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Shintoku R, Shimizu T, Aihara M, Asano H, Yamaguchi R, Tsuneoka H, Shimauchi-Ohtaki H, Tosaka M, Yoshimoto Y. Factors associated with decreasing diffusion-weighted imaging-positive area volume after mechanical thrombectomy in patients with large early ischemic changes. Interv Neuroradiol 2024:15910199241245279. [PMID: 38576326 DOI: 10.1177/15910199241245279] [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: 04/06/2024] Open
Abstract
OBJECTIVES This study aimed to evaluate the factors associated with decreasing diffusion-weighted imaging (DWI) positive areas in patients with large early ischemic changes after mechanical thrombectomy (MT). MATERIALS AND METHODS This retrospective single-center clinical study was conducted between January 2013 and December 2022. We included consecutive patients who underwent MT for acute large-vessel occlusion of the anterior circulation with low pretreatment DWI-Alberta Stroke Program Early Computed Tomography Scores (ASPECTS) (0-5), effective recanalization [thrombolysis in cerebral infarction (TICI) 2b or TICI3], and magnetic resonance imaging (MRI) acquired before and after MT. We measured the DWI-positive area volume before and after MT. The primary endpoint was the after/before-MT DWI-positive area-volume ratio. RESULTS In total, 28 patients were included in this study. Eight patients (29%) had an after/before-MT DWI-positive area-volume ratio of <1. The median mean apparent diffusion coefficient (ADC) levels of the DWI-positive areas in the groups with a ratio of <1 or >1 were 717 × 10⁶ mm2/s and 637 × 106 mm2/s, respectively (p = 0.011). Multivariate logistic regression analysis showed that ADC level (OR, 1.020 [95% confidence intervals (CIs), 1.001-1.040]; p = 0.040) was an independent predictor of a decreased DWI-positive area after MT. There was a negative correlation between the mean ADC level and the after/before-MT DWI-positive area-volume ratio (p < 0.001, |ρ| = 0.650), and the mean pretreatment ADC cutoff level was 649 × 106 mm2/s (area under the curve (AUC) = 0.806) for predicting a volume ratio of <1. CONCLUSIONS The mean ADC level before-MT correlated with the after/before-MT DWI-positive area-volume ratio. A mean pretreatment ADC cutoff level of 649 × 106 mm2/s predicted a decreased DWI-positive area after MT.
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Affiliation(s)
- Ryosuke Shintoku
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Tatsuya Shimizu
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Masanori Aihara
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hirofumi Asano
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Rei Yamaguchi
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Haruka Tsuneoka
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Japan
| | | | - Masahiko Tosaka
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Yuhei Yoshimoto
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Japan
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Sotardi ST, Alves CAPF, Serai SD, Beslow LA, Schwartz ES, Magee R, Vossough A. Magnetic resonance imaging protocols in pediatric stroke. Pediatr Radiol 2023; 53:1324-1335. [PMID: 36604317 DOI: 10.1007/s00247-022-05576-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/30/2022] [Accepted: 12/14/2022] [Indexed: 01/07/2023]
Abstract
Neuroimaging protocols play an important role in the timely evaluation and treatment of pediatric stroke and its mimics. MRI protocols for stroke in the pediatric population should be guided by the clinical scenario and neurologic examination, with consideration of age, suspected infarct type and underlying risk factors. Acute stroke diagnosis and causes in pediatric age groups can differ significantly from those in adult populations, and delay in stroke diagnosis among children is a common problem. An awareness of pediatric stroke presentations and risk factors among pediatric emergency physicians, neurologists, pediatricians, subspecialists and radiologists is critical to ensuring timely diagnosis. Given special considerations related to unique pediatric stroke risk factors and the need for sedation in some children, expert consensus guidelines for the imaging of suspected pediatric infarct have been proposed. In this article the authors review standard and rapid MRI protocols for the diagnosis of pediatric stroke, as well as the key differences between pediatric and adult stroke imaging.
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Affiliation(s)
- Susan T Sotardi
- Division of Neuroradiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Cesar Augusto P F Alves
- Division of Neuroradiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Suraj D Serai
- Division of Neuroradiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Lauren A Beslow
- Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Erin Simon Schwartz
- Division of Neuroradiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Ralph Magee
- Division of Neuroradiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Arastoo Vossough
- Division of Neuroradiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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3
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Panni P, Lapergue B, Maïer B, Finitsis S, Clarençon F, Richard S, Marnat G, Bourcier R, Sibon I, Dargazanli C, Blanc R, Consoli A, Eugène F, Vannier S, Spelle L, Denier C, Boulanger M, Gauberti M, Saleme S, Macian F, Rosso C, Naggara O, Turc G, Ozkul-Wermester O, Papagiannaki C, Albucher JF, Darcourt J, Le Bras A, Evain S, Wolff V, Pop R, Timsit S, Gentric JC, Bourdain F, Veunac L, Arquizan C, Gory B. Clinical Impact and Predictors of Diffusion Weighted Imaging (DWI) Reversal in Stroke Patients with Diffusion Weighted Imaging Alberta Stroke Program Early CT Score 0-5 Treated by Thrombectomy : Diffusion Weighted Imaging Reversal in Large Volume Stroke. Clin Neuroradiol 2022; 32:939-950. [PMID: 35412044 DOI: 10.1007/s00062-022-01156-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/02/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE To determine whether reversal of DWI lesions (DWIr) on the DWI-ASPECTS (diffusion weighted imaging Alberta Stroke Program CT Score) template should serve as a predictor of 90-day clinical outcome in acute ischemic stroke (AIS) patients with pretreatment diffusion-weighted imaging (DWI)-ASPECTS 0-5 treated with thrombectomy, and to determine its predictors in current practice. METHODS We analyzed data of all consecutive patients included in the prospective multicenter national Endovascular Treatment in Ischemic Stroke Registry between 1 January 2015 and 31 December 2020 with a premorbid mRS ≤ 2, who presented with a pretreatment DWI-ASPECTS 0-5 score, underwent thrombectomy and had an available 24 h post-interventional MRI follow-up. Multivariable analyses were performed to evaluate the clinical impact of DWIr on early neurological improvement (ENI), 3‑month modified Rankin scale (mRS) score distribution (shift analysis) and to define independent predictors of DWIr. RESULTS Early neurological improvement was detected in 82/211 (41.7%) of patients while 3‑month functional independence was achieved by 75 (35.5%) patients. The DWI reversal (39/211, 18.9%) resulted an independent predictor of both ENI (aOR 3.6, 95% CI 1.2-7.7; p 0.018) and 3‑month clinical outcome (aOR for mRS shift: 2.2, 95% CI 1-4.6; p 0.030). Only successful recanalization (mTICI 2c-3) independently predicted DWIr in the studied population (aOR 3.3, 95% CI 1.3-7.9; p 0.009). CONCLUSION The DWI reversal occurs in a non-negligible proportion of DWI-ASPECTS 0-5 patients subjected to thrombectomy and significantly influences clinical outcome. The mTICI 2c-3 recanalization emerged as an independent DWIr predictor.
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Affiliation(s)
- Pietro Panni
- Department of Neuroradiology, Division of Interventional Neuroradiology, Department of Neurosurgery, San Raffaele University Hospital, Milan, Italy.
| | - Bertrand Lapergue
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - Benjamin Maïer
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Stephanos Finitsis
- AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Sébastien Richard
- CHRU-Nancy, Department of Neurology, Stroke Unit, Université de Lorraine, 54000, Nancy, France.,CIC-P 1433, INSERM U1116, CHRU-Nancy, 54000, Nancy, France
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Romain Bourcier
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Igor Sibon
- Neurology, University Hospital of Bordeaux, Bordeaux, France
| | - Cyril Dargazanli
- Department of Interventional Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | - Raphaël Blanc
- Department of Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Arturo Consoli
- Diagnostic and Interventional Neuroradiology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - François Eugène
- Department of Neuroradiology, University Hospital of Rennes, Rennes, France
| | | | | | | | | | | | | | | | - Charlotte Rosso
- Department of Neurology, CHU Pitié-Salpétrière, Paris, France
| | | | - Guillaume Turc
- Department of Neurology, Hôpital Saint-Anne, Paris, France
| | | | | | | | | | - Anthony Le Bras
- Department of Neuroradiology, CHBA Bretagne Atlantique, Vannes, France
| | - Sarah Evain
- Neurology, CHBA Bretagne Atlantique, Vannes, France
| | - Valérie Wolff
- Department of Neurology, CHU Strasbourg, Strasbourg, France
| | - Raoul Pop
- Neuroradiology, CHU Strasbourg, Strasbourg, France
| | - Serge Timsit
- Department of Neurology, CHU Brest, Brest, France
| | | | | | | | | | - Benjamin Gory
- CHRU-Nancy, Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, 54000, Nancy, France.,IADI, INSERM U1254, Université de Lorraine, 54000, Nancy, France
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Umemura T, Hatano T, Ogura T, Miyata T, Agawa Y, Nakajima H, Tomoyose R, Sakamoto H, Tsujimoto Y, Nakazawa Y, Wakabayashi T, Hashimoto T, Fujiki R, Shiraishi W, Nagata I. ADC Level is Related to DWI Reversal in Patients Undergoing Mechanical Thrombectomy: A Retrospective Cohort Study. AJNR Am J Neuroradiol 2022; 43:893-898. [PMID: 35550283 DOI: 10.3174/ajnr.a7510] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/17/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE In patients with ischemic stroke, DWI lesions can occasionally be reversed by reperfusion therapy. This study aimed to ascertain the relationship between ADC levels and DWI reversal in patients with acute ischemic stroke who underwent recanalization treatment. MATERIALS AND METHODS We conducted a retrospective cohort study in patients with acute ischemic stroke who underwent endovascular mechanical thrombectomy with successful recanalization between April 2017 and March 2021. DWI reversal was assessed through follow-up MR imaging approximately 24 hours after treatment. RESULTS In total, 118 patients were included. DWI reversal was confirmed in 42 patients. The ADC level in patients with reversal was significantly higher than that in patients without reversal. Eighty-three percent of patients with DWI reversal areas had mean ADC levels of ≥520 × 10-6 mm2/s, and 71% of patients without DWI reversal areas had mean ADC levels of <520 × 10-6 mm2/s. The mean ADC threshold was 520 × 10-6 mm2/s with a sensitivity and specificity of 71% and 83%, respectively. In multivariate analysis, the mean ADC level (OR, 1.023; 95% CI, 1.013-1.033; P < .0001) was independently associated with DWI reversal. Patients with DWI reversal areas had earlier neurologic improvement (NIHSS at 7 days) than patients without reversal areas (P < .0001). CONCLUSIONS In acute ischemic stroke, the ADC value is independently associated with DWI reversal. Lesions with a mean ADC of ≥520 × 10-6 mm2/s are salvageable by mechanical thrombectomy, and DWI reversal areas regain neurologic function. The ADC value is easily assessed and is a useful tool to predict viable lesions.
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Affiliation(s)
- T Umemura
- From the Department of Neurosurgery (T.U., T.H., T.O., T.M., Y.A., N.H., R.T., H.S., Y.T., Y.N., T.W., I.N.), Stroke Center, Kokura Memorial Hospital, Kitakyushu City, Japan
| | - T Hatano
- From the Department of Neurosurgery (T.U., T.H., T.O., T.M., Y.A., N.H., R.T., H.S., Y.T., Y.N., T.W., I.N.), Stroke Center, Kokura Memorial Hospital, Kitakyushu City, Japan
| | - T Ogura
- From the Department of Neurosurgery (T.U., T.H., T.O., T.M., Y.A., N.H., R.T., H.S., Y.T., Y.N., T.W., I.N.), Stroke Center, Kokura Memorial Hospital, Kitakyushu City, Japan
| | - T Miyata
- From the Department of Neurosurgery (T.U., T.H., T.O., T.M., Y.A., N.H., R.T., H.S., Y.T., Y.N., T.W., I.N.), Stroke Center, Kokura Memorial Hospital, Kitakyushu City, Japan
| | - Y Agawa
- From the Department of Neurosurgery (T.U., T.H., T.O., T.M., Y.A., N.H., R.T., H.S., Y.T., Y.N., T.W., I.N.), Stroke Center, Kokura Memorial Hospital, Kitakyushu City, Japan
| | - H Nakajima
- From the Department of Neurosurgery (T.U., T.H., T.O., T.M., Y.A., N.H., R.T., H.S., Y.T., Y.N., T.W., I.N.), Stroke Center, Kokura Memorial Hospital, Kitakyushu City, Japan
| | - R Tomoyose
- From the Department of Neurosurgery (T.U., T.H., T.O., T.M., Y.A., N.H., R.T., H.S., Y.T., Y.N., T.W., I.N.), Stroke Center, Kokura Memorial Hospital, Kitakyushu City, Japan
| | - H Sakamoto
- From the Department of Neurosurgery (T.U., T.H., T.O., T.M., Y.A., N.H., R.T., H.S., Y.T., Y.N., T.W., I.N.), Stroke Center, Kokura Memorial Hospital, Kitakyushu City, Japan
| | - Y Tsujimoto
- From the Department of Neurosurgery (T.U., T.H., T.O., T.M., Y.A., N.H., R.T., H.S., Y.T., Y.N., T.W., I.N.), Stroke Center, Kokura Memorial Hospital, Kitakyushu City, Japan
| | - Y Nakazawa
- From the Department of Neurosurgery (T.U., T.H., T.O., T.M., Y.A., N.H., R.T., H.S., Y.T., Y.N., T.W., I.N.), Stroke Center, Kokura Memorial Hospital, Kitakyushu City, Japan
| | - T Wakabayashi
- From the Department of Neurosurgery (T.U., T.H., T.O., T.M., Y.A., N.H., R.T., H.S., Y.T., Y.N., T.W., I.N.), Stroke Center, Kokura Memorial Hospital, Kitakyushu City, Japan
| | - T Hashimoto
- Department of Neurology (T.H., R.F., W.B.), Stroke Center, Kokura Memorial Hospital, Kitakyushu City, Japan
| | - R Fujiki
- Department of Neurology (T.H., R.F., W.B.), Stroke Center, Kokura Memorial Hospital, Kitakyushu City, Japan
| | - W Shiraishi
- Department of Neurology (T.H., R.F., W.B.), Stroke Center, Kokura Memorial Hospital, Kitakyushu City, Japan
| | - I Nagata
- From the Department of Neurosurgery (T.U., T.H., T.O., T.M., Y.A., N.H., R.T., H.S., Y.T., Y.N., T.W., I.N.), Stroke Center, Kokura Memorial Hospital, Kitakyushu City, Japan
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Lemale CL, Lückl J, Horst V, Reiffurth C, Major S, Hecht N, Woitzik J, Dreier JP. Migraine Aura, Transient Ischemic Attacks, Stroke, and Dying of the Brain Share the Same Key Pathophysiological Process in Neurons Driven by Gibbs–Donnan Forces, Namely Spreading Depolarization. Front Cell Neurosci 2022; 16:837650. [PMID: 35237133 PMCID: PMC8884062 DOI: 10.3389/fncel.2022.837650] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/19/2022] [Indexed: 12/15/2022] Open
Abstract
Neuronal cytotoxic edema is the morphological correlate of the near-complete neuronal battery breakdown called spreading depolarization, or conversely, spreading depolarization is the electrophysiological correlate of the initial, still reversible phase of neuronal cytotoxic edema. Cytotoxic edema and spreading depolarization are thus different modalities of the same process, which represents a metastable universal reference state in the gray matter of the brain close to Gibbs–Donnan equilibrium. Different but merging sections of the spreading-depolarization continuum from short duration waves to intermediate duration waves to terminal waves occur in a plethora of clinical conditions, including migraine aura, ischemic stroke, traumatic brain injury, aneurysmal subarachnoid hemorrhage (aSAH) and delayed cerebral ischemia (DCI), spontaneous intracerebral hemorrhage, subdural hematoma, development of brain death, and the dying process during cardio circulatory arrest. Thus, spreading depolarization represents a prime and simultaneously the most neglected pathophysiological process in acute neurology. Aristides Leão postulated as early as the 1940s that the pathophysiological process in neurons underlying migraine aura is of the same nature as the pathophysiological process in neurons that occurs in response to cerebral circulatory arrest, because he assumed that spreading depolarization occurs in both conditions. With this in mind, it is not surprising that patients with migraine with aura have about a twofold increased risk of stroke, as some spreading depolarizations leading to the patient percept of migraine aura could be caused by cerebral ischemia. However, it is in the nature of spreading depolarization that it can have different etiologies and not all spreading depolarizations arise because of ischemia. Spreading depolarization is observed as a negative direct current (DC) shift and associated with different changes in spontaneous brain activity in the alternating current (AC) band of the electrocorticogram. These are non-spreading depression and spreading activity depression and epileptiform activity. The same spreading depolarization wave may be associated with different activity changes in adjacent brain regions. Here, we review the basal mechanism underlying spreading depolarization and the associated activity changes. Using original recordings in animals and patients, we illustrate that the associated changes in spontaneous activity are by no means trivial, but pose unsolved mechanistic puzzles and require proper scientific analysis.
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Affiliation(s)
- Coline L. Lemale
- Center for Stroke Research Berlin, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Experimental Neurology, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Janos Lückl
- Center for Stroke Research Berlin, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Viktor Horst
- Center for Stroke Research Berlin, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Clemens Reiffurth
- Center for Stroke Research Berlin, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Experimental Neurology, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Sebastian Major
- Center for Stroke Research Berlin, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Experimental Neurology, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurology, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, University of Oldenburg, Oldenburg, Germany
| | - Jens P. Dreier
- Center for Stroke Research Berlin, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Experimental Neurology, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurology, Berlin Institute of Health, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany
- Einstein Center for Neurosciences Berlin, Berlin, Germany
- *Correspondence: Jens P. Dreier,
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Cheung J, Doerr M, Hu R, Sun PZ. Refined Ischemic Penumbra Imaging with Tissue pH and Diffusion Kurtosis Magnetic Resonance Imaging. Transl Stroke Res 2021; 12:742-753. [PMID: 33159656 PMCID: PMC8102648 DOI: 10.1007/s12975-020-00868-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 10/14/2020] [Accepted: 10/18/2020] [Indexed: 12/19/2022]
Abstract
Imaging has played a vital role in our mechanistic understanding of acute ischemia and the management of acute stroke patients. The most recent DAWN and DEFUSE-3 trials showed that endovascular therapy could be extended to a selected group of late-presenting stroke patients with the aid of imaging. Although perfusion and diffusion MRI have been commonly used in stroke imaging, the approximation of their mismatch as the penumbra is oversimplified, particularly in the era of endovascular therapy. Briefly, the hypoperfusion lesion includes the benign oligemia that does not proceed to infarction. Also, with prompt and effective reperfusion therapy, a portion of the diffusion lesion is potentially reversible. Therefore, advanced imaging that provides improved ischemic tissue characterization may enable new experimental stroke therapeutics and eventually further individualize stroke treatment upon translation to the clinical setting. Specifically, pH imaging captures tissue of altered metabolic state that demarcates the hypoperfused lesion into ischemic penumbra and benign oligemia, which remains promising to define the ischemic penumbra's outer boundary. On the other hand, diffusion kurtosis imaging (DKI) differentiates the most severely damaged and irreversibly injured diffusion lesion from the portion of diffusion lesion that is potentially reversible, refining the inner boundary of the penumbra. Altogether, the development of advanced imaging has the potential to not only transform the experimental stroke research but also aid clinical translation and patient management.
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Affiliation(s)
- Jesse Cheung
- Emory College of Arts and Sciences, Emory University, Atlanta, GA, 30329, USA
- Yerkes Imaging Center, Yerkes National Primate Research Center, Emory University, Atlanta, GA, 30329, USA
| | - Madeline Doerr
- Yerkes Imaging Center, Yerkes National Primate Research Center, Emory University, Atlanta, GA, 30329, USA
- Dartmouth College, Hanover, NH, 03755, USA
| | - Ranliang Hu
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton RD NE, Atlanta, GA, 30322, USA
| | - Phillip Zhe Sun
- Yerkes Imaging Center, Yerkes National Primate Research Center, Emory University, Atlanta, GA, 30329, USA.
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton RD NE, Atlanta, GA, 30322, USA.
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7
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Wu D, Zhou Y, Cho J, Shen N, Li S, Qin Y, Zhang G, Yan S, Xie Y, Zhang S, Zhu W, Wang Y. The Spatiotemporal Evolution of MRI-Derived Oxygen Extraction Fraction and Perfusion in Ischemic Stroke. Front Neurosci 2021; 15:716031. [PMID: 34483830 PMCID: PMC8415351 DOI: 10.3389/fnins.2021.716031] [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: 05/28/2021] [Accepted: 07/12/2021] [Indexed: 12/13/2022] Open
Abstract
Purpose This study aimed to assess the spatiotemporal evolution of oxygen extraction fraction (OEF) in ischemic stroke with a newly developed cluster analysis of time evolution (CAT) for a combined quantitative susceptibility mapping and quantitative blood oxygen level-dependent model (QSM + qBOLD, QQ). Method One hundred and fifteen patients in different ischemic stroke phases were retrospectively collected for measurement of OEF of the infarcted area defined on diffusion-weighted imaging (DWI). Clinical severity was assessed using the National Institutes of Health Stroke Scale (NIHSS). Of the 115 patients, 11 underwent two longitudinal MRI scans, namely, three-dimensional (3D) multi-echo gradient recalled echo (mGRE) and 3D pseudo-continuous arterial spin labeling (pCASL), to evaluate the reversal region (RR) of the initial diffusion lesion (IDL) that did not overlap with the final infarct (FI). The temporal evolution of OEF and the cerebral blood flow (CBF) in the IDL, the RR, and the FI were assessed. Results Compared to the contralateral mirror area, the OEF of the infarcted region was decreased regardless of stroke phases (p < 0.05) and showed a declining tendency from the acute to the chronic phase (p = 0.022). Five of the 11 patients with longitudinal scans showed reversal of the IDL. Relative oxygen extraction fraction (rOEF, compared to the contralateral mirror area) of the RR increased from the first to the second MRI (p = 0.044). CBF was about 1.5-fold higher in the IDL than in the contralateral mirror area in the first MRI. Two patients showed penumbra according to the enlarged FI volume. The rOEF of the penumbra fluctuated around 1.0 at earlier scan times and then decreased, while the CBF decreased continuously. Conclusion The spatiotemporal evolution of OEF and perfusion in ischemic lesions is heterogeneous, and the CAT-based QQ method is feasible to capture cerebral oxygen metabolic information.
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Affiliation(s)
- Di Wu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yiran Zhou
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Junghun Cho
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States.,Department of Biomedical Engineering, Cornell University, Ithaca, NY, United States
| | - Nanxi Shen
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shihui Li
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuanyuan Qin
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guiling Zhang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Su Yan
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yan Xie
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shun Zhang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wenzhen Zhu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yi Wang
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States.,Department of Biomedical Engineering, Cornell University, Ithaca, NY, United States
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8
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Modrau B, Winder A, Hjort N, Nygård Johansen M, Andersen G, Fiehler J, Vorum H, Forkert ND. Perfusion Changes in Acute Stroke Treated with Theophylline as an Add-on to Thrombolysis : A Randomized Clinical Trial Subgroup Analysis. Clin Neuroradiol 2021; 32:345-352. [PMID: 34259904 PMCID: PMC9187573 DOI: 10.1007/s00062-021-01029-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: 12/22/2020] [Accepted: 04/28/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Theophylline has been suggested to have a neuroprotective effect in ischemic stroke; however, results from animal stroke models and clinical trials in humans are controversial. The aim of this study was to assess the effect of theophylline on the cerebral perfusion with multiparametric magnetic resonance imaging (MRI). METHODS The relative cerebral blood flow (rCBF), relative cerebral blood volume (rCBV), and relative mean transit time (rMTT) in the infarct core, penumbra, and unaffected tissue were measured using multi-parametric MRI at baseline and 3‑h follow-up in patients treated with theophylline or placebo as an add-on to thrombolytic therapy. RESULTS No significant differences in mean rCBF, rCBV, and rMTT was found in the penumbra and unaffected tissue between the theophylline group and the control group between baseline and 3‑h follow-up. In the infarct core, mean rCBV increased on average by 0.05 in the theophylline group and decreased by 0.14 in the control group (p < 0.04). Mean rCBF and mean rMTT in the infarct core were similar between the two treatment groups. CONCLUSION The results indicate that theophylline does not change the perfusion in potentially salvageable penumbral tissue but only affects the rCBV in the infarct core. In contrast to the penumbra, the infarct core is unlikely to be salvageable, which might explain why theophylline failed in clinical trials.
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Affiliation(s)
- Boris Modrau
- Department of Neurology, Aalborg University Hospital, Postbox 561, 9100, Aalborg, Denmark.
| | - Anthony Winder
- Departments of Radiology & Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Niels Hjort
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Grethe Andersen
- Department of Neurology and Clinical Medicine, Aarhus University Hospital, Aarhus University, Aarhus, Denmark
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henrik Vorum
- Department of Ophthalmology, Aalborg University Hospital, Aalborg, Denmark
| | - Nils D Forkert
- Departments of Radiology & Clinical Neurosciences, University of Calgary, Calgary, Canada
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9
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Nagaraja N. Diffusion weighted imaging in acute ischemic stroke: A review of its interpretation pitfalls and advanced diffusion imaging application. J Neurol Sci 2021; 425:117435. [PMID: 33836457 DOI: 10.1016/j.jns.2021.117435] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 03/08/2021] [Accepted: 04/02/2021] [Indexed: 12/28/2022]
Abstract
Diffusion weighted imaging (DWI) is a widely used imaging technique to evaluate patients with stroke. It can detect brain ischemia within minutes of stroke onset. However, DWI has few potential pitfalls that should be recognized during interpretation. DWI lesion could be reversible in the early hours of stroke and the entire lesion may not represent ischemic core. False negative DWI could lead to diagnosis of DWI negative stroke or to a missed stroke diagnosis. Ischemic stroke mimics can occur on DWI with non-cerebrovascular neurological conditions. In this article, the history of DWI, its clinical applications, and potential pitfalls for use in acute ischemic stroke are reviewed. Advanced diffusion imaging techniques with reference to Diffusion Kurtosis Imaging and Diffusion Tensor Imaging that has been studied to evaluate ischemic core are discussed.
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Affiliation(s)
- Nandakumar Nagaraja
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.
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10
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Greenberg K, Bykowski J. Modern Neuroimaging Techniques in Diagnosing Transient Ischemic Attack and Acute Ischemic Stroke. Emerg Med Clin North Am 2021; 39:29-46. [PMID: 33218661 DOI: 10.1016/j.emc.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Karen Greenberg
- Neurologic Emergency Department, Global Neurosciences Institute, Crozer Chester Medical Center, 3100 Princeton Pike, Building 3, Suite D, Lawrenceville, NJ 08648, USA
| | - Julie Bykowski
- Department of Radiology, UC San Diego Health, 200 West Arbor Drive, San Diego, CA 92013, USA.
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11
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TASHIRO R, FUJIMURA M, NISHIZAWA T, SAITO A, TOMINAGA T. Cerebral Hyperperfusion and Concomitant Reversible Lesion at the Splenium after Direct Revascularization Surgery for Adult Moyamoya Disease: Possible Involvement of MERS and Watershed Shift Phenomenon. NMC Case Rep J 2021; 8:451-456. [PMID: 35079503 PMCID: PMC8769435 DOI: 10.2176/nmccrj.cr.2020-0337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/13/2021] [Indexed: 11/20/2022] Open
Abstract
Superficial temporal artery (STA)–middle cerebral artery (MCA) bypass is the standard surgical treatment for moyamoya disease (MMD). Local cerebral hyperperfusion (CHP) is one of the potential complications, which could enhance intrinsic inflammation and oxidative stress in MMD patients and accompany concomitant watershed shift (WS) phenomenon, defined as the paradoxical decrease in the cerebral blood flow (CBF) near the site of CHP. However, CHP and simultaneous remote reversible lesion at the splenium have never been reported. A 22-year-old man with ischemic-onset MMD underwent left STA–MCA bypass. Although asymptomatic, local CHP and a paradoxical CBF decrease at the splenium were evident on N-isopropyl-p-[123I] iodoamphetamine single-photon emission computed tomography 1 day after surgery. The patient was maintained under strict blood pressure control, but he subsequently developed transient delirium 4 days after surgery. MRI revealed a high-signal-intensity lesion with a low apparent diffusion coefficient at the splenium. After continued intensive management, the splenial lesion disappeared 14 days after surgery. The patient was discharged without neurological deficits. Catheter angiography 2 months later confirmed marked regression of posterior-to-anterior collaterals via the posterior pericallosal artery, suggesting dynamic watershed shift between blood flow supplies from the posterior and anterior circulation. Mild encephalitis/encephalopathy with a reversible splenial lesion could explain the pathophysiology of the postoperative splenial lesion in this case, which is associated with generation of oxidative stress, enhanced inflammation, and metabolic abnormalities. Rapid postoperative hemodynamic changes, including local CHP and concomitant WS phenomenon, might participate in the formation of the splenial lesion.
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Affiliation(s)
- Ryosuke TASHIRO
- Department of Neurosurgery, Kohnan Hospital, Sendai, Miyagi, Japan
| | - Miki FUJIMURA
- Department of Neurosurgery, Kohnan Hospital, Sendai, Miyagi, Japan
| | - Taketo NISHIZAWA
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Atsushi SAITO
- Department of Neurosurgery, Kohnan Hospital, Sendai, Miyagi, Japan
| | - Teiji TOMINAGA
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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12
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Kirov SA, Fomitcheva IV, Sword J. Rapid Neuronal Ultrastructure Disruption and Recovery during Spreading Depolarization-Induced Cytotoxic Edema. Cereb Cortex 2020; 30:5517-5531. [PMID: 32483593 PMCID: PMC7566686 DOI: 10.1093/cercor/bhaa134] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 04/08/2020] [Accepted: 04/29/2020] [Indexed: 01/29/2023] Open
Abstract
Two major pathogenic events that cause acute brain damage during neurologic emergencies of stroke, head trauma, and cardiac arrest are spreading depolarizing waves and the associated brain edema that course across the cortex injuring brain cells. Virtually nothing is known about how spreading depolarization (SD)-induced cytotoxic edema evolves at the ultrastructural level immediately after insult and during recovery. In vivo 2-photon imaging followed by quantitative serial section electron microscopy was used to assess synaptic circuit integrity in the neocortex of urethane-anesthetized male and female mice during and after SD evoked by transient bilateral common carotid artery occlusion. SD triggered a rapid fragmentation of dendritic mitochondria. A large increase in the density of synapses on swollen dendritic shafts implies that some dendritic spines were overwhelmed by swelling or merely retracted. The overall synaptic density was unchanged. The postsynaptic dendritic membranes remained attached to axonal boutons, providing a structural basis for the recovery of synaptic circuits. Upon immediate reperfusion, cytotoxic edema mainly subsides as affirmed by a recovery of dendritic ultrastructure. Dendritic recuperation from swelling and reversibility of mitochondrial fragmentation suggests that neurointensive care to improve tissue perfusion should be paralleled by treatments targeting mitochondrial recovery and minimizing the occurrence of SDs.
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Affiliation(s)
- Sergei A Kirov
- Department of Neuroscience and Regenerative Medicine, Medical College of Georgia at Augusta University, Augusta, GA 30912, USA
- Department of Neurosurgery, Medical College of Georgia at Augusta University, Augusta, GA 30912, USA
| | - Ioulia V Fomitcheva
- Department of Neurosurgery, Medical College of Georgia at Augusta University, Augusta, GA 30912, USA
| | - Jeremy Sword
- Department of Neuroscience and Regenerative Medicine, Medical College of Georgia at Augusta University, Augusta, GA 30912, USA
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13
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Shrot S, Hoffmann C, Katorza E. Reversible parenchymal ischemic injury on fetal brain MRI following fetoscopic laser coagulation-Implication on parental counseling. Radiol Case Rep 2020; 15:1369-1372. [PMID: 32636975 PMCID: PMC7327126 DOI: 10.1016/j.radcr.2020.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 11/29/2022] Open
Abstract
We present a case of reversible extensive ischemic injury seen on fetal-brain MRI in a fetus following laser coagulation performed for treatment of severe twin-twin transfusion syndrome twin-twin transfusion syndrome. A 32-year-old pregnant mother presented with twin-twin transfusion syndrome. Following fetoscopic laser coagulation, intrauterine fetal death of the donor fetus was diagnosed. On fetal-brain MRI, multiple areas of restricted diffusion were noted, consistent with acute infarctions. Nevertheless, follow-up MRI showed only subtle parenchymal injury, also confirmed on postnatal brain MRI. Our case illustrates that ischemic injury, as depicted on diffusion-weighted imaging, might be reversible, possibly with reperfusion before irreversible insult follows. Two to 3 weeks follow-up fetal MRI might provide additional information on the extent of irreversible injury in cases of restricted diffusion seen on initial fetal-brain MRI and might assist in parental counseling regarding long-term sequela.
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Affiliation(s)
- Shai Shrot
- Section of Neuroradiology, Department of Diagnostic Imaging, Sheba Medical Center, Ramat-Gan, Israel, 2 Sheba Rd, Ramat-Gan 52621, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Chen Hoffmann
- Section of Neuroradiology, Department of Diagnostic Imaging, Sheba Medical Center, Ramat-Gan, Israel, 2 Sheba Rd, Ramat-Gan 52621, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eldad Katorza
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Obstetrics and Gynecology, Sheba Medical Center, Ramat-Gan, Israel
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14
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Arnold SA, Platt SR, Gendron KP, West FD. Imaging Ischemic and Hemorrhagic Disease of the Brain in Dogs. Front Vet Sci 2020; 7:279. [PMID: 32528985 PMCID: PMC7266937 DOI: 10.3389/fvets.2020.00279] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/27/2020] [Indexed: 01/12/2023] Open
Abstract
Strokes, both ischemic and hemorrhagic, are the most common underlying cause of acute, non-progressive encephalopathy in dogs. In effect, substantial information detailing the underlying causes and predisposing factors, affected vessels, imaging features, and outcomes based on location and extent of injury is available. The features of canine strokes on both computed tomography (CT) and magnetic resonance imaging (MRI) have been described in numerous studies. This summary article serves as a compilation of these various descriptions. Drawing from the established and emerging stroke evaluation sequences used in the investigation of strokes in humans, this summary describes all theoretically available sequences. Particular detail is given to logistics of image acquisition, description of imaging findings, and each sequence's advantages and disadvantages. As the imaging features of both forms of strokes are highly representative of the underlying pathophysiologic stages in the hours to months following stroke onset, the descriptions of strokes at various stages are also discussed. It is unlikely that canine strokes can be diagnosed within the same rapid time frame as human strokes, and therefore the opportunity for thrombolytic intervention in ischemic strokes is unattainable. However, a thorough understanding of the appearance of strokes at various stages can aid the clinician when presented with a patient that has developed a stroke in the days or weeks prior to evaluation. Additionally, investigation into new imaging techniques may increase the sensitivity and specificity of stroke diagnosis, as well as provide new ways to monitor strokes over time.
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Affiliation(s)
- Susan A Arnold
- Department of Veterinary Clinical Sciences, University of Minnesota Twin Cities, St. Paul, MN, United States
| | - Simon R Platt
- Department of Small Animal Medicine and Surgery, University of Georgia, Athens, GA, United States
| | - Karine P Gendron
- Department of Small Animal Medicine and Surgery, University of Georgia, Athens, GA, United States
| | - Franklin D West
- Department of Small Animal Medicine and Surgery, University of Georgia, Athens, GA, United States
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15
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Nagaraja N, Forder JR, Warach S, Merino JG. Reversible diffusion-weighted imaging lesions in acute ischemic stroke: A systematic review. Neurology 2020; 94:571-587. [PMID: 32132175 DOI: 10.1212/wnl.0000000000009173] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 01/27/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To systematically review the literature for reversible diffusion-weighted imaging (DWIR) lesions and to describe its prevalence, predictors, and clinical significance. METHODS Studies were included if the first DWI MRI was performed within 24 hours of stroke onset and follow-up DWI or fluid-attenuated inversion recovery (FLAIR)/T2 was performed within 7 or 90 days, respectively, to measure DWIR. We abstracted clinical, imaging, and outcomes data. RESULTS Twenty-three studies met the study criteria. The prevalence of DWIR was 26.5% in DWI-based studies and 6% in FLAIR/T2-based studies. DWIR was associated with recanalization or reperfusion of the ischemic tissue with or without the use of tissue plasminogen activator (t-PA) or endovascular therapy, earlier treatment with t-PA, shorter time to endovascular therapy after MRI, and absent or less severe perfusion deficit within the DWI lesion. DWIR was associated with early neurologic improvement in 5 of 6 studies (defined as improvement in the NIH Stroke Scale (NIHSS) score by 4 or 8 points from baseline or NIHSS score 0 to 2 at 24 hours after treatment or at discharge or median NIHSS score at 7 days) and long-term outcome in 6 of 7 studies (defined as NIHSS score ≤1, improvement in the NIHSS score ≥8 points, or modified Rankin Scale score up to ≤2 at 30 or 90 days) likely due to reperfusion. CONCLUSIONS DWIR is seen in up to a quarter of patients with acute ischemic stroke, and it is associated with good clinical outcome following reperfusion. Our findings highlight the pitfalls of DWI to define ischemic core in the early hours of stroke.
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Affiliation(s)
- Nandakumar Nagaraja
- From the Department of Neurology (N.N.), University of Florida College of Medicine, Gainesville; Department of Radiology and Biomedical Engineering (J.R.F.), University of Florida, Gainesville; Dell Medical School (S.W.), University of Texas at Austin; and Department of Neurology (J.G.M.), Georgetown University School of Medicine, Washington, DC.
| | - John R Forder
- From the Department of Neurology (N.N.), University of Florida College of Medicine, Gainesville; Department of Radiology and Biomedical Engineering (J.R.F.), University of Florida, Gainesville; Dell Medical School (S.W.), University of Texas at Austin; and Department of Neurology (J.G.M.), Georgetown University School of Medicine, Washington, DC
| | - Steven Warach
- From the Department of Neurology (N.N.), University of Florida College of Medicine, Gainesville; Department of Radiology and Biomedical Engineering (J.R.F.), University of Florida, Gainesville; Dell Medical School (S.W.), University of Texas at Austin; and Department of Neurology (J.G.M.), Georgetown University School of Medicine, Washington, DC
| | - Jośe G Merino
- From the Department of Neurology (N.N.), University of Florida College of Medicine, Gainesville; Department of Radiology and Biomedical Engineering (J.R.F.), University of Florida, Gainesville; Dell Medical School (S.W.), University of Texas at Austin; and Department of Neurology (J.G.M.), Georgetown University School of Medicine, Washington, DC
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16
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Major S, Huo S, Lemale CL, Siebert E, Milakara D, Woitzik J, Gertz K, Dreier JP. Direct electrophysiological evidence that spreading depolarization-induced spreading depression is the pathophysiological correlate of the migraine aura and a review of the spreading depolarization continuum of acute neuronal mass injury. GeroScience 2020; 42:57-80. [PMID: 31820363 PMCID: PMC7031471 DOI: 10.1007/s11357-019-00142-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 11/20/2019] [Indexed: 02/07/2023] Open
Abstract
Spreading depolarization is observed as a large negative shift of the direct current potential, swelling of neuronal somas, and dendritic beading in the brain's gray matter and represents a state of a potentially reversible mass injury. Its hallmark is the abrupt, massive ion translocation between intraneuronal and extracellular compartment that causes water uptake (= cytotoxic edema) and massive glutamate release. Dependent on the tissue's energy status, spreading depolarization can co-occur with different depression or silencing patterns of spontaneous activity. In adequately supplied tissue, spreading depolarization induces spreading depression of activity. In severely ischemic tissue, nonspreading depression of activity precedes spreading depolarization. The depression pattern determines the neurological deficit which is either spreading such as in migraine aura or migraine stroke or nonspreading such as in transient ischemic attack or typical stroke. Although a clinical distinction between spreading and nonspreading focal neurological deficits is useful because they are associated with different probabilities of permanent damage, it is important to note that spreading depolarization, the neuronal injury potential, occurs in all of these conditions. Here, we first review the scientific basis of the continuum of spreading depolarizations. Second, we highlight the transition zone of the continuum from reversibility to irreversibility using clinical cases of aneurysmal subarachnoid hemorrhage and cerebral amyloid angiopathy. These illustrate how modern neuroimaging and neuromonitoring technologies increasingly bridge the gap between basic sciences and clinic. For example, we provide direct electrophysiological evidence for the first time that spreading depolarization-induced spreading depression is the pathophysiological correlate of the migraine aura.
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Affiliation(s)
- Sebastian Major
- Center for Stroke Research, Campus Charité Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Shufan Huo
- Center for Stroke Research, Campus Charité Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Coline L Lemale
- Center for Stroke Research, Campus Charité Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Eberhard Siebert
- Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Denny Milakara
- Solution Centre for Image Guided Local Therapies (STIMULATE), Otto-von-Guericke-University, Magdeburg, Germany
| | - Johannes Woitzik
- Evangelisches Krankenhaus Oldenburg, University of Oldenburg, Oldenburg, Germany
| | - Karen Gertz
- Center for Stroke Research, Campus Charité Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jens P Dreier
- Center for Stroke Research, Campus Charité Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany.
- Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
- Department of Neurology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
- Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany.
- Einstein Center for Neurosciences Berlin, Berlin, Germany.
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17
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Hsia AW, Luby M, Cullison K, Burton S, Armonda R, Liu AH, Leigh R, Nadareishvili Z, Benson RT, Lynch JK, Latour LL. Rapid Apparent Diffusion Coefficient Evolution After Early Revascularization. Stroke 2019; 50:2086-2092. [PMID: 31238830 DOI: 10.1161/strokeaha.119.025784] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- In this era of endovascular therapy (EVT) with early, complete recanalization and reperfusion, we have observed an even more rapid apparent diffusion coefficient (ADC) normalization within the acute ischemic lesion compared with the natural history or IV-tPA-treated patient. In this study, we aimed to evaluate the effect of revascularization on ADC evolution within the core lesion in the first 24 hours in acute ischemic stroke patients. Methods- This retrospective study included anterior circulation acute ischemic stroke patients treated with EVT with or without intravenous tPA (IVT) from 2015 to 2017 compared with a consecutive cohort of IVT-only patients treated before 2015. Diffusion-weighted imaging and ADC maps were used to quantify baseline core lesions. Median ADC value change and core reversal were determined at 24 hours. Diffusion-weighted imaging lesion growth was measured at 24 hours and 5 days. Good clinical outcome was defined as modified Rankin Scale score of 0 to 2 at 90 days. Results- Twenty-five patients (50%) received IVT while the other 25 patients received EVT (50%) with or without IVT. Between these patient groups, there were no differences in age, sex, baseline National Institutes of Health Stroke Scale, interhospital transfer, or IVT rates. Thirty-two patients (64%) revascularized with 69% receiving EVT. There was a significant increase in median ADC value of the core lesion at 24 hours in patients who revascularized compared with further ADC reduction in nonrevascularization patients. Revascularization patients had a significantly higher rate of good clinical outcome at 90 days, 63% versus 9% (P=0.003). Core reversal at 24 hours was significantly higher in revascularization patients, 69% versus 22% (P=0.002). Conclusions- ADC evolution in acute ischemic stroke patients with early, complete revascularization, now more commonly seen with EVT, is strikingly different from our historical understanding. The early ADC normalization we have observed in this setting may include a component of secondary injury and serve as a potential imaging biomarker for the development of future adjunctive therapies. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT00009243.
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Affiliation(s)
- Amie W Hsia
- From the NIH/National Institute of Neurological Disorders and Stroke, Stroke Branch, Bethesda, MD (A.W.H., M.L., K.C., S.B., R.L., Z.N., R.T.B., J.K.L., L.L.L.).,MedStar Washington Hospital Center Comprehensive Stroke Center, Washington, DC (A.W.H., S.B., R.T.B.)
| | - Marie Luby
- From the NIH/National Institute of Neurological Disorders and Stroke, Stroke Branch, Bethesda, MD (A.W.H., M.L., K.C., S.B., R.L., Z.N., R.T.B., J.K.L., L.L.L.)
| | - Kaylie Cullison
- From the NIH/National Institute of Neurological Disorders and Stroke, Stroke Branch, Bethesda, MD (A.W.H., M.L., K.C., S.B., R.L., Z.N., R.T.B., J.K.L., L.L.L.)
| | - Shannon Burton
- From the NIH/National Institute of Neurological Disorders and Stroke, Stroke Branch, Bethesda, MD (A.W.H., M.L., K.C., S.B., R.L., Z.N., R.T.B., J.K.L., L.L.L.).,MedStar Washington Hospital Center Comprehensive Stroke Center, Washington, DC (A.W.H., S.B., R.T.B.)
| | - Rocco Armonda
- From the NIH/National Institute of Neurological Disorders and Stroke, Stroke Branch, Bethesda, MD (A.W.H., M.L., K.C., S.B., R.L., Z.N., R.T.B., J.K.L., L.L.L.)
| | | | - Richard Leigh
- From the NIH/National Institute of Neurological Disorders and Stroke, Stroke Branch, Bethesda, MD (A.W.H., M.L., K.C., S.B., R.L., Z.N., R.T.B., J.K.L., L.L.L.)
| | - Zurab Nadareishvili
- From the NIH/National Institute of Neurological Disorders and Stroke, Stroke Branch, Bethesda, MD (A.W.H., M.L., K.C., S.B., R.L., Z.N., R.T.B., J.K.L., L.L.L.).,MedStar Washington Hospital Center Comprehensive Stroke Center, Washington, DC (A.W.H., S.B., R.T.B.)
| | - Richard T Benson
- From the NIH/National Institute of Neurological Disorders and Stroke, Stroke Branch, Bethesda, MD (A.W.H., M.L., K.C., S.B., R.L., Z.N., R.T.B., J.K.L., L.L.L.)
| | - John K Lynch
- From the NIH/National Institute of Neurological Disorders and Stroke, Stroke Branch, Bethesda, MD (A.W.H., M.L., K.C., S.B., R.L., Z.N., R.T.B., J.K.L., L.L.L.)
| | - Lawrence L Latour
- From the NIH/National Institute of Neurological Disorders and Stroke, Stroke Branch, Bethesda, MD (A.W.H., M.L., K.C., S.B., R.L., Z.N., R.T.B., J.K.L., L.L.L.)
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18
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Yoo J, Choi JW, Lee SJ, Hong JM, Hong JH, Kim CH, Kim YW, Kang DH, Kim YS, Hwang YH, Ovbiagele B, Demchuk AM, Lee JS, Sohn SI. Ischemic Diffusion Lesion Reversal After Endovascular Treatment. Stroke 2019; 50:1504-1509. [DOI: 10.1161/strokeaha.118.024263] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Joonsang Yoo
- From the Department of Neurology (J.Y., J.-H.H., S.-I.S.), Keimyung University School of Medicine, Daegu, Korea
| | - Jin Wook Choi
- Department of Radiology (J.W.C.), Ajou University School of Medicine, Suwon, Korea
| | - Seong-Joon Lee
- Department of Neurology (S.-J.L., J.M.H., J.S.L.), Ajou University School of Medicine, Suwon, Korea
| | - Ji Man Hong
- Department of Neurology (S.-J.L., J.M.H., J.S.L.), Ajou University School of Medicine, Suwon, Korea
| | - Jeong-Ho Hong
- From the Department of Neurology (J.Y., J.-H.H., S.-I.S.), Keimyung University School of Medicine, Daegu, Korea
| | - Chang-Hyun Kim
- Department of Neurosurgery, Brain Research Institute (C.-H.K.), Keimyung University School of Medicine, Daegu, Korea
| | - Yong-Won Kim
- Department of Neurology (Y.-W.K., Y.-H.H.), Kyungpook National University School of Medicine, Daegu, Korea
| | - Dong-Hun Kang
- Department of Neurosurgery (D.-H.K.), Kyungpook National University School of Medicine, Daegu, Korea
| | - Yong-Sun Kim
- Department of Radiology (Y.-S.K.), Kyungpook National University School of Medicine, Daegu, Korea
| | - Yang-Ha Hwang
- Department of Neurology (Y.-W.K., Y.-H.H.), Kyungpook National University School of Medicine, Daegu, Korea
| | - Bruce Ovbiagele
- Department of Neurology, Medical University of South Carolina, Charleston (B.O.)
| | - Andrew M. Demchuk
- Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, AB, Canada (A.M.D.)
| | - Jin Soo Lee
- Department of Neurology (S.-J.L., J.M.H., J.S.L.), Ajou University School of Medicine, Suwon, Korea
| | - Sung-Il Sohn
- From the Department of Neurology (J.Y., J.-H.H., S.-I.S.), Keimyung University School of Medicine, Daegu, Korea
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19
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Maetani Y, Nakamori M, Imamura E, Ishii Y, Aihara H, Suyama Y, Wakabayashi S, Maruyama H. Utility of Minimum Apparent Diffusion Coefficient Ratios in Alberta Stroke Program Early CT Score Regions for Deciding on Stroke Therapy. J Stroke Cerebrovasc Dis 2019; 28:1371-1380. [PMID: 30803784 DOI: 10.1016/j.jstrokecerebrovasdis.2019.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 01/28/2019] [Accepted: 02/05/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND AND PURPOSE Therapeutic indications for recombinant tissue plasminogen activator therapy and endovascular therapy need to be assessed for patients with hyperacute ischemic stroke. We investigated the relationship between the minimum apparent diffusion coefficient ratios in each Alberta Stroke Program Early CT Score region and reversible lesion in patients with hyperacute ischemic stroke receiving recombinant tissue plasminogen activator therapy and/or treated with endovascular therapy. MATERIALS AND METHODS We retrospectively evaluated 29 patients with first ischemic stroke due to stenosis/occlusion of the internal carotid artery or horizontal portion of the middle cerebral artery that was successfully recanalized by recombinant tissue plasminogen activator therapy and/or treated with endovascular therapy. We measured the minimum apparent diffusion coefficient value in each Alberta Stroke Program Early CT Score region (11 regions) and calculated the ratio. RESULTS There was a significant difference in minimum apparent diffusion coefficient ratios between regions that included and did not include infarction (P < .0001), which were distinguishable with a cutoff value of .808 (area under the curve = .80, P < .001). A statistical difference in the proportion of infarction with the cutoff value was observed between patients treated with endovascular therapy and receiving recombinant tissue plasminogen activator therapy alone (9.9% versus 24.6%, P = .0041) and between patients with affected middle cerebral and internal carotid arteries (7.0% versus 24.2%, P = .0002). The lowest apparent diffusion coefficient ratio was associated with the time to recombinant tissue plasminogen activator injection. CONCLUSIONS Minimum apparent diffusion coefficient ratios in Alberta Stroke Program Early CT Score regions are useful in predicting therapeutic effect.
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Affiliation(s)
- Yuta Maetani
- Department of Neurology, Suiseikai Kajikawa Hospital, Hiroshima, Japan; Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Masahiro Nakamori
- Department of Neurology, Suiseikai Kajikawa Hospital, Hiroshima, Japan.
| | - Eiji Imamura
- Department of Neurology, Suiseikai Kajikawa Hospital, Hiroshima, Japan
| | - Yosuke Ishii
- Department of Neurosurgery, Suiseikai Kajikawa Hospital, Hiroshima, Japan
| | - Hiroshi Aihara
- Department of Neurosurgery, Suiseikai Kajikawa Hospital, Hiroshima, Japan
| | - Yoshio Suyama
- Department of Neurosurgery, Suiseikai Kajikawa Hospital, Hiroshima, Japan
| | | | - Hirofumi Maruyama
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
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20
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Alegiani AC, MacLean S, Braass H, Gellißen S, Cho TH, Derex L, Hermier M, Berthezene Y, Nighoghossian N, Gerloff C, Fiehler J, Thomalla G. Dynamics of Water Diffusion Changes in Different Tissue Compartments From Acute to Chronic Stroke-A Serial Diffusion Tensor Imaging Study. Front Neurol 2019; 10:158. [PMID: 30863361 PMCID: PMC6399390 DOI: 10.3389/fneur.2019.00158] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 02/07/2019] [Indexed: 01/09/2023] Open
Abstract
Background and Purpose: The immediate decrease of the apparent diffusion coefficient (ADC) is the main characteristic change of water diffusion in acute ischemic stroke. There is only limited information on the time course of diffusion parameters in different tissue compartments of cerebral ischemia. Materials and Methods: In a longitudinal study, we examined 21 patients with acute ischemic stroke by diffusion tensor imaging within 5 h after symptom onset, 3 h later, 2 days, and 1 month after symptom onset. Acute diffusion lesion and the fluid-attenuated inversion recovery (FLAIR) after 2 days were used as volumes of interest to define persistent core, lesion growth, and reversible acute diffusion lesion. For all diffusion parameters ratios between the stroke lesion VOIs and the mirror VOIs were calculated for each time point. ADC ratio, fractional anisotropy ratios, and eigenvalues ratios were measured in these volumes of interest and in contralateral mirror regions at each time points. Results: In the persistent core, ADC ratio (0.772) and all eigenvalues ratios were reduced on admission up to 1 day after stroke and increased after 1 month (ADC ratio 1.067). Within the region of infarct growth time course of diffusion parameter changes was similar, but delayed. In the brain area with reversible diffusion lesion, a partial normalization of diffusion parameters over the time was observed, while after 1 month diffusion parameters did not show the signature of healthy brain tissue. There were significantly different trends for all parameters over time between the three tissue compartments. Conclusion: Diffusion tensor imaging displays characteristic changes of water diffusion in different tissue compartments over time in acute ischemic stroke. Even regions with reversible diffusion lesion show diffusion signatures of persisting tissue alterations.
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Affiliation(s)
| | - Simon MacLean
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hanna Braass
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellißen
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tae-Hee Cho
- Department of Stroke Medicine, Université Lyon, Lyon, France
| | - Laurent Derex
- Department of Stroke Medicine, Université Lyon, Lyon, France
| | - Marc Hermier
- Department of Neuroradiology, Université Lyon, Lyon, France
| | | | | | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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21
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Yamada K, Yoshimura S, Shirakawa M, Uchida K, Nakahara S, Nishida S, Iwamoto Y, Sato Y, Kawasaki M. Asymptomatic moderate carotid artery stenosis with intraplaque hemorrhage: Progression of degree of stenosis and new ischemic stroke. J Clin Neurosci 2019; 63:95-99. [PMID: 30732983 DOI: 10.1016/j.jocn.2019.01.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 01/06/2019] [Accepted: 01/28/2019] [Indexed: 10/27/2022]
Abstract
Carotid intraplaque hemorrhage (IPH) plays a critical role in the progression of carotid atherosclerotic disease. IPH was associated with high intensity signal (HIS) in the plaque on Maximum intensity projection (MIP) images from routine three dimensional magnetic resonance imaging (3D-TOF MRA). The aim of this study was to evaluate the relationships among HIS, new ipsilateral ischemic stroke and a progression rate in carotid plaques with moderate stenosis. We included 45 carotid plaques with moderate stenosis (50%-69%) in 45 patients who could be followed more than 12 months. Carotid IPH was defined as the presence of HIS on 3DTOF MRA using the criteria previously we published. We analyzed the relation between the presence of HIS and new ischemic strokes and annual progression rate of carotid stenosis. HIS was present in 21 (47%) carotid arteries. Over a follow-up period of 24 ± 9 months, six ischemic strokes occurred in ipsilateral side. New ipsilateral ischemic stroke occurred more frequently in HIS positive group (P group: 6 of 21, 29%) than negative group (N group: 0 of 24, 0%) (p = 0.017). Annual progression rate of carotid stenosis is significantly higher in P group (+3.35%/year) than N group (-0.02%/year) (p = 0.0026). In multivariate regression analysis, HIS positive was an independent predictor for annual progression rate of carotid stenosis (p = 0.003). Evaluation of HIS in asymptomatic moderate carotid stenosis can potentially provide risk stratification of new ipsilateral ischemic strokes.
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Affiliation(s)
- Kiyofumi Yamada
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.
| | - Manabu Shirakawa
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | | | - Shuji Nishida
- Department of Radiology, Sato Daiichi Hospital, Usa, Japan
| | | | - Yoshikazu Sato
- Department of Radiology, Sato Daiichi Hospital, Usa, Japan
| | - Masanori Kawasaki
- Department of Cardiology, Gifu University Graduate School of Medicine, Gifu, Japan
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22
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Leigh R, Knutsson L, Zhou J, van Zijl PC. Imaging the physiological evolution of the ischemic penumbra in acute ischemic stroke. J Cereb Blood Flow Metab 2018; 38:1500-1516. [PMID: 28345479 PMCID: PMC6125975 DOI: 10.1177/0271678x17700913] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We review the hemodynamic, metabolic and cellular parameters affected during early ischemia and their changes as a function of approximate cerebral blood flow ( CBF) thresholds. These parameters underlie the current practical definition of an ischemic penumbra, namely metabolically affected but still viable brain tissue. Such tissue is at risk of infarction under continuing conditions of reduced CBF, but can be rescued through timely intervention. This definition will be useful in clinical diagnosis only if imaging techniques exist that can rapidly, and with sufficient accuracy, visualize the existence of a mismatch between such a metabolically affected area and regions that have suffered cell depolarization. Unfortunately, clinical data show that defining the outer boundary of the penumbra based solely on perfusion-related thresholds may not be sufficiently accurate. Also, thresholds for CBF and cerebral blood volume ( CBV) differ for white and gray matter and evolve with time for both inner and outer penumbral boundaries. As such, practical penumbral imaging would involve parameters in which the physiology is immediately displayed in a manner independent of baseline CBF or CBF threshold, namely pH, oxygen extraction fraction ( OEF), diffusion constant and mean transit time ( MTT). Suitable imaging technologies will need to meet this requirement in a 10-20 min exam.
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Affiliation(s)
- Richard Leigh
- 1 National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, USA
| | - Linda Knutsson
- 2 Department of Medical Radiation Physics, Lund University, Lund, Sweden.,3 Department of Radiology, Johns Hopkins University, Baltimore, MD, USA
| | - Jinyuan Zhou
- 3 Department of Radiology, Johns Hopkins University, Baltimore, MD, USA.,4 F.M. Kirby Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Peter Cm van Zijl
- 3 Department of Radiology, Johns Hopkins University, Baltimore, MD, USA.,4 F.M. Kirby Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, USA
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23
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Yamada K, Yoshimura S, Shirakawa M, Uchida K, Maruyama F, Nakahara S, Nishida S, Iwamoto Y, Sato Y, Kawasaki M. High intensity signal in the plaque on routine 3D-TOF MRA is associated with ischemic stroke in the patients with low-grade carotid stenosis. J Neurol Sci 2018; 385:164-167. [DOI: 10.1016/j.jns.2017.12.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 12/02/2017] [Accepted: 12/18/2017] [Indexed: 10/18/2022]
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24
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Vilela P, Rowley HA. Brain ischemia: CT and MRI techniques in acute ischemic stroke. Eur J Radiol 2017; 96:162-172. [DOI: 10.1016/j.ejrad.2017.08.014] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 08/07/2017] [Accepted: 08/12/2017] [Indexed: 11/17/2022]
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25
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Abbott AL, Silvestrini M, Topakian R, Golledge J, Brunser AM, de Borst GJ, Harbaugh RE, Doubal FN, Rundek T, Thapar A, Davies AH, Kam A, Wardlaw JM. Optimizing the Definitions of Stroke, Transient Ischemic Attack, and Infarction for Research and Application in Clinical Practice. Front Neurol 2017; 8:537. [PMID: 29104559 PMCID: PMC5654955 DOI: 10.3389/fneur.2017.00537] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 09/25/2017] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND PURPOSE Until now, stroke and transient ischemic attack (TIA) have been clinically based terms which describe the presence and duration of characteristic neurological deficits attributable to intrinsic disorders of particular arteries supplying the brain, retina, or (sometimes) the spinal cord. Further, infarction has been pathologically defined as death of neural tissue due to reduced blood supply. Recently, it has been proposed we shift to definitions of stroke and TIA determined by neuroimaging results alone and that neuroimaging findings be equated with infarction. METHODS We examined the scientific validity and clinical implications of these proposals using the existing published literature and our own experience in research and clinical practice. RESULTS We found that the proposals to change to imaging-dominant definitions, as published, are ambiguous and inconsistent. Therefore, they cannot provide the standardization required in research or its application in clinical practice. Further, we found that the proposals are scientifically incorrect because neuroimaging findings do not always correlate with the clinical status or the presence of infarction. In addition, we found that attempts to use the proposals are disrupting research, are otherwise clinically unhelpful and do not solve the problems they were proposed to solve. CONCLUSION We advise that the proposals must not be accepted. In particular, we explain why the clinical focus of the definitions of stroke and TIA should be retained with continued sub-classification of these syndromes depending neuroimaging results (with or without other information) and that infarction should remain a pathological term. We outline ways the established clinically based definitions of stroke and TIA, and use of them, may be improved to encourage better patient outcomes in the modern era.
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Affiliation(s)
- Anne L. Abbott
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- The Neurology Department, The Alfred Hospital, Melbourne, VIC, Australia
| | | | - Raffi Topakian
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, QLD, Australia
| | - Alejandro M. Brunser
- Cerebrovascular Program, Neurology Service, Department of Medicine, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana – Universidad del Desarrollo, Santiago, Chile
| | - Gert J. de Borst
- Department of Vascular Surgery, University Medical Centre of Utrecht, Utrecht, Netherlands
| | - Robert E. Harbaugh
- Department of Neurosurgery, Penn State University, State College, PA, United States
| | - Fergus N. Doubal
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Department of Medicine, Elderly Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, Miami, FL, United States
| | - Ankur Thapar
- Imperial College Healthcare NHS Trust, London, United Kingdom
- Imperial College, London, United Kingdom
| | - Alun H. Davies
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College School of Medicine, Charing Cross Hospital, London, United Kingdom
| | - Anthony Kam
- Department of Radiology, Alfred Health, Melbourne, VIC, Australia
| | - Joanna M. Wardlaw
- Division of Neuroimaging Sciences, Centre for Clinical Brain Sciences, UK Dementia Research Institute at the University of Edinburgh, Edinburgh, United Kingdom
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26
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Pereira D, Fragata I, Amorim J, Reis J. ADC quantification in basilar artery occlusion as an indicator of clinical outcome after endovascular treatment. Neuroradiol J 2017; 30:586-592. [PMID: 28699370 DOI: 10.1177/1971400917706197] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Acute ischemic stroke due to basilar artery occlusion (BAO) is associated with a dismal prognosis and, even though endovascular treatment (EVT) contributed to an improvement in clinical outcomes, patient selection is difficult and frequently results in futile recanalization. We investigated the prognostic value of baseline ADC quantification in patients with BAO undergoing EVT. Methods We retrospectively evaluated MRI at admission in 11 patients with BAO undergoing EVT. Ischemic lesions were defined on baseline DWI and minimum ADC (minADC), ADC ratio and total area were quantified. Final infarction area was determined on follow-up T2WI/CT. We assessed the correlation between imaging parameters, recanalization grade and clinical scores (NIHSS at admission, NIHSS and mRS at discharge and mRS at three months) using Spearman rank correlation coefficient and correcting for multiple comparisons with the false discovery rate (FDR). Results Lower values of minADC at admission MRI are strongly correlated with higher scores in NIHSS (rs = -0.845, p = 0.001) and mRS at discharge (rs = -0.743, p = 0.009). We also found a negative correlation between minADC and NIHSS at admission (rs = -0.67, p = 0.02), mRS at three months and difference between pre- and post-treatment ischemic area (rs = -0.664, p = 0.026) that lost significance with FDR correction. Ischemic area and TICI grade were not significantly associated with clinical results. Conclusions ADC quantification of ischemic lesions at baseline MRI seems to predict clinical outcome in patients with BAO undergoing EVT, more importantly than ischemic area or TICI grade.
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Affiliation(s)
| | | | | | - João Reis
- 2 Centro Hospitalar de Lisboa Central, Portugal
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27
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Simpkins AN, Dias C, Norato G, Kim E, Leigh R. Early Change in Stroke Size Performs Best in Predicting Response to Therapy. Cerebrovasc Dis 2017; 44:141-149. [PMID: 28683442 DOI: 10.1159/000477945] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 05/31/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Reliable imaging biomarkers of response to therapy in acute stroke are needed. The final infarct volume and percent of early reperfusion have been used for this purpose. Early fluctuation in stroke size is a recognized phenomenon, but its utility as a biomarker for response to therapy has not been established. This study examined the clinical relevance of early change in stroke volume and compared it with the final infarct volume and percent of early reperfusion in identifying early neurologic improvement (ENI). METHODS Acute stroke patients, enrolled between 2013 and 2014 with serial magnetic resonance imaging (MRI) scans (pretreatment baseline, 2 h post, and 24 h post), who received thrombolysis were included in the analysis. Early change in stroke volume, infarct volume at 24 h on diffusion, and percent of early reperfusion were calculated from the baseline and 2 h MRI scans were compared. ENI was defined as ≥4 point decrease in National Institutes of Health Stroke Scales within 24 h. Logistic regression models and receiver operator characteristics analysis were used to compare the efficacy of 3 imaging biomarkers. RESULTS Serial MRIs of 58 acute stroke patients were analyzed. Early change in stroke volume was significantly associated with ENI by logistic regression analysis (OR 0.93, p = 0.048) and remained significant after controlling for stroke size and severity (OR 0.90, p = 0.032). Thus, for every 1 mL increase in stroke volume, there was a 10% decrease in the odds of ENI, while for every 1 mL decrease in stroke volume, there was a 10% increase in the odds of ENI. Neither infarct volume at 24 h nor percent of early reperfusion were significantly associated with ENI by logistic regression. Receiver-operator characteristic analysis identified early change in stroke volume as the only biomarker of the 3 that performed significantly different than chance (p = 0.03). CONCLUSIONS Early fluctuations in stroke size may represent a more reliable biomarker for response to therapy than the more traditional measures of final infarct volume and percent of early reperfusion.
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Affiliation(s)
- Alexis Nétis Simpkins
- Neuro Vascular Brain Imaging Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
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28
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Shinoda N, Hori S, Mikami K, Bando T, Shimo D, Kuroyama T, Kuramoto Y, Matsumoto M, Hirai O, Ueno Y. Utility of relative ADC ratio in patient selection for endovascular revascularization of large vessel occlusion. J Neuroradiol 2017; 44:185-191. [DOI: 10.1016/j.neurad.2016.12.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 12/19/2016] [Accepted: 12/30/2016] [Indexed: 10/19/2022]
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Sato A, Shimizu Y, Koyama J, Hongo K. A new threshold of apparent diffusion coefficient values in white matter after successful tissue plasminogen activator treatment for acute brain ischemia. J Neuroradiol 2017; 44:223-226. [DOI: 10.1016/j.neurad.2016.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 11/02/2015] [Accepted: 12/21/2016] [Indexed: 11/16/2022]
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30
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von Kummer R, Dzialowski I. Imaging of cerebral ischemic edema and neuronal death. Neuroradiology 2017; 59:545-553. [PMID: 28540400 DOI: 10.1007/s00234-017-1847-6] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 05/03/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE In acute cerebral ischemia, the assessment of irreversible injury is crucial for treatment decisions and the patient's prognosis. There is still uncertainty how imaging can safely differentiate reversible from irreversible ischemic brain tissue in the acute phase of stroke. METHODS We have searched PubMed and Google Scholar for experimental and clinical papers describing the pathology and pathophysiology of cerebral ischemia under controlled conditions. RESULTS Within the first 6 h of stroke onset, ischemic cell injury is subtle and hard to recognize under the microscope. Functional impairment is obvious, but can be induced by ischemic blood flow allowing recovery with flow restoration. The critical cerebral blood flow (CBF) threshold for irreversible injury is ~15 ml/100 g × min. Below this threshold, ischemic brain tissue takes up water in case of any residual capillary flow (ionic edema). Because tissue water content is linearly related to X-ray attenuation, computed tomography (CT) can detect and measure ionic edema and, thus, determine ischemic brain infarction. In contrast, diffusion-weighted magnetic resonance imaging (DWI) detects cytotoxic edema that develops at higher thresholds of ischemic CBF and is thus highly sensitive for milder levels of brain ischemia, but not specific for irreversible brain tissue injury. CONCLUSION CT and MRI are complimentary in the detection of ischemic stroke pathology and are valuable for treatment decisions.
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Affiliation(s)
- Rüdiger von Kummer
- Institut für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Germany.
| | - Imanuel Dzialowski
- Elblandklinikum Meißen, Neurologische Rehabilitationsklinik Großenhain, Nassauweg 7, 01662, Meißen, Germany
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31
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Weller P, Wittsack HJ, Siebler M, Hömberg V, Seitz RJ. Motor Recovery as Assessed with Isometric Finger Movements and Perfusion Magnetic Resonance Imaging after Acute Ischemic Stroke. Neurorehabil Neural Repair 2016; 20:390-7. [PMID: 16885425 DOI: 10.1177/1545968305285037] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective. Recovery from hemiparetic stroke is variable. An important goal for clinicians and clinical researchers is to identify predictors of recovery. The initial phase after acute ischemic stroke is considered to be of major importance for neurological outcome. The authors sought to determine in patients with acute ischemic stroke whether early motor recovery, as measured by repetitive isometric index-thumb oppositions, is correlated with ischemic lesion volume. Methods. Thirty-six acute hemiparetic stroke patients with residual hand function were investigated. The European Stroke Scale (ESS) score was determined on admission and at discharge. Performance of repetitive index finger-thumb pinch movements was measured daily during the 1st 8 days after stroke onset. Brain ischemia volume was determined digitally in time-to-peak magnetic resonance images of per-fusion. Results. The recovery of patients with ( P = 0.002) and without ( P < 0.001) thrombolysis as assessed with the ESS was paralleled by an increase in isometric grip force and movement rate ( P < 0.05). Recovery was predicted by the area of moderately impaired perfusion indicated by the per-fusion mismatch volume ( r = 0.578, P < 0.001). Conclusions. In acute stroke, recovery of hand function is predicted by the volume of salvageable ischemic tissue, as determined by the perfusion mismatch.
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Affiliation(s)
- Patrick Weller
- Department of Neurology, University Hospital Düsseldorf, Düsseldorf, Germany
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33
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MR image features predicting hemorrhagic transformation in acute cerebral infarction: a multimodal study. Neuroradiology 2015; 57:1145-52. [DOI: 10.1007/s00234-015-1575-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 08/07/2015] [Indexed: 11/27/2022]
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34
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Roldan-Valadez E, Lopez-Mejia M. Current concepts on magnetic resonance imaging (MRI) perfusion-diffusion assessment in acute ischaemic stroke: a review & an update for the clinicians. Indian J Med Res 2015; 140:717-28. [PMID: 25758570 PMCID: PMC4365345 DOI: pmid/25758570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Recently, several medical societies published joint statements about imaging recommendations for acute stroke and transient ischaemic attack patients. In following with these published guidelines, we considered it appropriate to present a brief, practical and updated review of the most relevant concepts on the MRI assessment of acute stroke. Basic principles of the clinical interpretation of diffusion, perfusion, and MRI angiography (as part of a global MRI protocol) are discussed with accompanying images for each sequence. Brief comments on incidence and differential diagnosis are also included, together with limitations of the techniques and levels of evidence. The purpose of this article is to present knowledge that can be applied in day-to-day clinical practice in specialized stroke units or emergency rooms to attend patients with acute ischaemic stroke or transient ischaemic attack according to international standards.
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Abstract
Background and Purpose—
Here, we assessed how sustained is reversal of the acute diffusion lesion (RAD) observed 24 hours after intravenous thrombolysis, and the relationships between RAD fate and early neurological improvement.
Methods—
We analyzed 155 consecutive patients thrombolyzed intravenously 152 minutes (median) after stroke onset and who underwent 3 MR sessions: 1 before and 2 after treatment (median times from onset, 25.6 and 54.3 hours, respectively). Using voxel-based analysis of diffusion-weighted imaging (DWI)
1
, DWI
2
, and DWI
3
lesions on coregistered image data sets, we assessed the outcome of RAD voxels (hyperintense on DWI
1
but not on DWI
2
) as transient or sustained on DWI
3
, and their relationships with early neurological improvement, defined as ΔNational Institutes of Health Stroke Scale ≥8 or National Institutes of Health Stroke Scale ≤1 at 24 hours.
T
max
and apparent diffusion coefficient values were compared between sustained and transient RAD voxels.
Results—
The median (interquartile range) baseline National Institutes of Health Stroke Scale and DWI
1
lesion volume were 11 (7–18) mL and 15.6 (6.0–50.9) mL, respectively. The median (interquartile range) RAD volume on DWI
2
was 2.8 (1.1–6.6) mL, of which 70% was sustained on DWI
3
. Sixteen (10.3%) patients had sustained RAD ≥10 mL. As compared with transient RAD voxels, sustained RAD voxels had nonsignificantly higher baseline apparent diffusion coefficient values (median [interquartile range], 793 [717–887] versus 777 [705–869]×10
−6
mm
2
·s
−1
, respectively;
P
=0.08) and significantly better perfusion (
T
max
, mean±SD, 6.3±3.2 versus 7.8±4.0 s;
P
<0.001). At variance with transient RAD, the volume of sustained RAD was associated with early neurological improvement in multivariate analysis (odds ratio, 1.08; 95% confidence interval, [1.01–1.17], per 1-mL increase;
P
=0.03).
Conclusions—
After thrombolysis, over two-thirds of the DWI lesion reversal captured on 24-hour follow-up MR is sustained. Sustained DWI lesion reversal volume is a strong imaging correlate of early neurological improvement.
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Abstract
PURPOSE OF REVIEW To summarize what is known about the use of MRI in acute stroke treatment (predominantly thrombolysis), to examine the assumptions and theories behind the interpretation of magnetic resonance images of acute ischemic stroke and how they are used to select patients for therapies, and to suggest directions for future research. RECENT FINDINGS Recent studies have been contradictory about the usefulness of MRI in selecting patients for treatment. New MRI models for selecting patients have emerged that focus not only on the ischemic penumbra but also on the infarct core. Fixed time-window selection parameters are being replaced by timing-based individualized MRI stroke features. New ways to interpret traditional MRI stroke sequences are emerging. SUMMARY Although the efficacy of acute stroke treatment is time dependent, the use of fixed time windows cannot account for individual differences in infarct evolution, which could potentially be detected with MRI. Although MRI shows promise for identifying patients who should be treated, as well as excluding patients who should not be treated, definitive evidence is still lacking. Future research should focus on validating the use of MRI to select patients for intravenous therapies in extended time windows.
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von Kummer R, Dzialowski I, Gerber J. Therapeutic efficacy of brain imaging in acute ischemic stroke patients. J Neuroradiol 2015; 42:47-54. [DOI: 10.1016/j.neurad.2014.10.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 10/10/2014] [Indexed: 10/24/2022]
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Spatial distribution of perfusion abnormality in acute MCA occlusion is associated with likelihood of later recanalization. J Cereb Blood Flow Metab 2014; 34:813-9. [PMID: 24473482 PMCID: PMC4013754 DOI: 10.1038/jcbfm.2014.13] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 11/29/2013] [Accepted: 12/23/2013] [Indexed: 11/08/2022]
Abstract
The aim of this study is to investigate whether different spatial perfusion-deficit patterns, which indicate differing compensatory mechanisms, can be recognized and used to predict recanalization success of intravenous fibrinolytic therapy in acute stroke patients. Twenty-seven acute stroke data sets acquired within 6 hours from symptom onset including diffusion- (DWI) and perfusion-weighted magnetic resonance (MR) imaging (PWI) were analyzed and dichotomized regarding recanalization outcome using time-of-flight follow-up data sets. The DWI data sets were used for calculation of apparent diffusion coefficient (ADC) maps and subsequent infarct core segmentation. A patient-individual three-dimensional (3D) shell model was generated based on the segmentation and used for spatial analysis of the ADC as well as cerebral blood volume (CBV), cerebral blood flow, time to peak (TTP), and mean transit time (MTT) parameters derived from PWI. Skewness, kurtosis, area under the curve, and slope were calculated for each parameter curve and used for classification (recanalized/nonrecanalized) using a LogitBoost Alternating Decision Tree (LAD Tree). The LAD tree optimization revealed that only ADC skewness, CBV kurtosis, and MTT kurtosis are required for best possible prediction of recanalization success with a precision of 85%. Our results suggest that the propensity for macrovascular recanalization after intravenous fibrinolytic therapy depends not only on clot properties but also on distal microvascular bed perfusion. The 3D approach for characterization of perfusion parameters seems promising for further research.
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Tisserand M, Malherbe C, Turc G, Legrand L, Edjlali M, Labeyrie MA, Seners P, Mas JL, Méder JF, Baron JC, Oppenheim C. Is White Matter More Prone to Diffusion Lesion Reversal After Thrombolysis? Stroke 2014; 45:1167-9. [DOI: 10.1161/strokeaha.113.004000] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Marie Tisserand
- From the Departments of Radiology (M.T., C.M., L.L., M.E., M.-A.L., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France
| | - Caroline Malherbe
- From the Departments of Radiology (M.T., C.M., L.L., M.E., M.-A.L., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France
| | - Guillaume Turc
- From the Departments of Radiology (M.T., C.M., L.L., M.E., M.-A.L., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France
| | - Laurence Legrand
- From the Departments of Radiology (M.T., C.M., L.L., M.E., M.-A.L., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France
| | - Myriam Edjlali
- From the Departments of Radiology (M.T., C.M., L.L., M.E., M.-A.L., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France
| | - Marc-Antoine Labeyrie
- From the Departments of Radiology (M.T., C.M., L.L., M.E., M.-A.L., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France
| | - Pierre Seners
- From the Departments of Radiology (M.T., C.M., L.L., M.E., M.-A.L., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France
| | - Jean-Louis Mas
- From the Departments of Radiology (M.T., C.M., L.L., M.E., M.-A.L., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France
| | - Jean-François Méder
- From the Departments of Radiology (M.T., C.M., L.L., M.E., M.-A.L., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France
| | - Jean-Claude Baron
- From the Departments of Radiology (M.T., C.M., L.L., M.E., M.-A.L., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France
| | - Catherine Oppenheim
- From the Departments of Radiology (M.T., C.M., L.L., M.E., M.-A.L., J.-F.M., C.O.) and Neurology (G.T., P.S., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France
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Abstract
OBJECTIVE This article addresses questions that radiologists frequently ask when planning, performing, processing, and interpreting MRI perfusion studies in CNS imaging. CONCLUSION Perfusion MRI is a promising tool in assessing stroke, brain tumors, and neurodegenerative diseases. Most of the impediments that have limited the use of per-fusion MRI can be overcome to allow integration of these methods into modern neuroimaging protocols.
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Microstructural basis of contusion expansion in traumatic brain injury: insights from diffusion tensor imaging. J Cereb Blood Flow Metab 2013; 33:855-62. [PMID: 23423189 PMCID: PMC3677102 DOI: 10.1038/jcbfm.2013.11] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Traumatic brain injury (TBI) is often exacerbated by events that lead to secondary brain injury, and represent potentially modifiable causes of mortality and morbidity. Diffusion tensor imaging was used to characterize tissue at-risk in a group of 35 patients scanned at a median of 50 hours after injury. Injury progression was assessed in a subset of 16 patients with two scans. All contusions within the first few days of injury showed a core of restricted diffusion, surrounded by an area of raised apparent diffusion coefficient (ADC). In addition to these two well-defined regions, a thinner rim of reduced ADC was observed surrounding the region of increased ADC in 91% of patients scanned within the first 3 days after injury. In patients who underwent serial imaging, the rim of ADC hypointensity was subsumed into the high ADC region as the contusion enlarged. Overall contusion enlargement tended to be more frequent with early lesions, but its extent was unrelated to the time of initial imaging, initial contusion size, or the presence of hemostatic abnormalities. This rim of hypointensity may characterize a region of microvascular failure resulting in cytotoxic edema, and may represent a 'traumatic penumbra' which may be rescued by effective therapy.
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42
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Albach FN, Brunecker P, Usnich T, Villringer K, Ebinger M, Fiebach JB, Nolte CH. Complete Early Reversal of Diffusion-Weighted Imaging Hyperintensities After Ischemic Stroke Is Mainly Limited to Small Embolic Lesions. Stroke 2013; 44:1043-8. [DOI: 10.1161/strokeaha.111.676346] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Case reports have demonstrated complete early reversal of hyperintensities on diffusion-weighted imaging (DWI) after clinically diagnosed stroke. We aimed to investigate systematically the rate and characteristics of reversible diffusion hyperintensities (RDHs) in the first week after stroke.
Methods—
Patients with clinical diagnosis of an acute cerebrovascular event and evidence of ischemia on DWI were included. MRI scans were performed on admission, on the following day, and 4 to 7 days after onset of symptoms with DWI and fluid-attenuated inversion recovery. Baseline and follow-up DWIs were coregistered and examined for individual RDHs. Characteristics of patients and of hyperintensities associated with early reversal were identified.
Results—
We included 153 patients with a median National Institutes of Health Stroke Scale score of 4 (interquartile range, 2–8). In 3 patients (2%), MR images normalized completely. Thirty-seven patients (24%) displayed individual RDHs. Of 611 initial DWI hyperintensities, 97 (16%) reversed. Thirteen percent of the RDHs had corresponding abnormalities on fluid-attenuated inversion recovery images at the third measurement. Median size of the RDHs was 0.029 mL (interquartile range, 0.013–0.055). RDHs were associated with a multiple infarct pattern (odds ratio, 22.1; 95% confidence interval, 4.5–109.7) and symptomatic carotid stenosis (odds ratio, 5.5; 95% confidence interval, 1.4–21.5). Fifty-nine percent of the patients with RDHs had new additional lesions on follow-up DWI. RDHs were not associated with functional improvement on the National Institutes of Health Stroke Scale score.
Conclusions—
In this population of mainly minor to moderate stroke patients, complete normalization of MR images was rare. Complete reversal of individual DWI hyperintensities was limited to very small lesions and mostly occurred in embolic stroke patients.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00715533.
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Affiliation(s)
- Fredrik N. Albach
- From the Department of Neurology (F.N.A., T.U., M.E., C.H.N.) and Center for Stroke Research Berlin (P.B., K.V., M.E., J.B.F., C.H.N.), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Brunecker
- From the Department of Neurology (F.N.A., T.U., M.E., C.H.N.) and Center for Stroke Research Berlin (P.B., K.V., M.E., J.B.F., C.H.N.), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Tatiana Usnich
- From the Department of Neurology (F.N.A., T.U., M.E., C.H.N.) and Center for Stroke Research Berlin (P.B., K.V., M.E., J.B.F., C.H.N.), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Kersten Villringer
- From the Department of Neurology (F.N.A., T.U., M.E., C.H.N.) and Center for Stroke Research Berlin (P.B., K.V., M.E., J.B.F., C.H.N.), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Ebinger
- From the Department of Neurology (F.N.A., T.U., M.E., C.H.N.) and Center for Stroke Research Berlin (P.B., K.V., M.E., J.B.F., C.H.N.), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen B. Fiebach
- From the Department of Neurology (F.N.A., T.U., M.E., C.H.N.) and Center for Stroke Research Berlin (P.B., K.V., M.E., J.B.F., C.H.N.), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H. Nolte
- From the Department of Neurology (F.N.A., T.U., M.E., C.H.N.) and Center for Stroke Research Berlin (P.B., K.V., M.E., J.B.F., C.H.N.), Charité Universitätsmedizin Berlin, Berlin, Germany
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43
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Labeyrie MA, Turc G, Hess A, Hervo P, Mas JL, Meder JF, Baron JC, Touzé E, Oppenheim C. Diffusion Lesion Reversal After Thrombolysis. Stroke 2012; 43:2986-91. [DOI: 10.1161/strokeaha.112.661009] [Citation(s) in RCA: 110] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Marc-Antoine Labeyrie
- From the From Departments of Radiology (M.A.L., A.H., J.F.M., C.O.), and Neurology (G.T., J.C.B., J.L.M., E.T.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and General Electric Healthcare, Buc, France (P.H.)
| | - Guillaume Turc
- From the From Departments of Radiology (M.A.L., A.H., J.F.M., C.O.), and Neurology (G.T., J.C.B., J.L.M., E.T.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and General Electric Healthcare, Buc, France (P.H.)
| | - Agathe Hess
- From the From Departments of Radiology (M.A.L., A.H., J.F.M., C.O.), and Neurology (G.T., J.C.B., J.L.M., E.T.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and General Electric Healthcare, Buc, France (P.H.)
| | - Patrice Hervo
- From the From Departments of Radiology (M.A.L., A.H., J.F.M., C.O.), and Neurology (G.T., J.C.B., J.L.M., E.T.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and General Electric Healthcare, Buc, France (P.H.)
| | - Jean-Louis Mas
- From the From Departments of Radiology (M.A.L., A.H., J.F.M., C.O.), and Neurology (G.T., J.C.B., J.L.M., E.T.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and General Electric Healthcare, Buc, France (P.H.)
| | - Jean-François Meder
- From the From Departments of Radiology (M.A.L., A.H., J.F.M., C.O.), and Neurology (G.T., J.C.B., J.L.M., E.T.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and General Electric Healthcare, Buc, France (P.H.)
| | - Jean-Claude Baron
- From the From Departments of Radiology (M.A.L., A.H., J.F.M., C.O.), and Neurology (G.T., J.C.B., J.L.M., E.T.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and General Electric Healthcare, Buc, France (P.H.)
| | - Emmanuel Touzé
- From the From Departments of Radiology (M.A.L., A.H., J.F.M., C.O.), and Neurology (G.T., J.C.B., J.L.M., E.T.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and General Electric Healthcare, Buc, France (P.H.)
| | - Catherine Oppenheim
- From the From Departments of Radiology (M.A.L., A.H., J.F.M., C.O.), and Neurology (G.T., J.C.B., J.L.M., E.T.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and General Electric Healthcare, Buc, France (P.H.)
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44
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Fiehler J, Söderman M, Turjman F, White PM, Bakke SJ, Mangiafico S, von Kummer R, Muto M, Cognard C, Gralla J. Future trials of endovascular mechanical recanalisation therapy in acute ischemic stroke patients - a position paper endorsed by ESMINT and ESNR : part II: methodology of future trials. Neuroradiology 2012; 54:1303-12. [PMID: 22948788 DOI: 10.1007/s00234-012-1076-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 07/13/2012] [Indexed: 10/27/2022]
Abstract
Based on current data and experience, the joint working group of the European Society of Minimally Invasive Neurological Therapy (ESMINT) and the European Society of Neuroradiology (ESNR) make suggestions on trial design and conduct aimed to investigate therapeutic effects of mechanical thrombectomy (MT). We anticipate that this roadmap will facilitate the setting up and conduct of successful trials in close collaboration with our neighbouring disciplines.
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Affiliation(s)
- Jens Fiehler
- Department of Neuroradiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
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45
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Yoo AJ, Chaudhry ZA, Leslie-Mazwi TM, Chandra RV, Hirsch JA, González RG, Simonsen CZ. Endovascular treatment of acute ischemic stroke: current indications. Tech Vasc Interv Radiol 2012; 15:33-40. [PMID: 22464300 DOI: 10.1053/j.tvir.2011.12.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Endovascular stroke therapy is an effective means of achieving reperfusion in stroke patients with proximal cerebral artery occlusions. However, current guideline recommendations express uncertainty regarding the clinical efficacy of catheter-based treatments, given the lack of supportive trial data. A critical problem is that it remains unclear which patients will benefit from endovascular therapy. As such, patient selection is likely highly variable in clinical practice. This article will review the existing data to discuss the clinical and imaging factors that are relevant to patient outcomes, and which may be used to guide endovascular treatment decisions. Anterior circulation strokes represent the primary focus of this review.
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Affiliation(s)
- Albert J Yoo
- Division of Interventional Neuroradiology and Endovascular Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
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46
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47
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Siemonsen S, Löbel U, Sedlacik J, Forkert ND, Mouridsen K, Østergaard L, Thomalla G, Fiehler J. Elevated T2-values in MRI of stroke patients shortly after symptom onset do not predict irreversible tissue infarction. Brain 2012; 135:1981-9. [PMID: 22505333 DOI: 10.1093/brain/aws079] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Distinct from signal alterations in diffusion-weighted images, T(2)-values are also dependent on tissue water content and known to increase with time from symptom onset in acute ischaemic stroke. The purpose of this study was to evaluate whether there is a detectable increase of T(2)-values in different regions in acute ischaemic stroke in the acute and subacute situation and to study the effect of recanalization on the evaluation of T(2)-values in the subacute phase. In addition, we sought to evaluate whether this increase in T(2)-values is reversible. For this purpose, 22 patients with acute ischaemic stroke in the territory of the middle cerebral artery underwent magnetic resonance imaging including diffusion-weighted imaging, perfusion-weighted imaging, fluid-attenuated inversion recovery to determine final infarct size, time-of-flight-angiography (acute and on day 1 or 2) and a triple echo-T(2)-sequence (calculation of T(2) maps) within 6 h after symptom onset. Images were co-registered and regions of diffusion restriction and prolonged time-to-peak as well as surviving tissue (surviving tissue = time-to-peak - final infarct size) and lesion growth (lesion growth = final infarct size-diffusion restriction) were defined and superimposed onto the quantitative T(2) map. In addition, patients were dichotomized according to recanalization information. Mean quantitative T(2)-values were derived for each patient within each region of interest. Mean T(2)-values for patients with recanalization (n = 15) in surviving tissue region of interest were 115.8 ± 7.2 ms (mean ± SD) and in the lesion growth region of interest 114.6 ± 7.0 ms. T(2)-values for patients without recanalization (n = 7) were 117.7 ± 11.4 ms in surviving tissue region of interest and 117.3 ± 12.1 ms in lesion growth region of interest. There was no significant difference between T(2)-values measured in lesion growth and surviving tissue region of interest for patients with or without recanalization. Even though it has been shown that T(2)-values increase with time from symptom onset within the infarct core, increased T(2)-values in areas of perfusion impairment do not identify irreversible damaged brain tissue and high T(2)-values are even found in tissue that is not part of the final infarct lesion and can therefore normalize. In conclusion, this study suggests that T(2)-values are not a valid imaging biomarker in acute stroke to predict tissue outcome.
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Affiliation(s)
- Susanne Siemonsen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.
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48
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Visual assessment of magnetic resonance imaging perfusion lesions in a large patient group. Clin Neuroradiol 2012; 22:305-13. [PMID: 22484907 DOI: 10.1007/s00062-012-0143-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Accepted: 03/08/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE Few magnetic resonance imaging (MRI) studies of stroke have evaluated the value of visual assessment of perfusion/diffusion mismatch, which is crucial for routine application. In this study an attempt was made to visually assess perfusion lesions resembling the acute clinical situation and identify parameters with the highest interobserver reliability when used to define a perfusion/diffusion mismatch and the highest accuracy for prediction of infarct growth. METHODS Magnetic resonance imaging was performed within 6 h of symptom onset and again 1-11 days thereafter in 86 consecutive stroke patients who received intravenous thrombolytic therapy. The MRI protocol included diffusion-weighted imaging apparent diffusion coefficient (DWI/ADC), fluid-attenuated inversion recovery (FLAIR) and perfusion imaging (PI). Maps for different perfusion parameters, e.g. cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT) and time to peak (TTP) were calculated. Areas of perfusion deficits of all perfusion parameters were visually compared to corresponding ADCs and final infarct size by two independent observers. RESULTS The final infarct size was overestimated by TTP (in 81/83 patients by raters 1 and 2, respectively), MTT (82/83) and CBF (65/74) lesions. The ADC lesions were rated smaller than the final infarct size in 43/38 cases by raters 1 and 2 and the CBV decrease was rated to underestimate final infarct size in 40/31 cases. The only significantly increased OR of 3.883 (95 % CI 1.466-10.819, p = 0.004, rater 1)/5.142 (95 % CI 1.828-15.142, p = 0.001, rater 2) for predicting infarct growth was observed for the presence of a CBV > ADC mismatch, which also showed the highest kappa value of 0.407. CONCLUSIONS All mismatch patterns were prone to high interrater variability when assessed under conditions resembling the clinical setting. Of all tested mismatch patterns the CBV > ADC mismatch was the strongest predictor of lesion growth while visual assessment of TTP and CBF generally resulted in an overestimation of infarct sizes and the presence of a TTP > ADC or CBF > ADC mismatch was not significantly predictive for lesion growth. Visual inspection of these most commonly used mismatch patterns has a low value for the prediction of infarct growth and thus the estimation of the penumbra in ischemic stroke patients.
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Smith EE, Schneider JA, Wardlaw JM, Greenberg SM. Cerebral microinfarcts: the invisible lesions. Lancet Neurol 2012; 11:272-82. [PMID: 22341035 PMCID: PMC3359329 DOI: 10.1016/s1474-4422(11)70307-6] [Citation(s) in RCA: 332] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The association between small but still visible lacunar infarcts and cognitive decline has been established by population-based radiological and pathological studies. Microscopic examination of brain sections shows even smaller but substantially more numerous microinfarcts, the focus of this Review. These lesions often result from small vessel pathologies such as arteriolosclerosis or cerebral amyloid angiopathy. They typically go undetected in clinical-radiological correlation studies that rely on conventional structural MRI, although the largest acute microinfarcts can be detected by diffusion-weighted imaging. In view of their high numbers and widespread distribution, microinfarcts could directly disrupt important cognitive networks and thus account for some of the neurological dysfunction associated with lesions visible on conventional MRI such as lacunar infarcts and white matter hyperintensities. Standardised neuropathological assessment criteria and the development of non-invasive means of detection during life would be major steps towards understanding the causes and consequences of otherwise macroscopically invisible microinfarcts.
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Affiliation(s)
- Eric E. Smith
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Julie A. Schneider
- Departments of Pathology and Neurological Sciences, Rush Alzheimer’s Disease Centre, Rush University Medical Center, Chicago, IL, USA
| | - Joanna M. Wardlaw
- Centre for Cognitive Ageing and Cognitive Epidemiology (CCACE), University of Edinburgh, UK,Scottish Imaging Network, A Platform for Scientific Excellence (SINAPSE) Collaboration
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Tenser MS, Amar AP, Mack WJ. Mechanical thrombectomy for acute ischemic stroke using the MERCI retriever and penumbra aspiration systems. World Neurosurg 2012; 76:S16-23. [PMID: 22182267 DOI: 10.1016/j.wneu.2011.07.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Revised: 06/08/2011] [Accepted: 07/06/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Intracranial large-vessel ischemia is associated with poor clinical outcome and increased mortality. Early reperfusion of ischemic tissue remains the goal of treatment of stroke. Intravenous tissue plasminogen activator (IV tPA) has been shown to improve clinical outcomes for patients who experience ischemic stroke, but it has been shown to be less efficacious for large-vessel occlusions. Mechanical clot extraction provides a therapeutic option for those who are ineligible for, or who do not respond to, conventional ischemic stroke treatment. METHODS We reviewed the initial studies of the Merci Retriever and Penumbra System for mechanical clot extraction. Baseline patient characteristics, as well as revascularization rates and clinical outcome, were examined. RESULTS Baseline National Institutes of Health Stroke Scale scores were greater than those observed in previous IV tPA studies, consistent with large-vessel occlusion. Successful recanalization occurred more frequently than with IV tPA and was associated with improved clinical outcome and mortality. Symptomatic intracranial hemorrhage and mortality rates were greater than those seen with IV tPA. CONCLUSIONS Mechanical clot extraction can be performed safely in patients with large-vessel occlusions, and successful recanalization resulted in better clinical outcomes than those without. Mechanical thrombectomy provides a therapeutic option for ischemic stroke patients who are ineligible for, or who do not respond to, IV thrombolytics. Further studies, including randomized clinical trials, are needed to validate these findings.
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Affiliation(s)
- Matthew S Tenser
- Department of Neurosurgery, University of Southern California, Los Angeles, California, USA.
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