion growth ratio was the ratio of the follow-up lesion volume to the baseline lesion volume on diffusion-weighted imaging (DWI). The time-to-maximum (Tmax)/DWI ratio was the ratio of the baseline Tmax > 6 s volume to the baseline lesion volume. The collateral ratio was the ratio of the hypoperfused lesion volume of the phase_FU (phase with the hypoperfused lesions most approximate to the follow-up DWI lesion) to the hypoperfused lesion volume of the phase_baseline of the collateral map. Multiple logistic regression analyses were conducted to identify independent predictors of lesion growth. The concordance correlation coefficients of Tmax/DWI ratio and collateral ratio for lesion growth ratio were analyzed. RESULTS Fifty-two patients, including twenty-six males (mean age, 74 years), were included. Intermediate (OR, 1234.5; p < 0.001) and poor collateral perfusion grades (OR, 664.7; p = 0.006) were independently associated with lesion growth. Phase_FUs were immediately preceded phases of the phase_baselines in intermediate or poor collateral perfusion grades. The concordance correlation coefficients of the Tmax/DWI ratio and collateral ratio for the lesion growth ratio were 0.28 (95% CI, 0.17-0.38) and 0.88 (95% CI, 0.82-0.92), respectively. CONCLUSION Precise prediction of lesion growth and penumbra can be possible using collateral maps, allowing for personalized application of recanalization treatments. Further studies are needed to generalize the findings of this study. CLINICAL RELEVANCE STATEMENT Precise prediction of lesion growth and penumbra can be possible using collateral maps, allowing for personalized application of recanalization treatments. KEY POINTS • Cell viability in cerebral ischemia due to proximal arterial steno-occlusion mainly depends on the collateral circulation. • The collateral map shows salvageable brain extent, which can survive by recanalization treatments after acute anterior circulation ischemic stroke. • Precise estimation of salvageable brain makes it possible to make patient-specific treatment decision.
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Affiliation(s)
- Jin Seok Yi
- Department of Neurosurgery, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Republic of Korea
| | - Hee Jong Ki
- Department of Neurosurgery, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Republic of Korea
| | - Yoo Sung Jeon
- Department of Neurosurgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Jeong Jin Park
- Department of Neurology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
- Department of Neurosurgery, Kangwon National University College of Medicine, Chuncheon, Republic of Korea
| | - Taek-Jun Lee
- Department of Neurology, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Republic of Korea
| | - Jin Tae Kwak
- School of Electrical Engineering, Korea University, Seoul, Republic of Korea
| | - Sang Bong Lee
- Department of Neurology, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Republic of Korea
| | - Hyung Jin Lee
- Department of Neurosurgery, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Republic of Korea
| | - In Seong Kim
- Siemens Healthineers Ltd., Seoul, Republic of Korea
| | - Joo Hyun Kim
- Philips Healthcare Korea, Seoul, Republic of Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Institute for Life Science, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hong Gee Roh
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, 120-1 Neungdong-Ro, Kwangjin-Gu, Seoul, 05030, Republic of Korea.
| | - Hyun Jeong Kim
- Department of Radiology, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 64 Daeheung-Ro, Jung-Gu, Daejeon, 34943, Republic of Korea.
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18
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Rostami A, Elyassirad D, Vatanparast M, Abouei Mehrizi MA, Hasanpour M, Rezaee H, Haghir A, Keykhosravi E. Functional Outcome and Mortality Predictors in Patients with Cerebral Ischemic Infarction After Decompressive Craniectomy: Cross-Sectional Study. World Neurosurg 2024; 182:e847-e853. [PMID: 38101538 DOI: 10.1016/j.wneu.2023.12.058] [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: 11/27/2023] [Accepted: 12/09/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE Surgeons commonly perform Decompressive craniectomy (DC) to manage patients with cerebral ischemic infarction. However, there are conflicting data on the long-term functional outcomes following DC. Therefore, this study aims to determine the functional outcome of patients with cerebral ischemic infarction after DC. METHODS This prospective and retrospective cross-sectional study included 148 patients with cerebral ischemic infarction who underwent DC at Ghaem Hospital, Mashhad, Iran, from March 2011 to March 2021. The Modified Rankin Scale (mRS) assesses disability in these patients and determines the recovery and degree of long-term functional outcomes. Demographic and clinical data were extracted and recorded in a researcher-made questionnaire. RESULTS In summary, the follow-up revealed a survival rate of 39.2% among patients with ischemic stroke. The comparison of the mean infarct volume in patients with various mRS scores showed that the mean infarct volume was significantly higher in patients with unfavorable functional outcomes, based on mRS scores at discharge (P = 0.05), 3 months mRS (P < 0.01), and mRS score at final follow-up (P = 0.01). Final mortality was higher in patients with higher mRS scores at discharge, after 3 months, and final follow-up (P < 0.01). Older age and infarction volume can predict mRS and mortality in patients with ischemic stroke (P < 0.01). CONCLUSIONS The present study showed that mortality and mRS scores at various times are associated with infarction volume and older age in patients with ischemic stroke.
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Affiliation(s)
- Amin Rostami
- Department of Neurosurgery, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Daniel Elyassirad
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahsa Vatanparast
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Mohammad Hasanpour
- Department of Neurosurgery, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Rezaee
- Department of Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amirhosein Haghir
- Department of Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ehsan Keykhosravi
- Department of Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Iran.
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Fladt J, Guo J, Specht JL, Wang M, Chan LL, Mctaggart R, Buck BH, Aviv R, Swartz RH, Field TS, Tarpley J, Shah R, Goyal M, Tymianski M, Hill MD, Demchuk A, d'Esterre C, Barber P. Infarct Evolution on MR-DWI After Thrombectomy in Acute Stroke Patients Randomized to Nerinetide or Placebo: The REPERFUSE-NA1 Study. Neurology 2024; 102:e207976. [PMID: 38165335 DOI: 10.1212/wnl.0000000000207976] [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: 03/16/2023] [Accepted: 09/27/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The neuroprotectant nerinetide has shown promise in reducing infarct volumes in primate models of ischemia reperfusion. We hypothesized that early secondary infarct growth after endovascular therapy (EVT) (1) may be a suitable surrogate biomarker for testing neuroprotective compounds, (2) is feasible to assess in the acute setting using sequential MRI, and (3) can be modified by treatment with nerinetide. METHODS REPERFUSE-NA1 was a prospective, multisite MRI substudy of the randomized controlled trial ESCAPE-NA1 (ClinicalTrials.gov NCT02930018) that involved patients with acute disabling large vessel occlusive stroke undergoing EVT within 12 hours of onset who were randomized to receive intravenous nerinetide or placebo. Patients enrolled in REPERFUSE-NA1 underwent sequential MRI <5 hours post-EVT (day 1) and at 24 hours (day 2). The primary outcome was total diffusion-weighted MRI infarct growth early after EVT, defined as the lesion volume difference between day 2 and day 1. The secondary outcome was region-specific infarct growth in different brain tissue compartments. Statistical analyses were performed using the Mann-Whitney U test and multiple linear regression. RESULTS Sixty-seven of 71 patients included had MRI of sufficient quality. The median infarct volume post-EVT was 12.98 mL (IQR, 5.93-28.08) in the nerinetide group and 10.80 mL (IQR, 3.11-24.45) in the control group (p = 0.59). Patients receiving nerinetide showed a median early secondary infarct growth of 5.92 mL (IQR, 1.09-21.30) compared with 10.80 mL (interquartile range [IQR], 2.54-21.81) in patients with placebo (p = 0.30). Intravenous alteplase modified the effect of nerinetide on region-specific infarct growth in white matter and basal ganglia compartments. In patients with no alteplase, the infarct growth rate was reduced by 120% (standard error [SE], 60%) in the white matter (p = 0.03) and by 340% (SE, 140%) in the basal ganglia (p = 0.02) in the nerinetide group compared with placebo after adjusting for confounders. DISCUSSION This study highlights the potential of using MR imaging as a biomarker to estimate the effect of a neuroprotective agent in acute stroke treatment. Patients with acute large vessel occlusive stroke exhibited appreciable early infarct growth both in the gray matter and the white matter after undergoing EVT. Acknowledging relatively small overall infarct volumes in this study, treatment with nerinetide was associated with slightly reduced percentage infarct growth in the white matter and basal ganglia compared with placebo in patients not receiving intravenous alteplase and had no effect on the total early secondary infarct growth. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov NCT02930018. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that for patients with acute large vessel ischemic stroke undergoing EVT, nerinetide did not significantly decrease early post-EVT infarct growth compared with placebo.
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Affiliation(s)
- Joachim Fladt
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Jen Guo
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Jacinta L Specht
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Meng Wang
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Leona L Chan
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Ryan Mctaggart
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Brian H Buck
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Richard Aviv
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Richard H Swartz
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Thalia S Field
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Jason Tarpley
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Ruchir Shah
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Mayank Goyal
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Michael Tymianski
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Michael D Hill
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Andrew Demchuk
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Christopher d'Esterre
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
| | - Philip Barber
- From the Calgary Stroke Program (J.F., J.G., J.L.S., M.W., L.L.C., M.G., M.D.H., A.D., C.E., P.B.), Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,Canada; Stroke Center and Department of Neurology (J.F.), University Hospital Basel and University of Basel, Switzerland; Department of Neurology and Neurosurgery (R.M.), Rhode Island Medical Imaging, Providence, RI; Division of Neurology (B.H.B.), University of Alberta, Edmonton; Department of Radiology (R.A.), Radiation Oncology and Medical Physics, University of Ottawa, The Ottawa Hospital; Department of Medical Imaging (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre; Vancouver Stroke Program (T.S.F.), University of British Columbia, Canada; Pacific Neuroscience Institute (J.T.), Providence Little Company of Mary Medical Center, Torrance, CA; and UT Erlanger Neurology (R.S.), Chattanooga, TN; NoNO Inc (M.T.), Toronto, Canada
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Ballout AA. Endovascular thrombectomy of large ischemic strokes: Reimagining the boundaries of reperfusion. Interv Neuroradiol 2023; 29:493-497. [PMID: 37069819 PMCID: PMC10549720 DOI: 10.1177/15910199231170283] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/29/2023] [Indexed: 04/19/2023] Open
Abstract
The cumulative results of the SELECT-2, ANGEL-ASPECTS, and RESCUE-JAPAN LIMIT clinical trials suggest that endovascular thrombectomy performed within 24 h of symptom onset, in patients presenting with large ischemic strokes, defined by parenchymal and/or perfusion imaging, is safe and is associated with better functional outcomes with a treatment effect that persisted across all subgroups of patients. Our aim was to review these studies and to discuss the implications that these studies may have on patient selection, systems of care, and the utility of our imaging modalities.
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Affiliation(s)
- Ahmad A Ballout
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
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Subramaniam JC, Cheung A, Manning N, Whitley J, Cordato D, Zagami A, Cappelen-Smith C, Tian H, Levi C, Parsons M, Butcher KS. Most endovascular thrombectomy patients have Target Mismatch despite absence of formal CT perfusion selection criteria. PLoS One 2023; 18:e0285679. [PMID: 37708105 PMCID: PMC10501580 DOI: 10.1371/journal.pone.0285679] [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: 10/11/2022] [Accepted: 04/27/2023] [Indexed: 09/16/2023] Open
Abstract
Endovascular thrombectomy (EVT) is the standard of care for large vessel occlusion stroke. Use of Computed Tomographic Perfusion (CTP) to select EVT candidates is variable. The frequency of treatment and outcome in patients with unfavourable CTP patterns is unknown. A retrospective analysis of CTP utilisation prior to EVT was conducted. All CTP data were analysed centrally and a Target Mismatch was defined as an infarct core ≤70 ml, penumbral volume ≥15ml, and a total hypoperfused volume:core volume ratio >1.8. The primary outcome was good functional outcome at 90 days, defined as a modified Rankin Scale (mRS) score 0-2. follow-up infarct volume, core expansion and penumbral salvage volumes were secondary outcomes. Of 572 anterior circulation EVT patients, CTP source image data required to generate objective maps were available in 170, and a Target Mismatch was present in 151 (89%). The rate of 90-day good functional outcome was similar between Target Mismatch (53%) and Large Core Non-Mismatch groups (46%, p = 0.629). Median follow-up infarct volume in the Large Core Non-Mismatch group (104ml [IQR 25ml-189ml]) was larger than that in the Target Mismatch patients (16ml [8ml-47ml], p<0.001). Despite a lack of formal CTP selection criteria, the majority of patients treated at our centres had a Target Mismatch. Patients without Target Mismatch had larger follow-up infarct volumes, but the functional recovery rate was similar to that in Target Mismatch patients. Infarct volumes should be included as objective assessment criteria in the evaluation of the efficacy of EVT in non-Target Mismatch patients.
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Affiliation(s)
| | - Andrew Cheung
- Department of Interventional Neuroradiology, The Prince of Wales Hospital, Sydney, Australia
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, Australia
| | - Nathan Manning
- Department of Interventional Neuroradiology, The Prince of Wales Hospital, Sydney, Australia
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, Australia
| | - Justin Whitley
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, Australia
| | - Dennis Cordato
- Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, Australia
- Ingham Institute of Applied Medical Research, Sydney, Australia
| | - Alessandro Zagami
- Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia
| | - Cecilia Cappelen-Smith
- Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, Australia
- Ingham Institute of Applied Medical Research, Sydney, Australia
| | - Huiqiao Tian
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Chris Levi
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - Mark Parsons
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Ingham Institute of Applied Medical Research, Sydney, Australia
| | - Ken S. Butcher
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia
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Viticchi G, Falsetti L, Riva A, Paolucci S, Malatini S, Guerrieri E, Bartolini M, Silvestrini M. Ipsilateral and contralateral carotid stenosis contribute to the outcome of reperfusion treatment for ischemic stroke. Front Neurol 2023; 14:1237721. [PMID: 37638193 PMCID: PMC10448052 DOI: 10.3389/fneur.2023.1237721] [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: 06/09/2023] [Accepted: 07/20/2023] [Indexed: 08/29/2023] Open
Abstract
Introduction Ipsilateral and contralateral carotid stenosis (ICS, CCS) influence acute ischemic stroke (AIS) severity and prognosis. Few data are available about their impact on reperfusion therapies efficacy. Aim of this study was to evaluate the impact of ICS and CCS on the effect of intravenous thrombolysis (IT), mechanical thrombectomy (MT) or both and of antiplatelet therapy (AT). Methods We enrolled all the consecutive patients admitted for AIS to our stroke unit and submitted to IT, MT, IT+MT, or AT. We established the presence of a significant ICS or CCS (≥70%) by ultrasound examination or brain angio-CT, or MRI. Clinical and instrumental information were collected; delta National Institutes of Health Stroke Scale (NIHSS) from pre-treatment to patients' discharge was employed as the main outcome measure. Results In total, 460 subjects were enrolled, 86 with ICS and 38 with CCS. We observed a significant linear trend of delta (NIHSS) between carotid stenosis categories for patients undergoing IT (p = 0.011), MT (p = 0.046), and MT+IT (p = 0.040), but no significant trend among subjects receiving no reperfusion treatments was observed (p = 0.174). Discussion According to our findings, ICS and CCS negatively influence AIS patients' outcome treated by interventional therapies. ICS might exert an unfavorable effect both by cerebral hypoperfusion and by continuous microembolization toward ischemic area, while CCS is probable involved in reducing the collateral circles effectiveness. The importance of early carotid stenosis detection and treatment should then be reevaluated not only to manage the prevention approaches but also to obtain insights about post-stroke treatment strategies efficacy.
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Affiliation(s)
| | - Lorenzo Falsetti
- Internal and Subintensive Medicine, Azienda Ospedaliero-Universitaria delle Marche, Ancona, Italy
| | - Alice Riva
- Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Silvia Paolucci
- Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Simone Malatini
- Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Emanuele Guerrieri
- Emergency Medicine Residency Program, Marche Polytechnic University, Ancona, Italy
| | - Marco Bartolini
- Neurological Clinic, Marche Polytechnic University, Ancona, Italy
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Chalos V, Venema E, Mulder MJHL, Roozenbeek B, Steyerberg EW, Wermer MJH, Lycklama à Nijeholt GJ, van der Worp HB, Goyal M, Campbell BCV, Muir KW, Guillemin F, Bracard S, White P, Dávalos A, Jovin TG, Hill MD, Mitchell PJ, Demchuk AM, Saver JL, van der Lugt A, Brown S, Dippel DWJ, Lingsma HF. Development and Validation of a Postprocedural Model to Predict Outcome After Endovascular Treatment for Ischemic Stroke. JAMA Neurol 2023; 80:2807606. [PMID: 37523199 PMCID: PMC10391355 DOI: 10.1001/jamaneurol.2023.2392] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/19/2023] [Indexed: 08/01/2023]
Abstract
Importance Outcome prediction after endovascular treatment (EVT) for ischemic stroke is important to patients, family members, and physicians. Objective To develop and validate a model based on preprocedural and postprocedural characteristics to predict functional outcome for individual patients after EVT. Design, Setting, and Participants A prediction model was developed using individual patient data from 7 randomized clinical trials, performed between December 2010 and December 2014. The model was developed within the Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials (HERMES) collaboration and external validation in data from the Dutch Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry of patients treated in clinical practice between March 2014 and November 2017. Participants included patients from multiple centers throughout different countries in Europe, North America, East Asia, and Oceania (derivation cohort), and multiple centers in the Netherlands (validation cohort). Included were adult patients with a history of ischemic stroke from an intracranial large vessel occlusion in the anterior circulation who underwent EVT within 12 hours of symptom onset or last seen well. Data were last analyzed in July 2022. Main Outcome(s) and Measure(s) A total of 19 variables were assessed by multivariable ordinal regression to predict functional outcome (modified Rankin Scale [mRS] score) 90 days after EVT. Variables were routinely available 1 day after EVT. Akaike information criterion (AIC) was used to optimize model fit vs model complexity. Probabilities for functional independence (mRS 0-2) and survival (mRS 0-5) were derived from the ordinal model. Model performance was expressed with discrimination (C statistic) and calibration. Results A total of 781 patients (median [IQR] age, 67 [57-76] years; 414 men [53%]) constituted the derivation cohort, and 3260 patients (median [IQR] age, 72 [61-80] years; 1684 men [52%]) composed the validation cohort. Nine variables were included in the model: age, baseline National Institutes of Health Stroke Scale (NIHSS) score, prestroke mRS score, history of diabetes, occlusion location, collateral score, reperfusion grade, NIHSS score at 24 hours, and symptomatic intracranial hemorrhage 24 hours after EVT. External validation in the MR CLEAN Registry showed excellent discriminative ability for functional independence (C statistic, 0.91; 95% CI, 0.90-0.92) and survival (0.89; 95% CI, 0.88-0.90). The proportion of functional independence in the MR CLEAN Registry was systematically higher than predicted by the model (41% vs 34%), whereas observed and predicted survival were similar (72% vs 75%). The model was updated and implemented for clinical use. Conclusion and relevance The prognostic tool MR PREDICTS@24H can be applied 1 day after EVT to accurately predict functional outcome for individual patients at 90 days and to provide reliable outcome expectations and personalize follow-up and rehabilitation plans. It will need further validation and updating for contemporary patients.
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Affiliation(s)
- Vicky Chalos
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Esmee Venema
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Emergency Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Maxim J. H. L. Mulder
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Ewout W. Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Marieke J. H. Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - H. Bart van der Worp
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Brain Center, Utrecht University, Utrecht, the Netherlands
| | - Mayank Goyal
- Departments of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Bruce C. V. Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Keith W. Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Francis Guillemin
- CHRU Nancy, Inserm, Université de Lorraine, CIC Clinical Epidemiology, Nancy, France
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, University of Lorraine and University Hospital of Nancy, Nancy, France
| | - Philip White
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Antoni Dávalos
- Department of Neuroscience, Hospital Germans Trias y Pujol, Barcelona, Spain
| | - Tudor G. Jovin
- Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, Presbyterian University Hospital, Pittsburgh, Pennsylvania
| | - Michael D. Hill
- Departments of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Peter J. Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew M. Demchuk
- Departments of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jeffrey L. Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of Los Angeles, Los Angeles, California
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Scott Brown
- Altair Biostatistics, Mooresville, North Carolina
| | - Diederik W. J. Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Hester F. Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Aguirre C, Trillo S, Ramos C, Zapata-Wainberg G, Sanz-García A, Ximénez-Carrillo Á, Barbosa A, Caniego JL, Vivancos J. Predictive value of ischemia location on multimodal CT in thrombectomy-treated patients. Neuroradiol J 2023; 36:319-328. [PMID: 36281569 PMCID: PMC10268084 DOI: 10.1177/19714009221128658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024] Open
Abstract
OBJECTIVE Alberta Stroke Program Early CT Score (ASPECTS) applied to CT-perfusion (CTP) and CT-angiography-source-images (CTA-SI) may improve outcome prediction in large vessel occlusion (LVO) stroke if compared to non-contrast CT (NCCT) alone. Besides, ischemia location may have enhanced capabilities, compared to ischemia volume alone, in predicting stroke outcomes. We aim to evaluate the association between ischemia location as measured by ASPECTS regions in NCCT, CTP maps and CTA-SI and 3 months outcome in patients with LVO treated with mechanical thrombectomy (MT). MATERIAL AND METHODS Consecutive patients with anterior circulation stroke treated with MT were recorded in a prospectively maintained database at a single center. Modified Rankin scale (mRS) at 3 months >2 was considered a poor outcome. Association of patients' characteristics, NCCT, CTP, and CTA-SI parameters with outcome was evaluated using single-variable analysis and binary logistic regression multivariate analysis for each imaging technique. RESULTS 177 patients were included. 115 (65%) patients reached a favorable outcome. The involvement of lenticular, caudate, M1, or M2 in all imaging techniques, insula in NCCT and CTA-SI and M5 in CBV maps and CTA-SI was related to functional outcome in bivariate analysis. However, in the multivariate analysis, none ischemia location was independently related to outcome, no matter the imaging technique studied. This finding remained unchanged when restricted to patients with good recanalization and when analyzing subpopulations according to hemisphere involvement or territories association. CONCLUSIONS Our study suggests ischemia location shouldn't be used solely for decision-making in LVO stroke patients. Its predictive value may be taken in consideration together with other clinical and radiological variables.
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Affiliation(s)
- Clara Aguirre
- Stroke Center, Neurology
Department, Instituto de Investigación Sanitaria, Hospital Universitario de La
Princesa, Madrid, Spain
| | - Santiago Trillo
- Stroke Center, Neurology
Department, Instituto de Investigación Sanitaria, Hospital Universitario de La
Princesa, Madrid, Spain
| | - Carmen Ramos
- Stroke Center, Neurology
Department, Instituto de Investigación Sanitaria, Hospital Universitario de La
Princesa, Madrid, Spain
| | - Gustavo Zapata-Wainberg
- Stroke Center, Neurology
Department, Instituto de Investigación Sanitaria, Hospital Universitario de La
Princesa, Madrid, Spain
| | - Ancor Sanz-García
- Data Analysis Unit, Instituto de
Investigación Sanitaria, Hospital Universitario de la
Princesa, Madrid, Spain
| | - Álvaro Ximénez-Carrillo
- Stroke Center, Neurology
Department, Instituto de Investigación Sanitaria, Hospital Universitario de La
Princesa, Madrid, Spain
| | - Antonio Barbosa
- Neuroradiology Department, Hospital Universitario de La
Princesa., Madrid, Spain
| | - José L Caniego
- Neuroradiology Department, Hospital Universitario de La
Princesa., Madrid, Spain
| | - José Vivancos
- Stroke Center, Neurology
Department, Instituto de Investigación Sanitaria, Hospital Universitario de La
Princesa, Madrid, Spain
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25
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Dai Y, Xu H, Fang X, Xiong X, Song Z, Hu S, Yu Y, Hu C, Zhang Y. Dual-energy CT in assessment of thrombus perviousness and its application in predicting outcomes after intravenous thrombolysis in acute ischemic stroke. Eur J Radiol 2023; 164:110861. [PMID: 37167682 DOI: 10.1016/j.ejrad.2023.110861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/02/2023] [Accepted: 05/02/2023] [Indexed: 05/13/2023]
Abstract
PURPOSE To evaluate the feasibility of using iodine overlay maps reconstructed from dual-energy CT (DECT) to assess thrombus perviousness and investigate its value in predicting outcomes after intravenous thrombolysis in patients with acute ischemic stroke. METHOD 86 patients with proximal intracranial occlusions of the anterior circulation who underwent intravenous thrombolysis were included in this study. Thrombus iodine concentrations (ICthrombus) and normalized iodine concentrations (NICthrombus) were compared to conventional perviousness parameters (thrombus attenuation increase, TAI; void fraction, ε and CTA-index). The associations between perviousness parameters and outcomes were analyzed by Spearman's correlation and regression analysis. RESULTS ICthrombus and NICthrombus were significantly correlated with conventional perviousness parameters (P < 0.001). The median ICthrombus was 6.81 (interquartile range [IQR], 4.76-8.73) mg/ml in the favorable functional outcome group, which was higher than 3.52 (IQR, 2.08-6.86) mg/ml in the unfavorable outcome group (P = 0.001). The median NICthrombus was 0.095 (IQR, 0.068-0.116) and 0.054 (IQR, 0.031-0.083) in the favorable and unfavorable outcome groups, respectively (P < 0.001). NICthrombus predicted favorable outcome with a higher area under the curve (AUC) of 0.755 than any conventional perviousness parameter (P < 0.05). In the multivariable regression model, ICthrombus was independently associated with favorable outcome (odds ratio [OR] = 1.472, 95 % CI: 1.154-1.877, P = 0.002) and successful recanalization (OR = 1.356, 95 % CI: 1.093-1.681, P = 0.006). ICthrombus was negatively correlated with the final infarct volume (FIV) (r = -0.262, P = 0.020). Results for NICthrombus were similar. CONCLUSIONS DECT is of great value in assessing thrombus perviousness. NICthrombus is a meaningful predictor of stroke prognosis and recanalization after intravenous thrombolysis in acute ischemic stroke.
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Affiliation(s)
- Yao Dai
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou 215006, China; Department of Radiology, Dushu Lake Hospital Affiliated to Soochow University, Suzhou 215124, China
| | - Haimin Xu
- Department of Radiology, Dushu Lake Hospital Affiliated to Soochow University, Suzhou 215124, China
| | - Xiang Fang
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Xing Xiong
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Ziyang Song
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Su Hu
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Yixing Yu
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Chunhong Hu
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou 215006, China.
| | - Yu Zhang
- Department of Radiology, Dushu Lake Hospital Affiliated to Soochow University, Suzhou 215124, China.
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26
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Hoving JW, van Voorst H, Kappelhof M, Tolhuisen M, Treurniet KM, LeCouffe NE, Rinkel LA, Koopman MS, Cavalcante F, Konduri PR, van den Wijngaard IR, Ghariq E, Anton Meijer FJ, Coutinho JM, Marquering HA, Roos YBWEM, Emmer BJ, Majoie CBLM. Infarct Evolution in Patients with Anterior Circulation Large-Vessel Occlusion Randomized to IV Alteplase and Endovascular Treatment versus Endovascular Treatment Alone. AJNR Am J Neuroradiol 2023; 44:434-440. [PMID: 36958803 PMCID: PMC10084906 DOI: 10.3174/ajnr.a7826] [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: 10/03/2022] [Accepted: 01/31/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND AND PURPOSE Infarct evolution after endovascular treatment varies widely among patients with stroke and may be affected by baseline characteristics and procedural outcomes. Moreover, IV alteplase and endovascular treatment may influence the relationship of these factors to infarct evolution. We aimed to assess whether the infarct evolution between baseline and follow-up imaging was different for patients who received IVT and EVT versus EVT alone. MATERIALS AND METHODS We included patients from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN)-NO IV trial with baseline CTP and follow-up imaging. Follow-up infarct volume was segmented on 24-hour or 1-week follow-up DWI or NCCT. Infarct evolution was defined as the follow-up lesion volume: CTP core volume. Substantial infarct growth was defined as an increase in follow-up infarct volume of >10 mL. We assessed whether infarct evolution was different for patients with IV alteplase and endovascular treatment versus endovascular treatment alone and evaluated the association of baseline characteristics and procedural outcomes with infarct evolution using multivariable regression. RESULTS From 228 patients with CTP results available, 145 patients had follow-up imaging and were included in our analysis. For patients with IV alteplase and endovascular treatment versus endovascular treatment alone, the baseline median CTP core volume was 17 (interquartile range = 4-35) mL versus 11 (interquartile range = 6-24) mL. The median follow-up infarct volume was 13 (interquartile range, 4-48) mL versus 17 (interquartile range = 4-50) mL. Collateral status and occlusion location were negatively associated with substantial infarct growth in patients with and without IV alteplase before endovascular treatment. CONCLUSIONS No statistically significant difference in infarct evolution was found in directly admitted patients who received IV alteplase and endovascular treatment within 4.5 hours of symptom onset versus patients who underwent endovascular treatment alone. Collateral status and occlusion location may be useful predictors of infarct evolution prognosis in patients eligible for IV alteplase who underwent endovascular treatment.
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Affiliation(s)
- J W Hoving
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - H van Voorst
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - M Kappelhof
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - M Tolhuisen
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - K M Treurniet
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Department of Radiology (K.M.T., I.R.v.d.W., E.G.), The Hague Medical Centers, The Hague, the Netherlands
| | - N E LeCouffe
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - L A Rinkel
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - M S Koopman
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - F Cavalcante
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - P R Konduri
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - I R van den Wijngaard
- Department of Radiology (K.M.T., I.R.v.d.W., E.G.), The Hague Medical Centers, The Hague, the Netherlands
| | - E Ghariq
- Department of Radiology (K.M.T., I.R.v.d.W., E.G.), The Hague Medical Centers, The Hague, the Netherlands
| | - F J Anton Meijer
- Department of Radiology (F.J.A.M.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - J M Coutinho
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - H A Marquering
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - Y B W E M Roos
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - B J Emmer
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - C B L M Majoie
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
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27
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Samuels N, Compagne KCJ, van der Ende NAM, Chalos V, Konduri PR, van Doormaal PJ, van Zwam WH, Majoie CBLM, Marquering HA, Roozenbeek B, Lingsma HF, Dippel DWJ, van der Lugt A. Infarct volume after ischemic stroke as a mediator of the effect of endovascular thrombectomy on early postprocedural neurologic deficit. J Stroke Cerebrovasc Dis 2023; 32:106906. [PMID: 36473395 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106906] [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: 08/25/2022] [Accepted: 11/20/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES The beneficial effect of endovascular thrombectomy (EVT) on clinical outcome is assumed to be caused by reduced follow-up infarct volume (FIV), which could serve as an early imaging endpoint. However, the effect of EVT on the modified Rankin Scale (mRS) was poorly explained by FIV. NIHSS at 5-7 days could be a more specific measure of the effect of reperfusion therapy, as opposed to the mRS at 3 months. Therefore, we aimed to assess to what extent the effect of EVT on NIHSS is explained by FIV. MATERIALS AND METHODS We used data from the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands; n = 500) trial to evaluate the mediating role of FIV within 1 week in the relationship between EVT and baseline adjusted NIHSS at 5-7 days. RESULTS Larger FIVs were associated with higher NIHSS after treatment (adjusted beta-coefficient (aβ) 0.47;95%CI 0.39-0.55). EVT was associated with smaller FIVs (β -0.35;95%CI-0.64 to -0.06) and lower NIHSS (β -0.63;95%CI-0.90 to -0.35). After adjustment for FIV, the effect of EVT on NIHSS decreased (aβ -0.47;95%CI-0.72 to -0.23), indicating that effect of EVT on neurologic deficit is partially mediated by FIV. Reduction of FIV explained 34% (95%CI;5%-93%) of the effect of EVT on the NIHSS at 5-7 days. CONCLUSIONS Larger FIV was significantly associated with larger neurological deficits after treatment. Reduced infarct volume after EVT explains one third of treatment benefit in terms of neurological deficit. This suggests that FIV is of interest as an imaging biomarker of stroke treatment effect.
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Affiliation(s)
- Noor Samuels
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands.
| | - Kars C J Compagne
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Nadinda A M van der Ende
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Vicky Chalos
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Praneeta R Konduri
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, the Netherlands; Department of Biomedical Engineering and Physics, Amsterdam UMC, location AMC, the Netherlands
| | - Pieter Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, the Netherlands
| | - Henk A Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, the Netherlands; Department of Biomedical Engineering and Physics, Amsterdam UMC, location AMC, the Netherlands
| | - Bob Roozenbeek
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Follow-Up Infarct Volume Prediction by CTP-Based Hypoperfusion Index, and the Discrepancy between Small Follow-Up Infarct Volume and Poor Functional Outcome-A Multicenter Study. Diagnostics (Basel) 2023; 13:diagnostics13010152. [PMID: 36611444 PMCID: PMC9818307 DOI: 10.3390/diagnostics13010152] [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: 11/16/2022] [Accepted: 12/29/2022] [Indexed: 01/04/2023] Open
Abstract
(1) Background: Follow-up infarct volume (FIV) may have implications for prognostication in acute ischemic stroke patients. Factors predicting the discrepancy between FIV and 90-day outcomes are poorly understood. We aimed to develop a comprehensive predictive model of FIV and explore factors associated with the discrepancy. (2) Methods: Patients with acute anterior circulation large vessel occlusion were included. Baseline clinical and CT features were extracted and analyzed, including the CTP-based hypoperfusion index (HI) and the NCCT-based e-ASPECT, measured by automated software. FIV was assessed on follow-up NCCT at 3−7 days. Multiple linear regression was used to construct the predictive model. Subgroup analysis was performed to explore factors associated with poor outcomes (90-mRS scores 3−6) in small FIV (<70 mL). (3) Results: There were 170 patients included. Baseline e-ASPECT, infarct core volume, hypoperfusion volume, HI, baseline international normalized ratio, and successful recanalization were associated with FIV and included in constructing the predictive model. Baseline NIHSS, baseline hypertension, stroke history, and current tobacco use were associated with poor outcomes in small FIV. (4) Conclusions: A comprehensive predictive model (including HI) of FIV was constructed. We also emphasized the importance of hypertension and smoking status at baseline for the functional outcomes in patients with a small FIV.
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29
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Gerbasi A, Konduri P, Tolhuisen M, Cavalcante F, Rinkel L, Kappelhof M, Wolff L, Coutinho JM, Emmer BJ, Costalat V, Arquizan C, Hofmeijer J, Uyttenboogaart M, van Zwam W, Roos Y, Quaglini S, Bellazzi R, Majoie C, Marquering H. Prognostic Value of Combined Radiomic Features from Follow-Up DWI and T2-FLAIR in Acute Ischemic Stroke. J Cardiovasc Dev Dis 2022; 9:jcdd9120468. [PMID: 36547465 PMCID: PMC9786822 DOI: 10.3390/jcdd9120468] [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: 11/18/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
The biological pathways involved in lesion formation after an acute ischemic stroke (AIS) are poorly understood. Despite successful reperfusion treatment, up to two thirds of patients with large vessel occlusion remain functionally dependent. Imaging characteristics extracted from DWI and T2-FLAIR follow-up MR sequences could aid in providing a better understanding of the lesion constituents. We built a fully automated pipeline based on a tree ensemble machine learning model to predict poor long-term functional outcome in patients from the MR CLEAN-NO IV trial. Several feature sets were compared, considering only imaging, only clinical, or both types of features. Nested cross-validation with grid search and a feature selection procedure based on SHapley Additive exPlanations (SHAP) was used to train and validate the models. Considering features from both imaging modalities in combination with clinical characteristics led to the best prognostic model (AUC = 0.85, 95%CI [0.81, 0.89]). Moreover, SHAP values showed that imaging features from both sequences have a relevant impact on the final classification, with texture heterogeneity being the most predictive imaging biomarker. This study suggests the prognostic value of both DWI and T2-FLAIR follow-up sequences for AIS patients. If combined with clinical characteristics, they could lead to better understanding of lesion pathophysiology and improved long-term functional outcome prediction.
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Affiliation(s)
- Alessia Gerbasi
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, 27100 PV Pavia, Italy
- Correspondence:
| | - Praneeta Konduri
- Department of Biomedical Engineering and Physics, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Manon Tolhuisen
- Department of Biomedical Engineering and Physics, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Fabiano Cavalcante
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Leon Rinkel
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Lennard Wolff
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, 3015 Rotterdam, The Netherlands
| | - Jonathan M. Coutinho
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Bart J. Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Vincent Costalat
- Department of Neuroradiology, Centre Hospitalier Universitaire de Montpellier, 34400 Montpellier, France
| | - Caroline Arquizan
- Department of Neurology, Centre Hospitalier Universitaire de Montpellier, 34400 Montpellier, France
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, 6836 BH Arnhem, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology and Department of Medical Imaging Center, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, 6229 HX Maastricht, The Netherlands
| | - Yvo Roos
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Silvana Quaglini
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, 27100 PV Pavia, Italy
| | - Riccardo Bellazzi
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, 27100 PV Pavia, Italy
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Henk Marquering
- Department of Biomedical Engineering and Physics, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
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Kis B, Neuhaus AA, Harston G, Joly O, Carone D, Gerry S, Chadaide Z, Pánczél A, Czifrus E, Csike V, Surányi Á, Szikora I, Erőss L. Automated quantification of atrophy and acute ischemic volume for outcome prediction in endovascular thrombectomy. Front Neurol 2022; 13:1056532. [PMID: 36588883 PMCID: PMC9797714 DOI: 10.3389/fneur.2022.1056532] [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: 09/28/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
Background Short- and long-term outcomes from endovascular thrombectomy (EVT) for large vessel occlusion stroke remain variable. Numerous relevant predictors have been identified, including severity of neurological deficits, age, and imaging features. The latter is typically defined as acute changes (most commonly Alberta Stroke Programme Early CT Score, ASPECTS, at presentation), but there is little information on the impact of imaging assessment of premorbid brain health as a determinant of outcome. Aims To examine the impact of automated measures of stroke severity and underlying brain frailty on short- and long-term outcomes in acute stroke treated with EVT. Methods In 215 patients with anterior circulation stroke, who subsequently underwent EVT, automated analysis of presenting non-contrast CT scans was used to determine acute ischemic volume (AIV) and e-ASPECTS as markers of stroke severity, and cerebral atrophy as a marker of brain frailty. Univariate and multivariate logistic regression were used to identify significant predictors of NIHSS improvement, modified Rankin scale (mRS) at 90 and 30 days, mortality at 90 days and symptomatic intracranial hemorrhage (sICH) following successful EVT. Results For long-term outcome, atrophy and presenting NIHSS were significant predictors of mRS 0-2 and death at 90 days, whereas age did not reach significance in multivariate analysis. Conversely, for short-term NIHSS improvement, AIV and age were significant predictors, unlike presenting NIHSS. The interaction between age and NIHSS was similar to the interaction of AIV and atrophy for mRS 0-2 at 90 days. Conclusion Combinations of automated software-based imaging analysis and clinical data can be useful for predicting short-term neurological outcome and may improve long-term prognostication in EVT. These results provide a basis for future development of predictive tools built into decision-aiding software in stroke.
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Affiliation(s)
- Balázs Kis
- National Institute of Mental Health, Neurology, and Neurosurgery (NIMNN), Budapest, Hungary,*Correspondence: Balázs Kis
| | - Ain A. Neuhaus
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom,Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - George Harston
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom,Brainomix Ltd., Oxford, United Kingdom
| | | | - Davide Carone
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom,Brainomix Ltd., Oxford, United Kingdom
| | - Stephen Gerry
- Centre for Statistics in Medicine, Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | | | - András Pánczél
- Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Eszter Czifrus
- Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Viktória Csike
- National Institute of Mental Health, Neurology, and Neurosurgery (NIMNN), Budapest, Hungary
| | - Ágnes Surányi
- National Institute of Mental Health, Neurology, and Neurosurgery (NIMNN), Budapest, Hungary
| | - István Szikora
- National Institute of Mental Health, Neurology, and Neurosurgery (NIMNN), Budapest, Hungary
| | - Loránd Erőss
- National Institute of Mental Health, Neurology, and Neurosurgery (NIMNN), Budapest, Hungary
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McDonough R, Elsayed S, Meyer L, Ewers T, Bechstein M, Kniep H, Nawka MT, Faizy TD, Schön G, Thomalla G, Fiehler J, Hanning U, Kemmling A, Broocks G. Low baseline ischemic water uptake is directly related to overestimation of CT perfusion-derived ischemic core volume. Sci Rep 2022; 12:20567. [PMID: 36446862 PMCID: PMC9708677 DOI: 10.1038/s41598-022-19176-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 08/25/2022] [Indexed: 11/30/2022] Open
Abstract
Computed-tomography perfusion (CTP) is frequently used to screen acute ischemic stroke (AIS) patients for endovascular treatment (EVT), despite known problems with ischemic "core" overestimation. This potentially leads to the unfair exclusion of patients from EVT. We propose that net water uptake (NWU) can be used in addition to CTP to more accurately assess the extent and/or stage of tissue infarction. Patients treated for AIS between 06/2015 and 07/2020 were retrospectively analyzed. Baseline CTP-derived core volume (pCore) and NWU were determined. Logistic regression tested the relationship between baseline clinical and imaging variables and core-overestimation (primary outcome). The secondary outcomes comprised 90-day functional independence (modified Rankin score) and lesion growth. 284 patients were included. Median NWU was 7.2% (IQR 2.6-12.8). ASPECTS (RR 1.28, 95% CI 1.09-1.51), NWU (RR 0.94, 95% CI 0.89-0.98), onset to recanalization (RR 1.00, 95% CI 0.99-1.00) and imaging (RR 1.00, 95% CI 1.00-1.00) times, and pCore (RR 1.02, 95% CI 1.01-1.02) were significantly associated with core overestimation. Core-overestimation was more likely to occur in patients with large pCores and low NWU at baseline. NWU was significantly correlated with lesion growth. We conclude that NWU can be used as a supplemental tool to CTP during admission imaging to more accurately assess the extent of ischemia, particularly relevant for patients with large CTP-defined cores who would otherwise be excluded from treatment.
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Affiliation(s)
- Rosalie McDonough
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Sarah Elsayed
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Lukas Meyer
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Theresa Ewers
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Matthias Bechstein
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Helge Kniep
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Marie Teresa Nawka
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Tobias D. Faizy
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Gerhard Schön
- grid.13648.380000 0001 2180 3484Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- grid.13648.380000 0001 2180 3484Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Uta Hanning
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Andre Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - Gabriel Broocks
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
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Zeng W, Li W, Huang K, Lin Z, Dai H, He Z, Liu R, Zeng Z, Qin G, Chen W, Wu Y. Predicting futile recanalization, malignant cerebral edema, and cerebral herniation using intelligible ensemble machine learning following mechanical thrombectomy for acute ischemic stroke. Front Neurol 2022; 13:982783. [PMID: 36247767 PMCID: PMC9554641 DOI: 10.3389/fneur.2022.982783] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/08/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeTo establish an ensemble machine learning (ML) model for predicting the risk of futile recanalization, malignant cerebral edema (MCE), and cerebral herniation (CH) in patients with acute ischemic stroke (AIS) who underwent mechanical thrombectomy (MT) and recanalization.MethodsThis prospective study included 110 patients with premorbid mRS ≤ 2 who met the inclusion criteria. Futile recanalization was defined as a 90-day modified Rankin Scale score >2. Clinical and imaging data were used to construct five ML models that were fused into a logistic regression algorithm using the stacking method (LR-Stacking). We added the Shapley Additive Explanation method to display crucial factors and explain the decision process of models for each patient. Prediction performances were compared using area under the receiver operating characteristic curve (AUC), F1-score, and decision curve analysis (DCA).ResultsA total of 61 patients (55.5%) experienced futile recanalization, and 34 (30.9%) and 22 (20.0%) patients developed MCE and CH, respectively. In test set, the AUCs for the LR-Stacking model were 0.949, 0.885, and 0.904 for the three outcomes mentioned above. The F1-scores were 0.882, 0.895, and 0.909, respectively. The DCA showed that the LR-Stacking model provided more net benefits for predicting MCE and CH. The most important factors were the hypodensity volume and proportion in the corresponding vascular supply area.ConclusionUsing the ensemble ML model to analyze the clinical and imaging data of AIS patients with successful recanalization at admission and within 24 h after MT allowed for accurately predicting the risks of futile recanalization, MCE, and CH.
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Affiliation(s)
- Weixiong Zeng
- Department of Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wei Li
- Department of Neurology, The Second Hospital of Jilin University, Changchun, China
| | - Kaibin Huang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhenzhou Lin
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hui Dai
- Hospital Office, Ganzhou People's Hospital, Ganzhou, China
- Hospital Office, Ganzhou Hospital-Nanfang Hospital, Southern Medical University, Ganzhou, China
| | - Zilong He
- Department of Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Renyi Liu
- Department of Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhaodong Zeng
- Department of Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Genggeng Qin
- Department of Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Genggeng Qin
| | - Weiguo Chen
- Department of Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Weiguo Chen
| | - Yongming Wu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
- *Correspondence: Yongming Wu
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Kim Y, Khose S, Zaidat OO, Hassan AE, Fifi JT, Nanda A, Atchie B, Woodward B, Doerfler A, Tomasello A, Yoo AJ, Sheth SA. Duration of Ischemia Affects Outcomes Independent of Infarct Size in Stroke. STROKE (HOBOKEN, N.J.) 2022; 2:e000163. [PMID: 37377482 PMCID: PMC10296784 DOI: 10.1161/svin.121.000163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 02/09/2022] [Indexed: 06/29/2023]
Abstract
BACKGROUND Delays in endovascular reperfusion for patients with large vessel occlusion stroke are known to worsen outcomes, and the mechanism is believed to be time-dependent expansion of the ischemic infarction. In this study, we hypothesize that delays in onset to reperfusion (OTR) assert an effect on outcomes independent of effects of final infarct (FI). METHODS We performed a subgroup analysis from the prospective multicenter COMPLETE (International Acute Ischemic Stroke Registry With the Penumbra System Aspiration Including the 3D Revascularization Device; Penumbra, Inc) registry for 257 patients with anterior circulation large vessel occlusion who underwent endovascular therapy with successful reperfusion (modified treatment in cerebral infarction score 2b/3). FI was measured by Alberta Stroke Program Early CT score and volume on 24- to 48-hour computed tomography or magnetic resonance imaging. The likelihood of 90-day good functional outcome (modified Rankin scale 0-2) was assessed by OTR and absolute risk difference (ARD) was estimated using multivariable logistic regressions adjusting for patient characteristics including FI. RESULTS In univariable analysis, longer OTR was associated with a decreased likelihood of good functional outcome (ARD -3% [95% CI -4.5 to -1.0]/h delay). In multivariable analysis accounting for FI, the association between OTR and functional outcome remained significant (ARD -2% [95% CI -3.5 to -0.4]/h delay) with similar ARD. This finding was maintained in the subset of patients with FI imaging using CT only, using Alberta Stroke Program Early CT Score or volumetric FI measurements, and also in patients with larger versus smaller FIs. CONCLUSIONS The impact of OTR on outcomes appears to be mostly through a mechanism that is independent of FI. Our findings suggest that although the field has moved toward imaging infarct core definitions of eligibility for endovascular treatment, time remains an important predictor of outcome, independent of infarct core.
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Affiliation(s)
- Youngran Kim
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Swapnil Khose
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Osama O Zaidat
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Ameer E Hassan
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Johanna T Fifi
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Ashish Nanda
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Benjamin Atchie
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Britton Woodward
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Arnd Doerfler
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Alejandro Tomasello
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Albert J Yoo
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Sunil A Sheth
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
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Chen L, Xu Z, Zhang C, Ji Y, Huang X, Yang W, Zhou Z, Wang S, Wang K, Luo B, Wang J. Post-ASPECTS based on hyperdensity in NCCT immediately after thrombectomy is an ultra-early predictor of hemorrhagic transformation and prognosis. Front Neurol 2022; 13:887277. [PMID: 36034273 PMCID: PMC9399794 DOI: 10.3389/fneur.2022.887277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 07/13/2022] [Indexed: 11/13/2022] Open
Abstract
Background and PurposeAlmost half of the patients exhibit futile recanalization after thrombectomy; however, the early postoperative predictors of futile recanalization remain unclear. We analyzed the relationship of post-thrombectomy ASPECTS (Post-ASPECTS) with 90-day prognosis and hemorrhagic transformation (HT).MethodsWe collected data from patients with acute ischemic stroke (AIS) with anterior-circulation large vessel occlusion (ACLVO) who were treated via thrombectomy within 10 h in 3 hospitals. Successful endovascular recanalization was achieved (modified thrombolysis in cerebral ischemia [mTICI] 2b/3). Non-contrast computed tomography (NCCT) examination was performed immediately (within 1 h) after thrombectomy. Post-ASPECTS were scored based on the brain parenchymal hyperdensity in NCCT according to the ASPECTS scoring method. HT was defined according to the ECASS II classification criteria. Linear correlation, logistic regression, and receiver operating characteristic curve analyses were used to determine the influencing factors and best predictive value of 90-day prognosis, 90-day death, and HT.ResultsA total of 231 patients were enrolled. The good prognosis rate, mortality rate, and HT rate were 57.1, 9.5, and 38.3%, respectively. The Post-ASPECTS affected poor prognosis, death, and HT. The best predictive value of Post-ASPECTS for poor prognosis, death, and HT was 7. The specificities of Post-ASPECTS for predicting HT, poor prognosis, and death were 87.6% (AUC, 0.811; P < 0.001), 87.1% (AUC, 0.768; P < 0.001), and 73.7% (AUC, 0.748; P < 0.001), with positive predictive values of 74.2, 75.7, and 21.4%, respectively.ConclusionPost-ASPECTS predicted 90-day prognosis, death, and HT with high specificity and high positive predictive value in patients with AIS with ACLVO. Post-ASPECTS may be an ultra-early predictor of prognosis after thrombectomy.
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Affiliation(s)
- Lulu Chen
- Department of Neurology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Ziqi Xu
- Department of Neurology, Brain Medical Centre, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chen Zhang
- Department of Neurology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yachen Ji
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Xianjun Huang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Weimin Yang
- Department of Neurology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Shuiping Wang
- Department of Neurology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Kai Wang
- Department of Neurology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Benyan Luo
- Department of Neurology, Brain Medical Centre, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jingye Wang
- Department of Neurology, First Affiliated Hospital of Anhui Medical University, Hefei, China
- *Correspondence: Jingye Wang
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Hoving JW, Koopman MS, Tolhuisen ML, van Voorst H, Brehm M, Berkhemer OA, Coutinho JM, Beenen LFM, Marquering HA, Emmer BJ, Majoie CBLM. Accuracy of CT perfusion ischemic core volume and location estimation: A comparison between four ischemic core estimation approaches using syngo.via. PLoS One 2022; 17:e0272276. [PMID: 35917382 PMCID: PMC9345340 DOI: 10.1371/journal.pone.0272276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 07/15/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Computed tomography perfusion (CTP) is widely used in the evaluation of acute ischemic stroke patients for endovascular thrombectomy (EVT). The stability of CTP core estimation is suboptimal and varies between software packages. We aimed to quantify the volumetric and spatial agreement between the CTP ischemic core and follow-up infarct for four ischemic core estimation approaches using syngo.via. METHODS We included successfully reperfused, EVT-treated patients with baseline CTP and 24h follow-up diffusion weighted magnetic resonance imaging (DWI) (November 2017-September 2020). Data were processed with syngo.via VB40 using four core estimation approaches based on: cerebral blood volume (CBV)<1.2mL/100mL with and without smoothing filter, relative cerebral blood flow (rCBF)<30%, and rCBF<20%. The follow-up infarct was segmented on DWI. RESULTS In 59 patients, median estimated CTP core volumes for four core estimation approaches ranged from 12-39 mL. Median 24h follow-up DWI infarct volume was 11 mL. The intraclass correlation coefficient (ICC) showed moderate-good volumetric agreement for all approaches (range 0.61-0.76). Median Dice was low for all approaches (range 0.16-0.21). CTP core overestimation >10mL occurred least frequent (14/59 [24%] patients) using the CBV-based core estimation approach with smoothing filter. CONCLUSIONS In successfully reperfused patients who underwent EVT, syngo.via CTP ischemic core estimation showed moderate volumetric and spatial agreement with the follow-up infarct on DWI. In patients with complete reperfusion after EVT, the volumetric agreement was excellent. A CTP core estimation approach based on CBV<1.2 mL/100mL with smoothing filter least often overestimated the follow-up infarct volume and is therefore preferred for clinical decision making using syngo.via.
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Affiliation(s)
- Jan W. Hoving
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Miou S. Koopman
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Manon L. Tolhuisen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus Brehm
- Siemens Healthcare GmbH, Computed Tomography, Forchheim, Germany
| | - Olvert A. Berkhemer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Jonathan M. Coutinho
- Department of Neurology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Ludo F. M. Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Henk A. Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Bart J. Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Charles B. L. M. Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
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36
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González RG. Diffusion MR Imaging of Large Vessel Occlusion Ischemic Stroke for Treatment Selection. Magn Reson Imaging Clin N Am 2022; 30:363-369. [PMID: 35995467 DOI: 10.1016/j.mric.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
The role of MR imaging in the evaluation and management of ischemic stroke patients is large, and to cover it all is far beyond the scope of one article. Thus, the focus will be on the role of MR imaging in the great leap forward in stroke therapy: endovascular thrombectomy of large vessel occlusions (LVOs). Diffusion MR imaging has played a key role in the research leading to the current standard of care for LVO stroke because it is the most sensitive and reliable method for the early delineation of the ischemic core.
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Affiliation(s)
- Ramon Gilberto González
- Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, GRB 273A, Boston, MA 02114, USA.
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37
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van Voorst H, Konduri PR, van Poppel LM, van der Steen W, van der Sluijs PM, Slot EMH, Emmer BJ, van Zwam WH, Roos YBWEM, Majoie CBLM, Zaharchuk G, Caan MWA, Marquering HA. Unsupervised Deep Learning for Stroke Lesion Segmentation on Follow-up CT Based on Generative Adversarial Networks. AJNR Am J Neuroradiol 2022; 43:1107-1114. [PMID: 35902122 PMCID: PMC9575413 DOI: 10.3174/ajnr.a7582] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 06/02/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Supervised deep learning is the state-of-the-art method for stroke lesion segmentation on NCCT. Supervised methods require manual lesion annotations for model development, while unsupervised deep learning methods such as generative adversarial networks do not. The aim of this study was to develop and evaluate a generative adversarial network to segment infarct and hemorrhagic stroke lesions on follow-up NCCT scans. MATERIALS AND METHODS Training data consisted of 820 patients with baseline and follow-up NCCT from 3 Dutch acute ischemic stroke trials. A generative adversarial network was optimized to transform a follow-up scan with a lesion to a generated baseline scan without a lesion by generating a difference map that was subtracted from the follow-up scan. The generated difference map was used to automatically extract lesion segmentations. Segmentation of primary hemorrhagic lesions, hemorrhagic transformation of ischemic stroke, and 24-hour and 1-week follow-up infarct lesions were evaluated relative to expert annotations with the Dice similarity coefficient, Bland-Altman analysis, and intraclass correlation coefficient. RESULTS The median Dice similarity coefficient was 0.31 (interquartile range, 0.08-0.59) and 0.59 (interquartile range, 0.29-0.74) for the 24-hour and 1-week infarct lesions, respectively. A much lower Dice similarity coefficient was measured for hemorrhagic transformation (median, 0.02; interquartile range, 0-0.14) and primary hemorrhage lesions (median, 0.08; interquartile range, 0.01-0.35). Predicted lesion volume and the intraclass correlation coefficient were good for the 24-hour (bias, 3 mL; limits of agreement, -64-59 mL; intraclass correlation coefficient, 0.83; 95% CI, 0.78-0.88) and excellent for the 1-week (bias, -4 m; limits of agreement,-66-58 mL; intraclass correlation coefficient, 0.90; 95% CI, 0.83-0.93) follow-up infarct lesions. CONCLUSIONS An unsupervised generative adversarial network can be used to obtain automated infarct lesion segmentations with a moderate Dice similarity coefficient and good volumetric correspondence.
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Affiliation(s)
- H van Voorst
- From the Departments of Radiology and Nuclear Medicine (H.v.V., P.R.K., L.M.v.P., B.J.E., C.B.L.M.M., H.A.M.)
- Biomedical Engineering and Physics (H.v.V., P.R.K., L.M.v.P., M.W.A.C., H.A.M.)
| | - P R Konduri
- From the Departments of Radiology and Nuclear Medicine (H.v.V., P.R.K., L.M.v.P., B.J.E., C.B.L.M.M., H.A.M.)
- Biomedical Engineering and Physics (H.v.V., P.R.K., L.M.v.P., M.W.A.C., H.A.M.)
| | - L M van Poppel
- From the Departments of Radiology and Nuclear Medicine (H.v.V., P.R.K., L.M.v.P., B.J.E., C.B.L.M.M., H.A.M.)
- Biomedical Engineering and Physics (H.v.V., P.R.K., L.M.v.P., M.W.A.C., H.A.M.)
| | - W van der Steen
- Departments of Neurology (W.v.d.S., P.M.v.d.S.)
- Radiology and Nuclear Medicine (W.v.d.S., P.M.v.d.S.), Erasmus University Medical Center, Rotterdam, the Netherlands
| | - P M van der Sluijs
- Departments of Neurology (W.v.d.S., P.M.v.d.S.)
- Radiology and Nuclear Medicine (W.v.d.S., P.M.v.d.S.), Erasmus University Medical Center, Rotterdam, the Netherlands
| | - E M H Slot
- Department of Neurology and Neurosurgery (E.M.H.S.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - B J Emmer
- From the Departments of Radiology and Nuclear Medicine (H.v.V., P.R.K., L.M.v.P., B.J.E., C.B.L.M.M., H.A.M.)
| | - W H van Zwam
- Department of Radiology and Nuclear Medicine (W.H.v.Z.), Maastricht University Medical Center, Maastricht, the Netherlands
| | - Y B W E M Roos
- Neurology (Y.B.W.E.M.R.), Faculty of Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - C B L M Majoie
- From the Departments of Radiology and Nuclear Medicine (H.v.V., P.R.K., L.M.v.P., B.J.E., C.B.L.M.M., H.A.M.)
| | - G Zaharchuk
- Department of Radiology (G.Z.), Stanford University, Stanford, California
| | - M W A Caan
- Biomedical Engineering and Physics (H.v.V., P.R.K., L.M.v.P., M.W.A.C., H.A.M.)
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Outcome Prediction Based on Automatically Extracted Infarct Core Image Features in Patients with Acute Ischemic Stroke. Diagnostics (Basel) 2022; 12:diagnostics12081786. [PMID: 35892499 PMCID: PMC9331690 DOI: 10.3390/diagnostics12081786] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/09/2022] [Accepted: 07/18/2022] [Indexed: 11/18/2022] Open
Abstract
Infarct volume (FIV) on follow-up diffusion-weighted imaging (FU-DWI) is only moderately associated with functional outcome in acute ischemic stroke patients. However, FU-DWI may contain other imaging biomarkers that could aid in improving outcome prediction models for acute ischemic stroke. We included FU-DWI data from the HERMES, ISLES, and MR CLEAN-NO IV databases. Lesions were segmented using a deep learning model trained on the HERMES and ISLES datasets. We assessed the performance of three classifiers in predicting functional independence for the MR CLEAN-NO IV trial cohort based on: (1) FIV alone, (2) the most important features obtained from a trained convolutional autoencoder (CAE), and (3) radiomics. Furthermore, we investigated feature importance in the radiomic-feature-based model. For outcome prediction, we included 206 patients: 144 scans were included in the training set, 21 in the validation set, and 41 in the test set. The classifiers that included the CAE and the radiomic features showed AUC values of 0.88 and 0.81, respectively, while the model based on FIV had an AUC of 0.79. This difference was not found to be statistically significant. Feature importance results showed that lesion intensity heterogeneity received more weight than lesion volume in outcome prediction. This study suggests that predictions of functional outcome should not be based on FIV alone and that FU-DWI images capture additional prognostic information.
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Reitz SC, Gerhard E, Breuer S, Bohmann FO, Pfeilschifter W, Berkefeld J. Outcome after Thrombectomy of Acute M1 and Carotid-T Occlusions with Involvement of the Corticospinal Tract in Postinterventional Imaging. J Clin Med 2022; 11:jcm11102823. [PMID: 35628948 PMCID: PMC9145944 DOI: 10.3390/jcm11102823] [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: 04/16/2022] [Revised: 05/14/2022] [Accepted: 05/16/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Until now, thrombectomy studies have provided little reliable information about the correlation between the infarct topography and clinical outcome of acute stroke patients with embolic large-vessel occlusions. Therefore, we aimed to analyze whether infarcts of the corticospinal tracts in the central white matter (CWM) or the internal capsule on postinterventional imaging controls are associated with poor clinical outcome after thrombectomy. MATERIALS AND METHODS We retrospectively analyzed imaging data from 70 patients who underwent endovascular thrombectomy for emergent middle cerebral artery or carotid-T occlusions. Inclusion criteria were postinterventional infarct demarcation in the regions of the internal capsule, caudate, lentiform nucleus, and CWM. Primary outcome was the mRS after 90 days and secondary endpoints were subgroup analyses regarding additional cortical infarction. CONCLUSIONS In this exploratory study, we found no indication that infarcts in the course of the corticospinal tracts predict poor clinical outcome after successful thrombectomy in patients with embolic carotid-T or M1 occlusions. In our analysis, a significant number of patients showed a favorable 90 day outcome. Additional cortical infarcts may have a greater impact on the risk of an unfavorable outcome. RESULTS Good clinical outcome after 90 days (mRS 0-2) was shown in 36 out of 70 patients (51.4%), with excellent clinical outcome (mRS 0-1) in 23 patients (32.9%). Here, 58.6% patients lived at home without nursing service after 90 days. Patients with minimal additional cortical infarction in postinterventional imaging had a 75.6% better chance of excellent outcome.
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Affiliation(s)
- Sarah Christina Reitz
- Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt am Main, Germany; (F.O.B.); (W.P.)
- Correspondence:
| | - Ellen Gerhard
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt am Main, Germany; (E.G.); (S.B.); (J.B.)
| | - Stella Breuer
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt am Main, Germany; (E.G.); (S.B.); (J.B.)
| | - Ferdinand Oliver Bohmann
- Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt am Main, Germany; (F.O.B.); (W.P.)
| | - Waltraud Pfeilschifter
- Department of Neurology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt am Main, Germany; (F.O.B.); (W.P.)
- Klinik für Neurologie und Klinische Neurophysiologie, Klinikum Lüneburg, 21339 Lüneburg, Germany
| | - Joachim Berkefeld
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe University, 60528 Frankfurt am Main, Germany; (E.G.); (S.B.); (J.B.)
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40
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McDonough RV, Qiu W, Ospel JM, Menon BK, Cimflova P, Goyal M. Multiphase CTA-derived tissue maps aid in detection of medium vessel occlusions. Neuroradiology 2022; 64:887-896. [PMID: 34668040 DOI: 10.1007/s00234-021-02830-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/08/2021] [Indexed: 12/30/2022]
Abstract
PURPOSE Medium vessel occlusions (MeVOs) can be challenging to detect on imaging. Multiphase computed tomography angiography (mCTA) has been shown to improve large vessel occlusion (LVO) detection and endovascular treatment (EVT) selection. The aims of this study were to determine if mCTA-derived tissue maps can (1) accurately detect MeVOs and (2) predict infarction on 24-h follow-up imaging with comparable accuracy to CT perfusion (CTP). METHODS Two readers assessed mCTA tissue maps of 116 ischemic stroke patients (58 MeVOs, 58 non-MeVOs) and determined by consensus: (1) MeVO (yes/no) and (2) occlusion site, blinded to clinical or imaging data. Sensitivity, specificity, and area under the curve (AUC) for MeVO detection were estimated in comparison to reference standards of (1) expert readings of baseline mCTA and (2) CTP maps. Volumetric and spatial agreement between mCTA- and CTP-predicted infarcts was assessed using concordance/intraclass correlation and Dice coefficients. Interrater agreement for MeVO detection on mCTA tissue maps was estimated with Cohen's kappa. RESULTS MeVO detection from mCTA-derived tissue maps had a sensitivity of 91% (95% CI: 80-97), specificity of 82% (95% CI: 70-90), and AUC of 0.87 (95% CI: 0.80-0.93) compared to expert reads of baseline mCTA. Interrater reliability was good (0.72, 95% CI: 0.60-0.85). Compared to CTP maps, sensitivity was 87% (95% CI: 75-95), specificity was 78% (95%CI: 65-88), and AUC was 0.83 (95% CI: 0.76-0.90). The mean difference between mCTA- and CTP-predicted final infarct volume was 4.8 mL (limits of agreement: - 58.5 to 68.1) with a Dice coefficient of 33.5%. CONCLUSION mCTA tissue maps can be used to reliably detect MeVO stroke and predict tissue fate.
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Affiliation(s)
- Rosalie V McDonough
- Department of Radiology, Foothills Medical Centre, University of Calgary, AB, Calgary, Canada.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wu Qiu
- Department of Radiology, Foothills Medical Centre, University of Calgary, AB, Calgary, Canada.,Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Johanna M Ospel
- Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Bijoy K Menon
- Department of Radiology, Foothills Medical Centre, University of Calgary, AB, Calgary, Canada.,Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Petra Cimflova
- Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada.,Department of Medical Imaging, St. Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Mayank Goyal
- Department of Radiology, Foothills Medical Centre, University of Calgary, AB, Calgary, Canada. .,Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada.
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Kim HJ, Roh HG. Imaging in Acute Anterior Circulation Ischemic Stroke: Current and Future. Neurointervention 2022; 17:2-17. [PMID: 35114749 PMCID: PMC8891584 DOI: 10.5469/neuroint.2021.00465] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/25/2021] [Accepted: 12/30/2021] [Indexed: 11/24/2022] Open
Abstract
Clinical trials on acute ischemic stroke have demonstrated the clinical effectiveness of revascularization treatments within an appropriate time window after stroke onset: intravenous thrombolysis (NINDS and ECASS-III) through the administration of tissue plasminogen activator within a 4.5-hour time window, endovascular thrombectomy (ESCAPE, REVASCAT, SWIFT-PRIME, MR CLEAN, EXTEND-IA) within a 6-hour time window, and extending the treatment time window up to 24 hours for endovascular thrombectomy (DAWN and DEFUSE 3). However, a substantial number of patients in these trials were ineligible for revascularization treatment, and treatments of some patients were considerably futile or sometimes dangerous in the clinical trials. Guidelines for the early management of patients with acute ischemic stroke have evolved to accept revascularization treatment as standard and include eligibility criteria for the treatment. Imaging has been crucial in selecting eligible patients for revascularization treatment in guidelines and clinical trials. Stroke specialists should know imaging criteria for revascularization treatment. Stroke imaging studies have demonstrated imaging roles in acute ischemic stroke management as follows: 1) exclusion of hemorrhage and stroke mimic disease, 2) assessment of salvageable brain, 3) localization of the site of vascular occlusion and thrombus, 4) estimation of collateral circulation, and 5) prediction of acute ischemic stroke expecting hemorrhagic transformation. Here, we review imaging methods and criteria to select eligible patients for revascularization treatment in acute anterior circulation stroke, focus on 2019 guidelines from the American Heart Association/American Stroke Association, and discuss the future direction of imaging-based patient selection to improve treatment effects.
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Affiliation(s)
- Hyun Jeong Kim
- Department of Radiology, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Hong Gee Roh
- Department of Radiology, Konkuk University Medical Center, Seoul, Korea
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Sutcliffe L, Lumley H, Shaw L, Francis R, Price CI. Surface electroencephalography (EEG) during the acute phase of stroke to assist with diagnosis and prediction of prognosis: a scoping review. BMC Emerg Med 2022; 22:29. [PMID: 35227206 PMCID: PMC8883639 DOI: 10.1186/s12873-022-00585-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 02/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stroke is a common medical emergency responsible for significant mortality and disability. Early identification improves outcomes by promoting access to time-critical treatments such as thrombectomy for large vessel occlusion (LVO), whilst accurate prognosis could inform many acute management decisions. Surface electroencephalography (EEG) shows promise for stroke identification and outcome prediction, but evaluations have varied in technology, setting, population and purpose. This scoping review aimed to summarise published literature addressing the following questions: 1. Can EEG during acute clinical assessment identify: a) Stroke versus non-stroke mimic conditions. b) Ischaemic versus haemorrhagic stroke. c) Ischaemic stroke due to LVO. 2. Can these states be identified if EEG is applied < 6 h since onset. 3. Does EEG during acute assessment predict clinical recovery following confirmed stroke. METHODS We performed a systematic search of five bibliographic databases ending 19/10/2020. Two reviewers assessed eligibility of articles describing diagnostic and/or prognostic EEG application < 72 h since suspected or confirmed stroke. RESULTS From 5892 abstracts, 210 full text articles were screened and 39 retained. Studies were small and heterogeneous. Amongst 21 reports of diagnostic data, consistent associations were reported between stroke, greater delta power, reduced alpha/beta power, corresponding ratios and greater brain asymmetry. When reported, the area under the curve (AUC) was at least good (0.81-1.00). Only one study combined clinical and EEG data (AUC 0.88). There was little data found describing whether EEG could identify ischaemic versus haemorrhagic stroke. Radiological changes suggestive of LVO were also associated with increased slow and decreased fast waves. The only study with angiographic proof of LVO reported AUC 0.86 for detection < 24 h since onset. Amongst 26 reports of prognostic data, increased slow and reduced fast wave EEG changes were associated with future dependency, neurological impairment, mortality and poor cognition, but there was little evidence that EEG enhanced outcome prediction relative to clinical and/or radiological variables. Only one study focussed solely on patients < 6 h since onset for predicting neurological prognosis post-thrombolysis, with more favourable outcomes associated with greater hemispheric symmetry and a greater ratio of fast to slow waves. CONCLUSIONS Although studies report important associations with EEG biomarkers, further technological development and adequately powered real-world studies are required before recommendations can be made regarding application during acute stroke assessment.
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Affiliation(s)
- Lou Sutcliffe
- Stroke Research Group, Population Health Science Institute, Newcastle University, Newcastle-Upon-Tyne, UK
| | - Hannah Lumley
- Stroke Research Group, Population Health Science Institute, Newcastle University, Newcastle-Upon-Tyne, UK.
| | - Lisa Shaw
- Stroke Research Group, Population Health Science Institute, Newcastle University, Newcastle-Upon-Tyne, UK
| | - Richard Francis
- Stroke Research Group, Population Health Science Institute, Newcastle University, Newcastle-Upon-Tyne, UK
| | - Christopher I Price
- Stroke Research Group, Population Health Science Institute, Newcastle University, Newcastle-Upon-Tyne, UK
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Guenego A, Fahed R. Stroke Prognostication Obeys the Same Rules as Real Estate: Location, Location, Location! Neurology 2022; 98:429-430. [PMID: 35101907 DOI: 10.1212/wnl.0000000000200168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Adrien Guenego
- Department of Interventional Neuroradiology, Erasme University Hospital - Brussels - Belgium
| | - Robert Fahed
- Department of Medicine - Division of Neurology; The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa-Ottawa-Ontario-CANADA
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Werdiger F, Bivard A, Parsons M. Artificial Intelligence in Acute Ischemic Stroke. Artif Intell Med 2022. [DOI: 10.1007/978-3-030-64573-1_287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Peerlings D, van Ommen F, Bennink E, Dankbaar JW, Velthuis BK, Emmer BJ, Hoving JW, Majoie CBLM, Marquering HA, de Jong HWAM. Probability maps classify ischemic stroke regions more accurately than CT perfusion summary maps. Eur Radiol 2022; 32:6367-6375. [PMID: 35357536 PMCID: PMC9381605 DOI: 10.1007/s00330-022-08700-y] [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: 10/18/2021] [Revised: 02/01/2022] [Accepted: 02/26/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To compare single parameter thresholding with multivariable probabilistic classification of ischemic stroke regions in the analysis of computed tomography perfusion (CTP) parameter maps. METHODS Patients were included from two multicenter trials and were divided into two groups based on their modified arterial occlusive lesion grade. CTP parameter maps were generated with three methods-a commercial method (ISP), block-circulant singular value decomposition (bSVD), and non-linear regression (NLR). Follow-up non-contrast CT defined the follow-up infarct region. Conventional thresholds for individual parameter maps were established with a receiver operating characteristic curve analysis. Probabilistic classification was carried out with a logistic regression model combining the available CTP parameters into a single probability. RESULTS A total of 225 CTP data sets were included, divided into a group of 166 patients with successful recanalization and 59 with persistent occlusion. The precision and recall of the CTP parameters were lower individually than when combined into a probability. The median difference [interquartile range] in mL between the estimated and follow-up infarct volume was 29/23/23 [52/50/52] (ISP/bSVD/NLR) for conventional thresholding and was 4/6/11 [31/25/30] (ISP/bSVD/NLR) for the probabilistic classification. CONCLUSIONS Multivariable probability maps outperform thresholded CTP parameter maps in estimating the infarct lesion as observed on follow-up non-contrast CT. A multivariable probabilistic approach may harmonize the classification of ischemic stroke regions. KEY POINTS • Combining CTP parameters with a logistic regression model increases the precision and recall in estimating ischemic stroke regions. • Volumes following from a probabilistic analysis predict follow-up infarct volumes better than volumes following from a threshold-based analysis. • A multivariable probabilistic approach may harmonize the classification of ischemic stroke regions.
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Affiliation(s)
- Daan Peerlings
- grid.7692.a0000000090126352Department of Radiology, University Medical Center Utrecht, Utrecht, 3584CX The Netherlands
| | - Fasco van Ommen
- grid.7692.a0000000090126352Department of Radiology, University Medical Center Utrecht, Utrecht, 3584CX The Netherlands
| | - Edwin Bennink
- grid.7692.a0000000090126352Department of Radiology, University Medical Center Utrecht, Utrecht, 3584CX The Netherlands ,grid.7692.a0000000090126352Image Sciences Institute, University Medical Center Utrecht, Utrecht, 3584CX The Netherlands
| | - Jan W. Dankbaar
- grid.7692.a0000000090126352Department of Radiology, University Medical Center Utrecht, Utrecht, 3584CX The Netherlands
| | - Birgitta K. Velthuis
- grid.7692.a0000000090126352Department of Radiology, University Medical Center Utrecht, Utrecht, 3584CX The Netherlands
| | - Bart J. Emmer
- grid.509540.d0000 0004 6880 3010Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, 1105AZ The Netherlands
| | - Jan W. Hoving
- grid.509540.d0000 0004 6880 3010Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, 1105AZ The Netherlands
| | - Charles B. L. M. Majoie
- grid.509540.d0000 0004 6880 3010Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, 1105AZ The Netherlands
| | - Henk A. Marquering
- grid.509540.d0000 0004 6880 3010Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, 1105AZ The Netherlands
| | - Hugo W. A. M. de Jong
- grid.7692.a0000000090126352Department of Radiology, University Medical Center Utrecht, Utrecht, 3584CX The Netherlands
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Ganesh A, Ospel JM, Menon BK, Demchuk AM, McTaggart RA, Nogueira RG, Poppe AY, Almekhlafi MA, Hanel RA, Thomalla G, Holmin S, Puetz V, van Adel BA, Tarpley JW, Tymianski M, Hill MD, Goyal M. Assessment of Discrepancies Between Follow-up Infarct Volume and 90-Day Outcomes Among Patients With Ischemic Stroke Who Received Endovascular Therapy. JAMA Netw Open 2021; 4:e2132376. [PMID: 34739060 PMCID: PMC8571657 DOI: 10.1001/jamanetworkopen.2021.32376] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
IMPORTANCE Some patients have poor outcomes despite small infarcts after endovascular therapy (EVT), while others with large infarcts do well. Understanding why these discrepancies occur may help to optimize EVT outcomes. OBJECTIVE To validate exploratory findings from the Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times (ESCAPE) trial regarding pretreatment, treatment-related, and posttreatment factors associated with discrepancies between follow-up infarct volume (FIV) and 90-day functional outcome. DESIGN, SETTING, AND PARTICIPANTS This cohort study is a post hoc analysis of the Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) trial, a double-blind, randomized, placebo-controlled, international, multicenter trial conducted from March 2017 to August 2019. Patients who participated in ESCAPE-NA1 and had available 90-day modified Rankin Scale (mRS) scores and 24-hour to 48-hour posttreatment follow-up parenchymal imaging were included. EXPOSURES Small FIV (volume ≤25th percentile) and large FIV (volume ≥75th percentile) on 24-hour computed tomography/magnetic resonance imaging. Baseline factors, outcomes, treatments, and poststroke serious adverse events (SAEs) were compared between discrepant cases (ie, patients with 90-day mRS score ≥3 despite small FIV or those with mRS scores ≤2 despite large FIV) and nondiscrepant cases. MAIN OUTCOMES AND MEASURES Area under the curve (AUC) and goodness of fit of prespecified logistic models, including pretreatment (eg, age, cancer, vascular risk factors) and treatment-related and posttreatment (eg, SAEs) factors, were compared with stepwise regression-derived models for ability to identify small FIV with higher mRS score and large FIV with lower mRS score. RESULTS Among 1091 patients (median [IQR] age, 70.8 [60.8-79.8] years; 549 [49.7%] women; median [IQR] FIV, 24.9 mL [6.6-92.2 mL]), 42 of 287 patients (14.6%) with FIV of 7 mL or less (ie, ≤25th percentile) had an mRS score of at least 3; 65 of 275 patients (23.6%) with FIV of 92 mL or greater (ie, ≥75th percentile) had an mRS score of 2 or less. Prespecified models of pretreatment factors (ie, age, cancer, vascular risk factors) associated with low FIV and higher mRS score performed similarly to models selected by stepwise regression (AUC, 0.92 [95% CI, 0.89-0.95] vs 0.93 [95% CI, 0.90-0.95]; P = .42). SAEs, specifically infarct in new territory, recurrent stroke, pneumonia, and congestive heart failure, were associated with low FIV and higher mRS scores; stepwise models also identified 24-hour hemoglobin as treatment-related/posttreatment factor (AUC, 0.92 [95% CI, 0.90-0.95] vs 0.94 [95% CI, 0.91-0.96]; P = .14). Younger age was associated with high FIV and lower mRS score; stepwise models identified absence of diabetes and higher baseline hemoglobin as additional pretreatment factors (AUC, 0.76 [95% CI, 0.70-0.82] vs 0.77 [95% CI, 0.71-0.83]; P = .82). Absence of SAEs, especially stroke progression, symptomatic intracerebral hemorrhage, and pneumonia, was associated with high FIV and lower mRS score2; stepwise models also identified 24-hour hemoglobin level, glucose, and diastolic blood pressure as posttreatment factors associated with discrepant cases (AUC, 0.80 [95% CI, 0.74-0.87] vs 0.79 [95% CI, 0.72-0.86]; P = .92). CONCLUSIONS AND RELEVANCE In this study, discrepancies between functional outcome and post-EVT infarct volume were associated with differences in pretreatment factors, such as age and comorbidities, and posttreatment complications related to index stroke evolution, secondary prevention, and quality of stroke unit care. Besides preventing such complications, optimization of blood pressure, glucose levels, and hemoglobin levels are potentially modifiable factors meriting further study.
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Affiliation(s)
- Aravind Ganesh
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Johanna M. Ospel
- Department of Radiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Bijoy K. Menon
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- The Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Andrew M. Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- The Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Ryan A. McTaggart
- Departments of Diagnostic Imaging, Neurology, and Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Raul G. Nogueira
- Departments of Neurology, Neurosurgery, and Radiology, Emory University School of Medicine, Atlanta, Georgia
- Neuroendovascular Service, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia
| | - Alexandre Y. Poppe
- Department of Neurosciences, Centre Hospitalier de l’Université de Montréal (CHUM), Université de Montréal, Montreal, Quebec, Canada
| | - Mohammed A. Almekhlafi
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- The Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | | | - Götz Thomalla
- Departments of Neurology and Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet and Departments of Neuroradiology and Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Volker Puetz
- Dresden Neurovascular Center, Department of Neurology, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
| | | | - Jason W. Tarpley
- Providence Little Company of Mary Medical Center, Providence Saint John’s Health Center and The Pacific Neuroscience Institute, Torrance, California
| | - Michael Tymianski
- Division of Neurosurgery and Neurovascular Therapeutics Program, University Health Network, Departments of Surgery and Physiology, University of Toronto, Toronto Western Hospital Research Institute, Toronto, Canada
- NoNO Inc, Toronto, Ontario, Canada
| | - Michael D. Hill
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- The Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Mayank Goyal
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Poalelungi A, Tulbă D, Turiac E, Stoian D, Popescu BO. Remote Ischemic Conditioning May Improve Disability and Cognition After Acute Ischemic Stroke: A Pilot Randomized Clinical Trial. Front Neurol 2021; 12:663400. [PMID: 34526950 PMCID: PMC8435589 DOI: 10.3389/fneur.2021.663400] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 08/05/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Aim: Remote ischemic conditioning is a procedure purported to reduce the ischemic injury of an organ. This study aimed to explore the efficiency and safety of remote ischemic conditioning in patients with acute ischemic stroke. We hypothesized that remote ischemic conditioning administered from the first day of hospital admission would improve the infarct volume and clinical outcome at 180 days. Material and Methods: We performed a unicentric double-blind randomized controlled trial. We included all patients consecutively admitted to an Emergency Neurology Department with acute ischemic stroke, ineligible for reperfusion treatment, up to 24 hours from onset. All subjects were assigned to receive secondary stroke prevention treatment along with remote ischemic conditioning on the non-paretic upper limb during the first 5 days of hospitalization, twice daily - a blood pressure cuff placed around the arm was inflated to 20 mmHg above the systolic blood pressure (up to 180 mmHg) in the experimental group and 30 mmHg in the sham group. The primary outcome was the difference in infarct volume (measured on brain CT scan) at 180 days compared to baseline, whereas the secondary outcomes included differences in clinical scores (NIHSS, mRS, IADL, ADL) and cognitive/mood changes (MoCA, PHQ-9) at 180 days compared to baseline. Results: We enrolled 40 patients; the mean age was 65 years and 60% were men. Subjects in the interventional group had slightly better recovery in terms of disability, as demonstrated by the differences in disability scores between admission and 6 months (e.g., the median difference score for Barthel was -10 in the sham group and -17.5 in the interventional group, for ADL -2 in the sham group and -2.5 in the interventional group), as well as cognitive performance (the median difference score for MoCA was -2 in the sham group and -3 in the interventional group), but none of these differences reached statistical significance. The severity of symptoms (median difference score for NIHSS = 5 for both groups) and depression rate (median difference score for PHQ-9 = 0 for both groups) were similar in the two groups. The median difference between baseline infarct volume and final infarct volume at 6 months was slightly larger in the sham group compared to the interventional group (p = 0.4), probably due to an initial larger infarct volume in the former. Conclusion: Our results suggest that remote ischemic conditioning might improve disability and cognition. The difference between baseline infarct volume and final infarct volume at 180 days was slightly larger in the sham group.
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Affiliation(s)
- Alina Poalelungi
- Department of Neurology, Emergency Clinical Hospital, Bucharest, Romania.,Department of Clinical Neurosciences, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Delia Tulbă
- Department of Clinical Neurosciences, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Neurology, Colentina Clinical Hospital, Bucharest, Romania.,Colentina-Research and Development Center, Colentina Clinical Hospital, Bucharest, Romania
| | - Elena Turiac
- Department of Radiology, Emergency Clinical Hospital, Bucharest, Romania
| | - Diana Stoian
- Department of Clinical Neurosciences, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Bogdan Ovidiu Popescu
- Department of Clinical Neurosciences, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Neurology, Colentina Clinical Hospital, Bucharest, Romania.,Laboratory of Cell Biology, Neurosciences and Experimental Myology, "Victor Babeş" National Institute of Pathology, Bucharest, Romania
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Zoetmulder R, Konduri PR, Obdeijn IV, Gavves E, Išgum I, Majoie CB, Dippel DW, Roos YB, Goyal M, Mitchell PJ, Campbell BCV, Lopes DK, Reimann G, Jovin TG, Saver JL, Muir KW, White P, Bracard S, Chen B, Brown S, Schonewille WJ, van der Hoeven E, Puetz V, Marquering HA. Automated Final Lesion Segmentation in Posterior Circulation Acute Ischemic Stroke Using Deep Learning. Diagnostics (Basel) 2021; 11:1621. [PMID: 34573963 PMCID: PMC8466415 DOI: 10.3390/diagnostics11091621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/25/2021] [Accepted: 08/30/2021] [Indexed: 11/17/2022] Open
Abstract
Final lesion volume (FLV) is a surrogate outcome measure in anterior circulation stroke (ACS). In posterior circulation stroke (PCS), this relation is plausibly understudied due to a lack of methods that automatically quantify FLV. The applicability of deep learning approaches to PCS is limited due to its lower incidence compared to ACS. We evaluated strategies to develop a convolutional neural network (CNN) for PCS lesion segmentation by using image data from both ACS and PCS patients. We included follow-up non-contrast computed tomography scans of 1018 patients with ACS and 107 patients with PCS. To assess whether an ACS lesion segmentation generalizes to PCS, a CNN was trained on ACS data (ACS-CNN). Second, to evaluate the performance of only including PCS patients, a CNN was trained on PCS data. Third, to evaluate the performance when combining the datasets, a CNN was trained on both datasets. Finally, to evaluate the performance of transfer learning, the ACS-CNN was fine-tuned using PCS patients. The transfer learning strategy outperformed the other strategies in volume agreement with an intra-class correlation of 0.88 (95% CI: 0.83-0.92) vs. 0.55 to 0.83 and a lesion detection rate of 87% vs. 41-77 for the other strategies. Hence, transfer learning improved the FLV quantification and detection rate of PCS lesions compared to the other strategies.
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Affiliation(s)
- Riaan Zoetmulder
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, 1105 Amsterdam, The Netherlands; (R.Z.); (P.R.K.); (I.V.O.); (I.I.)
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, 1105 Amsterdam, The Netherlands;
- Informatics Institute, University of Amsterdam, 1097 Amsterdam, The Netherlands;
| | - Praneeta R. Konduri
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, 1105 Amsterdam, The Netherlands; (R.Z.); (P.R.K.); (I.V.O.); (I.I.)
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, 1105 Amsterdam, The Netherlands;
| | - Iris V. Obdeijn
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, 1105 Amsterdam, The Netherlands; (R.Z.); (P.R.K.); (I.V.O.); (I.I.)
| | - Efstratios Gavves
- Informatics Institute, University of Amsterdam, 1097 Amsterdam, The Netherlands;
| | - Ivana Išgum
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, 1105 Amsterdam, The Netherlands; (R.Z.); (P.R.K.); (I.V.O.); (I.I.)
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, 1105 Amsterdam, The Netherlands;
- Informatics Institute, University of Amsterdam, 1097 Amsterdam, The Netherlands;
| | - Charles B.L.M. Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, 1105 Amsterdam, The Netherlands;
| | - Diederik W.J. Dippel
- Department of Neurology, Erasmus MC University Medical Center, 3015 Rotterdam, The Netherlands;
| | - Yvo B.W.E.M. Roos
- Department of Neurology, Amsterdam UMC, Location AMC, 1105 Amsterdam, The Netherlands;
| | - Mayank Goyal
- Radiology, Foothills Medical Centre, University of Calgary, Calgary, AB T2N 2T9, Canada;
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Peter J. Mitchell
- Department of Radiology, The University of Melbourne & The Royal Melbourne Hospital, Melbourne, VIC 3050, Australia;
| | - Bruce C. V. Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC 3052, Australia;
| | - Demetrius K. Lopes
- Department of Neurological Surgery, Rush University Medical Center, Chicago, IL 60612, USA;
| | - Gernot Reimann
- Department of Neurology, Community Hospital Klinikum Dortmund, 44137 Dortmund, Germany;
| | - Tudor G. Jovin
- Cooper Neurological Institute, Cooper University Medical Center, Camden, NJ 08103, USA;
| | - Jeffrey L. Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA;
| | - Keith W. Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow G12 8QB, UK;
| | - Phil White
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE1 7RU, UK;
- Department of Neuroradiology, Newcastle upon Tyne Hospitals, Newcastle upon Tyne NE1 4LP, UK
| | - Serge Bracard
- INSERM U1254, IADI, University Hospital, Neuroradiology, 54511 Nancy, France;
| | - Bailiang Chen
- INSERM CIC-IT 1433, University Hospital, 54511 Nancy, France;
| | - Scott Brown
- Altair Biostatistics, St Louis Park, MN 55416, USA;
| | | | - Erik van der Hoeven
- Department of Radiology, St. Antonius Hospital, P.O. Box 2500, 3430 Nieuwegein, The Netherlands;
| | - Volker Puetz
- Department of Neurology, Dresden University Stroke Centre, Technical University Dresden, Fetscherstraße 74, 01307 Dresden, Germany;
| | - Henk A. Marquering
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, 1105 Amsterdam, The Netherlands; (R.Z.); (P.R.K.); (I.V.O.); (I.I.)
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, 1105 Amsterdam, The Netherlands;
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Tolhuisen ML, Ernst M, Boers AMM, Brown S, Beenen LFM, Guillemin F, Roos YBWEM, Saver JL, van Oostenbrugge R, Demchuck AM, van Zwam W, Jovin TG, Berkhemer OA, Muir KW, Bracard S, Campbell BCV, van der Lugt A, White P, Hill MD, Dippel DWJ, Mitchell PJ, Goyal M, Caan MWA, Marquering HA, Majoie CBLM. Value of infarct location in the prediction of functional outcome in patients with an anterior large vessel occlusion: results from the HERMES study. Neuroradiology 2021; 64:521-530. [PMID: 34476512 PMCID: PMC8850210 DOI: 10.1007/s00234-021-02784-x] [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: 06/09/2021] [Accepted: 08/01/2021] [Indexed: 11/22/2022]
Abstract
Purpose Follow-up infarct volume (FIV) is moderately associated with functional outcome. We hypothesized that accounting for infarct location would strengthen the association of FIV with functional outcome. Methods We included 252 patients from the HERMES collaboration with follow-up diffusion weighted imaging. Patients received endovascular treatment combined with best medical management (n = 52%) versus best medical management alone (n = 48%). FIV was quantified in low, moderate and high modified Rankin Scale (mRS)-relevant regions. We used binary logistic regression to study the relation between the total, high, moderate or low mRS-relevant FIVs and favorable outcome (mRS < 2) after 90 days. The strength of association was evaluated using the c-statistic. Results Small lesions only occupied high mRS-relevant brain regions. Lesions additionally occupied lower mRS-relevant brain regions if FIV expanded. Higher FIV was associated with a higher risk of unfavorable outcome, as were volumes of tissue with low, moderate and high mRS relevance. In multivariable modeling, only the volume of high mRS-relevant infarct was significantly associated with favorable outcome. The c-statistic was highest (0.76) for the models that included high mRS-relevant FIV or the combination of high, moderate and low mRS-relevant FIV but was not significantly different from the model that included only total FIV (0.75). Conclusion This study confirms the association of FIV and unfavorable functional outcome but showed no strengthened association if lesion location was taken into account.
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Affiliation(s)
- Manon L Tolhuisen
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands. .,Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands.
| | - Marielle Ernst
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Scott Brown
- Altair Biostatistics, St Louis Park, MN, USA
| | - Ludo F M Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Francis Guillemin
- CIC-Epidémiologie Clinique, 1433, Inserm, CHRU, Université de Lorraine, Nancy, France
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Robert van Oostenbrugge
- Department of Neurology, Maastricht UMC, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Andrew M Demchuck
- Department of Clinical Neurosciences, Department of Radiology and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Wim van Zwam
- Department of Radiology, Maastricht UMC, Maastricht, The Netherlands
| | - Tudor G Jovin
- Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Olvert A Berkhemer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands.,Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, University Avenue, Glasgow, UK
| | - Serge Bracard
- CIC-Epidémiologie Clinique, 1433, Inserm, CHRU, Université de Lorraine, Nancy, France.,Department of Diagnostic and Interventional Neuroradiology, IADI, Inserm, CHRU, Université de Lorraine, Nancy, France
| | - Bruce C V Campbell
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia.,Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Aad van der Lugt
- Institute of Neuroscience and Psychology, University of Glasgow, University Avenue, Glasgow, UK
| | - Phill White
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Department of Neuroradiology, Newcastle upon Tyne hospitals, Newcastle upon Tyne, UK
| | - Michael D Hill
- Department of Clinical Neurosciences, Department of Radiology and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, Cumming School of Medicine, University of Calgary & Foothills Medical Centre, Calgary, Alberta, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary & Foothills Medical Centre, Calgary, Calgary, Canada
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Peter J Mitchell
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Mayank Goyal
- Department of Clinical Neurosciences, Department of Radiology and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthan W A Caan
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Henk A Marquering
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
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50
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Zhou T, Yi T, Li T, Zhu L, Li Y, Li Z, Wang M, Li Q, He Y, Yang P, Zhang Y, Li Z, Zhang Y, Ye X, Chen W, Wang S, Liu J. Predictors of futile recanalization in patients undergoing endovascular treatment in the DIRECT-MT trial. J Neurointerv Surg 2021; 14:752-755. [PMID: 34475255 DOI: 10.1136/neurintsurg-2021-017765] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/23/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Futile recanalization-when patients have a successful recanalization but fail to achieve a satisfactory functional outcome- is a common phenomenon of endovascular treatment of acute ischemic stroke (AIS). The present study aimed to identify the predictors of futile recanalization in AIS patients who received endovascular treatment. METHODS This is a post-hoc analysis of the DIRECT-MT trial. Demographics, clinical characteristics, acute stroke workflow interval times, biochemical parameters, and imaging characteristics were compared between futile and meaningful recanalization groups. Multivariate analysis was performed to identify the predictors of futile recanalization. RESULTS Futile recanalization was observed in 277 patients. In multivariable logistic regression analysis, older age (p<0.001), higher baseline systolic blood pressure (SBP) (p=0.032), incomplete reperfusion defined by extended Thrombolysis In Cerebral Infarction (eTICI) grades (p=0.020), and larger final infarct volume (FIV) (p<0.001) were independent predictors of futile recanalization. CONCLUSIONS Old age, high baseline SBP, incomplete reperfusion defined by eTICI, and large FIV were independent predictors of futile recanalization after endovascular therapy for AIS.
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Affiliation(s)
- Tengfei Zhou
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China.,Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Tingyu Yi
- Department of Neurology, Zhangzhou Municipal Hospital of Fujian Province and Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Tianxiao Li
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China .,Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Liangfu Zhu
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Yucheng Li
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Zhaoshuo Li
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Meiyun Wang
- Department of Radiology, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Qiang Li
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Yingkun He
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Pengfei Yang
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yongwei Zhang
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Zifu Li
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yongxin Zhang
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Xiaofei Ye
- Department of Statistics, Naval Medical University, Shanghai, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Municipal Hospital of Fujian Province and Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Shouchun Wang
- Department of Neurology, The First Affiliated Hospital of Jilin University, Changchun, China
| | - Jianmin Liu
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
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