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Koh S, Park SY, Liebeskind DS, Choi JW, Kim HK, Choi JY, Kim M, Lee S, Hong JM, Lee JS. Prediction of Intracranial Atherosclerotic Disease-Related Large-Vessel Occlusion Stroke on the Basis of Novel Cerebral Blood Volume Parameters. J Am Heart Assoc 2024; 13:e030936. [PMID: 38214247 PMCID: PMC10926804 DOI: 10.1161/jaha.123.030936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/23/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Mechanical thrombectomy is an effective treatment method for large-vessel occlusion stroke (LVOS); however, it has limited efficacy for intracranial atherosclerotic disease (ICAD)-related LVOS. We investigated the use of cerebral blood volume (CBV) maps for identifying ICAD as the underlying cause of LVOS before the initiation of endovascular treatment (EVT). METHODS AND RESULTS We reviewed clinical and imaging data from patients who presented with LVOS and underwent endovascular treatment between January 2011 and May 2021. The CBV patterns were analyzed to identify an increase in CBV within the hypoperfused area and estimate infarct patterns within the area of decreased CBV. Comparisons were made between the patients with an increase in CBV and those without, and among the estimated infarct patterns: territorial, cortical wedge, basal ganglia-only, subcortical, and normal CBV. Overall, 243 patients were included. CBV increase in the hypoperfused area was observed in 23.5% of patients. A significantly higher proportion of ICAD was observed in those with increased CBV than in those without (56.4% versus 19.8%; P<0.001). Regarding the estimated infarct patterns on the CBV, ICAD was most frequently observed in the normal CBV group (territorial, 14.9%; cortical wedge, 10.0%; basal ganglia-only, 43.8%; subcortical, 35.7%; normal, 61.7%). CBV parameters, including "an increase in CBV," "normal CBV infarct pattern," and "an increase in CBV or normal CBV infarct pattern composite," were independently associated with ICAD. CONCLUSIONS An increased CBV or normal CBV pattern may be associated with ICAD LVOS on the pretreatment perfusion imaging.
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Affiliation(s)
- Seungyon Koh
- Department of Brain ScienceAjou University School of MedicineSuwonRepublic of Korea
- Department of NeurologyAjou University School of Medicine, Ajou University HospitalSuwonRepublic of Korea
| | - So Young Park
- Department of NeurologyAjou University School of Medicine, Ajou University HospitalSuwonRepublic of Korea
| | | | - Jin Wook Choi
- Department of Radiology, Ajou University School of MedicineAjou University HospitalSuwonRepublic of Korea
| | - Han Ki Kim
- Department of Brain ScienceAjou University School of MedicineSuwonRepublic of Korea
| | - Jun Young Choi
- Department of Brain ScienceAjou University School of MedicineSuwonRepublic of Korea
- Department of NeurologyAjou University School of Medicine, Ajou University HospitalSuwonRepublic of Korea
| | - Min Kim
- Department of NeurologyAjou University School of Medicine, Ajou University HospitalSuwonRepublic of Korea
| | - Seong‐Joon Lee
- Department of NeurologyAjou University School of Medicine, Ajou University HospitalSuwonRepublic of Korea
| | - Ji Man Hong
- Department of NeurologyAjou University School of Medicine, Ajou University HospitalSuwonRepublic of Korea
| | - Jin Soo Lee
- Department of NeurologyAjou University School of Medicine, Ajou University HospitalSuwonRepublic of Korea
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Faropoulos K, Tsolaki V, Georgakopoulou VE, Trakas I, Tarantinos K, Papalexis P, Spandidos DA, Aravantinou-Fatorou A, Mathioudakis N, Trakas N, Lavdas E, Fotakopoulos G. Value of sildenafil treatment for the prevention of vasospasm‑related delayed ischemic neurological deficits and delayed brain infarction following aneurysmal subarachnoid hemorrhage. MEDICINE INTERNATIONAL 2023; 3:19. [PMID: 37032716 PMCID: PMC10080186 DOI: 10.3892/mi.2023.79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 03/14/2023] [Indexed: 04/11/2023]
Abstract
Cerebral vasospasm (CV) or delayed cerebral ischemia (DCI) constitutes the main reason for the unfavorable outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH). The present retrospective cohort study, through an evaluation with computed tomography (CT) perfusion (CTP), aimed to examine the utility of an intravenous or oral administration of sildenafil in preventing DCI that develops due to vasospasm in these patients. A retrospective cohort study was conducted, which included 34 patients in a tertiary care hospital. Of these patients, 18 were males (52.9%), and the median age was 54.4 years. Of these patients, 18 (52.9%) had undergone surgery, and 16 (47.1%) had an endovascular procedure. CTP was performed on the 3rd to the 6th day. The clinical outcome was documented at 30 days using a CT scan and a complete neurological evaluation, including the Glasgow Coma Scale assessment. There was a statistically significant difference in the number of patients who developed an ischemic event at 1 month between those who did not receive sildenafil compared to those who received sildenafil (P<0.05). In addition, the multivariate analysis revealed that cerebral blood flow was an independent factor for detecting an ischemic event in 1 month (P=0.001). On the whole, the findings of the present study indicate that the intravenous or oral administration of sildenafil may be beneficial for the prevention of DCI.
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Affiliation(s)
| | - Vasiliki Tsolaki
- Department of Pulmonary and Critical Care Medicine, General University Hospital of Larissa, 41221 Larissa, Greece
| | - Vasiliki Epameinondas Georgakopoulou
- Department of Infectious Diseases-COVID19 Unit, Laiko General Hospital, 11527 Athens, Greece
- Correspondence to: Dr Vasiliki Epameinondas Georgakopoulou, Department of Infectious Diseases-COVID19 Unit, Laiko General Hospital, 17 Agiou Thoma Street, 11527 Athens, Greece
| | - Ilias Trakas
- Department of Infectious Diseases-COVID19 Unit, Laiko General Hospital, 11527 Athens, Greece
| | - Kyriakos Tarantinos
- First Department of Pulmonology, Sismanogleio Hospital, 15126 Athens, Greece
| | - Petros Papalexis
- Unit of Endocrinology, First Department of Internal Medicine, Laiko General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Department of Biomedical Sciences, University of West Attica, 12243 Athens, Greece
| | - Demetrios A. Spandidos
- Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Aikaterini Aravantinou-Fatorou
- First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | | | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Eleftherios Lavdas
- Department of Medical Radiological Technologists, Technological Education Institute of Athens, 12243 Athens, Greece
| | - George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
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Alzahrani A, Zhang X, Albukhari A, Wardlaw JM, Mair G. Assessing Brain Tissue Viability on Nonenhanced Computed Tomography After Ischemic Stroke. Stroke 2023; 54:558-566. [PMID: 36601950 PMCID: PMC9855746 DOI: 10.1161/strokeaha.122.041241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/11/2022] [Accepted: 11/23/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Treatment for ischemic stroke can be offered beyond conventional time limits for patients with favorable computed tomography perfusion (CTP), but this is not universally available. We sought a threshold for brain attenuation on nonenhanced computed tomography (NECT) to differentiate CTP-defined penumbra vs core, and correlated NECT features with CTP. METHODS We retrospectively assessed consecutive patients presenting to King Abdulaziz University Hospital with ischemic stroke (2017-2020), baseline NECT, and a visible defect on concurrent CTP. Using CTP as the reference standard, we measured the attenuation of ischemic and healthy contralateral brain on NECT to produce attenuation ratios (ischemic/normal) for penumbra and core. We used area under the receiver operating characteristic curve to estimate the optimal computed tomography (CT) attenuation ratio for penumbra. Per patient, we qualitatively assessed 8 regions within the affected cerebral hemisphere: on NECT as normal, hypoattenuating (with/out swelling), or isolated swelling and on CTP as normal, penumbra, or core. We sought associations between isolated swelling and penumbra, and between hypoattenuation and core. RESULTS We include 142 patients (86 male), mean age 61±14 years. Median 261 minutes (interquartile range, 173-382) to NECT. We measured 206 ischemic lesions (124 penumbra, 82 core). Optimal CT attenuation ratio for identifying penumbra was >0.87, with 86% sensitivity 91% specificity (area under the receiver operating characteristic curve, 0.95 [95% CI, 0.92-0.98]; P<0.0001). We qualitatively assessed 976 cerebral regions (72 isolated swelling, 254 hypoattenuation). On NECT, isolated swelling usually corresponded to CTP penumbra (70/72, 97%), whereas visible NECT hypoattenuation was found with core (141/254, 56%) and penumbra (109/254, 43%). CTP core lesions were rarely normal on NECT (13/155, 8%). CONCLUSIONS After ischemic stroke, brain tissue viability can be assessed using NECT. Isolated swelling is highly specific to penumbra. Visible hypoattenuation does not always represent core, nearly half of such lesions were penumbral on concurrent CTP and can be differentiated by measuring lesion attenuation.
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Affiliation(s)
- Awad Alzahrani
- Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (A. Alzahrani)
- Department of Diagnostic Radiology, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia (A. Alzahrani)
| | - Xinyu Zhang
- School of Medicine, University of Dundee, United Kingdom (X.Z.)
| | - Adel Albukhari
- Department of Radiology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia (A. Albukhari)
| | - Joanna M. Wardlaw
- Edinburgh Imaging, and UK Dementia Research Institute at the University of Edinburgh and Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (J.M.W., G.M.)
| | - Grant Mair
- Edinburgh Imaging, and UK Dementia Research Institute at the University of Edinburgh and Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (J.M.W., G.M.)
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Tsolaki V, Aravantinou-fatorou A, Georgakopoulou VE, Spandidos DA, Papalexis P, Mathioudakis N, Tarantinos K, Trakas N, Sklapani P, Fotakopoulos G. Early diagnosis of cerebral vasospasm associated with cerebral ischemia following subarachnoid hemorrhage: Evaluation of computed tomography perfusion and transcranial doppler as accurate methods. MEDICINE INTERNATIONAL 2022; 2:34. [PMID: 36699155 PMCID: PMC9829237 DOI: 10.3892/mi.2022.59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/01/2022] [Indexed: 01/27/2023]
Abstract
Cerebral vasospasm (CV) constitutes a major post-operative complication and source of morbidity in cases of subarachnoid hemorrhage (SAH). The early detection of CV in SAH may be difficult both clinically and radiographically. The present pilot study thus aimed to evaluate the practicability of the technique in a tertiary healthcare setting and to assess the diagnostic effectiveness of various diagnostic computed tomography (CT) perfusion (CTP) aspects in predicting the clinical outcome of patients with SAH (traumatic and aneurysmal). A retrospective study including 34 patients in a tertiary care hospital was thus conducted. The results revealed that of the 34 patients, 18 (52.9%) were males, and the mean age was 54.4±18.5 years (16-85 years old; range, 69 years). In total, 15 (44.1%) patients had traumatic SAH following traumatic brain injury (TBI), 11 (33.3%) had aneurysmal SAH, and 8 patients (23.6%) presented with TBI without SAH as controls. CTP was performed on the third to the sixth day, and 15-20 min prior to CPT, a transcranial Doppler ultrasound was performed. Clinical outcomes were documented at 30 days using a CT scan and a complete neurological evaluation, including Glasgow Coma Scale assessment. The results of a multivariate analysis revealed that cerebral blood flow (CBF) was an independent factor for detecting an ischemic event in 1 month (P=0.003). On the whole, the present study demonstrates that CTP, and consequently CBF, is a considerable index that may identify the onset of cerebral ischemia in patients with SAH.
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Affiliation(s)
- Vasiliki Tsolaki
- Department of Pulmonary and Critical Care Medicine, General University Hospital of Larisa, 41221 Larisa, Greece
| | - Aikaterini Aravantinou-fatorou
- First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Vasiliki Epameinondas Georgakopoulou
- Department of Infectious Diseases and COVID-19 Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece,Correspondence to: Dr Vasiliki Epameinondas Georgakopoulou, Department of Infectious Diseases and COVID-19 Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 17 Agiou Thoma Street, 11527 Athens, Greece
| | - Demetrios A. Spandidos
- Laboratory of Clinical Virology, Medical School, University of Crete, 71003 Heraklion, Greece
| | - Petros Papalexis
- Unit of Endocrinology, First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece,Department of Biomedical Sciences, University of West Attica, 12243 Athens, Greece
| | | | - Kyriakos Tarantinos
- First Department of Pulmonology, Sismanogleio Hospital, 15126 Athens, Greece
| | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Pagona Sklapani
- Department of Cytology, Mitera Hospital, 15123 Athens, Greece
| | - George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larisa, 41221 Larisa, Greece
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Application of Machine Learning Techniques for Characterization of Ischemic Stroke with MRI Images: A Review. Diagnostics (Basel) 2022; 12:diagnostics12102535. [DOI: 10.3390/diagnostics12102535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/07/2022] [Accepted: 10/14/2022] [Indexed: 11/16/2022] Open
Abstract
Magnetic resonance imaging (MRI) is a standard tool for the diagnosis of stroke, but its manual interpretation by experts is arduous and time-consuming. Thus, there is a need for computer-aided-diagnosis (CAD) models for the automatic segmentation and classification of stroke on brain MRI. The heterogeneity of stroke pathogenesis, morphology, image acquisition modalities, sequences, and intralesional tissue signal intensity, as well as lesion-to-normal tissue contrast, pose significant challenges to the development of such systems. Machine learning (ML) is increasingly being used in predictive neuroimaging diagnosis and prognostication. This paper reviews image processing and machine learning techniques that have been applied to detect ischemic stroke on brain MRI, including details on image acquisition, pre-processing, techniques to segment, extraction of features, and classification into stroke types. The main objective of this work is to find the state-of-art machine learning techniques used to predict the ischemic stroke and their application in clinical set-up. The article selection is performed according to PRISMA guideline. The state-of-the-art on automated MRI stroke diagnosis, with a focus on machine learning, is discussed, along with its advantages and limitations. We found that the various machine learning models discussed in this article are able to detect the infarcts with an acceptable accuracy of 70–90%. However, no one has highlighted the time complexity to predict the stroke in the model developed, which is an important factor. The work concludes with proposals for future recommendations for building efficient and robust deep learning (DL) models for quantitative brain MRI analysis. In recent work, with the application of DL approaches, using large datasets to train the models has improved the detection accuracy and reduced computational complexity. We suggest that the design of a decision support system based on artificial intelligence (AI) and clinical data presenting symptoms is essential to support clinicians to accelerate diagnosis and timeous therapy in the emergency management of stroke.
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Mair G, Wardlaw JM. Normal Appearing Ischaemic Brain Tissue on CT and Outcome After Intravenous Alteplase. FRONTIERS IN RADIOLOGY 2022; 2:902165. [PMID: 37492675 PMCID: PMC10364986 DOI: 10.3389/fradi.2022.902165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 05/30/2022] [Indexed: 07/27/2023]
Abstract
Background and Aims The visibility of ischaemic brain lesions on non-enhanced CT increases with time. Obviously hypoattenuating lesions likely represent infarction. Conversely, viable ischaemic brain lesions may be non-visible on CT. We tested whether patients with normal appearing ischaemic brain tissue (NAIBT) on their initial CT are identifiable, and if NAIBT yields better outcomes with alteplase. Methods With data from the Third International Stroke Trial (IST-3, a large randomized-controlled trial of intravenous alteplase for ischaemic stroke) we used receiver-operating characteristic analysis to find a baseline National Institutes of Health Stroke Scale (NIHSS) threshold for identifying patients who developed medium-large ischaemic lesions within 48 h. From patients with baseline CT (acquired <6 h from stroke onset), we used this NIHSS threshold for selection and tested whether favorable outcome after alteplase (6-month Oxford Handicap Score 0-2) differed between patients with NAIBT vs. with those with visible lesions on baseline CT using binary logistic regression (controlled for age, NIHSS, time from stroke onset to CT). Results From 2,961 patients (median age 81 years, median 2.6 h from stroke onset, 1,534 [51.8%] female, 1,484 [50.1%] allocated alteplase), NIHSS>11 best identified those with medium-large ischaemic lesions (area under curve = 0.79, sensitivity = 72.3%, specificity = 71.9%). In IST-3, 1,404/2,961 (47.4%) patients had baseline CT and NIHSS>11. Of these, 745/1,404 (53.1%) had visible baseline ischaemic lesions, 659/1,404 (46.9%) did not (NAIBT). Adjusted odds ratio for favorable outcome after alteplase was 1.54 (95% confidence interval, 1.01-2.36), p = 0.045 among patients with NAIBT vs. 1.61 (0.97-2.67), p = 0.066 for patients with visible lesions, with no evidence of an alteplase-NAIBT interaction (p-value = 0.895). Conclusions Patients with ischaemic stroke and NIHSS >11 commonly develop sizeable ischaemic brain lesions by 48 h that may not be visible within 6 h of stroke onset. Invisible ischaemic lesions may indicate tissue viability. In IST-3, patients with this clinical-radiological mismatch allocated to alteplase achieved more favorable outcome than those allocated to control.
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Affiliation(s)
- Grant Mair
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Joanna M. Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- UK Dementia Research Institute Centre at the University of Edinburgh, Edinburgh, United Kingdom
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Wang Y, Zhu J, Zhao J, Li W, Zhang X, Meng X, Chen T, Li M, Ye M, Hu R, Dou S, Hao H, Zhao X, Wu X, Hu W, Li C, Fan X, Jiang L, Lu X, Yan F. Deep Learning-Enabled Clinically Applicable CT Planbox for Stroke With High Accuracy and Repeatability. Front Neurol 2022; 13:755492. [PMID: 35359626 PMCID: PMC8961979 DOI: 10.3389/fneur.2022.755492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background Computed tomography (CT) plays an essential role in classifying stroke, quantifying penumbra size and supporting stroke-relevant radiomics studies. However, it is difficult to acquire standard, accurate and repeatable images during follow-up. Therefore, we invented an intelligent CT to evaluate stroke during the entire follow-up. Methods We deployed a region proposal network (RPN) and V-Net to endow traditional CT with intelligence. Specifically, facial detection was accomplished by identifying adjacent jaw positions through training and testing an RPN on 76,382 human faces using a preinstalled 2-dimensional camera; two regions of interest (ROIs) were segmented by V-Net on another training set with 295 subjects, and the moving distance of scanning couch was calculated based on a pre-generated calibration table. Multiple cohorts including 1,124 patients were used for performance validation under three clinical scenarios. Results Cranial Automatic Planbox Imaging Towards AmeLiorating neuroscience (CAPITAL)-CT was invented. RPN model had an error distance of 4.46 ± 0.02 pixels with a success rate of 98.7% in the training set and 100% with 2.23 ± 0.10 pixels in the testing set. V-Net-derived segmentation maintained a clinically tolerable distance error, within 3 mm on average, and all lines presented with a tolerable angle error, within 3° on average in all boundaries. Real-time, accurate, and repeatable automatic scanning was accomplished with and a lower radiation exposure dose (all P < 0.001). Conclusions CAPITAL-CT generated standard and reproducible images that could simplify the work of radiologists, which would be of great help in the follow-up of stroke patients and in multifield research in neuroscience.
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Affiliation(s)
- Yang Wang
- Department of Radiology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Junkai Zhu
- State Key Laboratory of Natural Medicines, Research Center of Biostatistics and Computational Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Jinli Zhao
- Department of Radiology, The Affiliated Hospital of Nantong University, Nantong, China
| | - Wenyi Li
- Department of Endocrinology, Tongren Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xin Zhang
- Department of Neurology, Drum Tower Hospital, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology, Institute of Brain Science, Nanjing University, Nanjing, China
| | - Xiaolin Meng
- Research & Advanced Algorithm Department of HSW BU, Shanghai United Imaging Healthcare Co., Ltd., Shanghai, China
| | - Taige Chen
- Medical School of Nanjing University, Nanjing, China
| | - Ming Li
- Department of Radiology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Meiping Ye
- Department of Radiology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Renfang Hu
- Calibration Physical Algorithm Department of CT BU, Shanghai United Imaging Healthcare Co., Ltd., Shanghai, China
| | - Shidan Dou
- Research & Advanced Algorithm Department of HSW BU, Shanghai United Imaging Healthcare Co., Ltd., Shanghai, China
| | - Huayin Hao
- Research & Advanced Algorithm Department of HSW BU, Shanghai United Imaging Healthcare Co., Ltd., Shanghai, China
| | - Xiaofen Zhao
- Clinical Workflow and Clinical Verification Department of CT BU, Shanghai United Imaging Healthcare Co., Ltd., Shanghai, China
| | - Xiaoming Wu
- Clinical Workflow and Clinical Verification Department of CT BU, Shanghai United Imaging Healthcare Co., Ltd., Shanghai, China
| | - Wei Hu
- Department of CT BU, Shanghai United Imaging Healthcare Co., Ltd., Shanghai, China
| | - Cheng Li
- Research & Advanced Algorithm Department of HSW BU, Shanghai United Imaging Healthcare Co., Ltd., Shanghai, China
| | - Xiaole Fan
- Department of Radiology, The Second Affiliated Hospital of Nantong University, Nantong, China
| | - Liyun Jiang
- State Key Laboratory of Natural Medicines, Research Center of Biostatistics and Computational Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Xiaofan Lu
- State Key Laboratory of Natural Medicines, Research Center of Biostatistics and Computational Pharmacy, China Pharmaceutical University, Nanjing, China
- *Correspondence: Xiaofan Lu
| | - Fangrong Yan
- State Key Laboratory of Natural Medicines, Research Center of Biostatistics and Computational Pharmacy, China Pharmaceutical University, Nanjing, China
- Fangrong Yan
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Mahendran SA, Flower O, Hemphill JC. Head CT for the intensivist: 10 tips and pearls. Minerva Anestesiol 2022; 88:508-515. [PMID: 35199970 DOI: 10.23736/s0375-9393.22.16200-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Head imaging is an essential diagnostic tool for the management of patients with most acute neurological emergencies involving the brain. While numerous modalities including magnetic resonance imaging and catheter angiography play a role, computed tomography (CT) of the brain is far and away the most widely utilized technique because of its widespread availability and the fact that it is usually easier to implement in critically ill and potentially unstable patients. CT is particularly useful in identifying acute intracranial hemorrhage and this makes it often indispensable in the management of patients with traumatic brain injury and hemorrhagic stroke. However, shortcomings in identifying early ischemia on non-contrast CT mean that care must be taken in considering findings early after symptom onset, with newer CT sequences such as CT angiography and CT perfusion adding value. The critical role played by intensivist in managing neurocritical care patients necessitates familiarity and ability with viewing and understanding the advantages and shortcomings of head CT imaging and under which circumstances other modalities may be appropriate to obtain. This manuscript provides ten different circumstances commonly encountered in neurocritical care and how intensivists can use CT for the benefit of their patients.
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Affiliation(s)
- Sajeev A Mahendran
- Malcolm Fisher Intensive Care Unit, Royal North Shore Hospital, Sydney NSW, Australia
| | - Oliver Flower
- Malcolm Fisher Intensive Care Unit, Royal North Shore Hospital, Sydney NSW, Australia
| | - J Claude Hemphill
- Department of Neurology, University of California, San Francisco, CA, USA -
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9
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Abstract
The discovery that brain tissue could potentially be salvaged from ischaemia due to stroke, has led to major advances in the development of therapies for ischemic stroke. In this review, we detail the advances in the understanding of this area termed the ischaemic penumbra, from its discovery to the evolution of imaging techniques, and finally some of the treatments developed. Evolving from animal studies from the 70s and 80s and translated to clinical practice, the field of ischemic reperfusion therapy has largely been guided by an array of imaging techniques developed to positively identify the ischemic penumbra, including positron emission tomography, computed tomography and magnetic resonance imaging. More recently, numerous penumbral identification imaging studies have allowed for a better understanding of the progression of the ischaemic core at the expense of the penumbra, and identification of patients than can benefit from reperfusion therapies in the acute phase. Importantly, 40 years of critical imaging research on the ischaemic penumbra have allowed for considerable extension of the treatment time window and better patient selection for reperfusion therapy. The translation of the penumbra concept into routine clinical practice has shown that "tissue is at least as important as time."
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Affiliation(s)
- Charlotte M Ermine
- Florey Institute of Neuroscience and Mental Health, Melbourne, Australia
| | - Andrew Bivard
- Department of Medicine, Melbourne Brain Centre at The Royal Melbourne Hospital, Parkville, Australia.,Department of Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, Parkville, Australia
| | - Mark W Parsons
- Department of Medicine, Melbourne Brain Centre at The Royal Melbourne Hospital, Parkville, Australia.,Department of Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, Parkville, Australia
| | - Jean-Claude Baron
- Institute of Psychiatry and Neuroscience of Paris (IPNP), Université de Paris, Paris, France.,GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte Anne, Paris, France
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10
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Aravantinou-Fatorou K, Fotakopoulos G. Efficacy of exercise rehabilitation program accompanied by experiential music for recovery of aphasia in single cerebrovascular accidents: a randomized controlled trial. Ir J Med Sci 2020; 190:771-778. [PMID: 32740716 DOI: 10.1007/s11845-020-02328-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 07/23/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The current study aims to evaluate the effects of daily traditional experiential music listening for clinical recovery of post-stroke aphasia. METHODS This was a prospective randomized trial with seventy-nine stroke survivors who suffered from post-stroke aphasia. All patients underwent a neuropsychological evaluation, at time = 0 during the admission at the rehabilitation structure (baseline), and 6 months post-stroke. All cases received standard treatment for stroke and post-stroke aphasia in terms of medical care and rehabilitation. Furthermore, patients were randomized to receive either standard care only or standard care with daily traditional experiential music listening. Computer tomography perfusion and neurological examination were assessed to all patients. Recovery was measured by the score at Aachener Aphasie Test. RESULTS The statistically significant differences between the control group (CG) and the rest of the patients were the clinical characteristics (hemiparesis) (p = 0.002), the cerebral blood flow in affected areas (p = 0.000), and the Mini-Mental Test (mMT) (p = 0.000). Only group and mMT were independent predictor factors for recovery, according to multivariate analysis odd ratio (ΟR) (95% confidence interval) 0.022 (0.009-0.435) and 0.658 (0.142-0.224) respectively. CONCLUSIONS The results of this study are promising and suggest that an enriched sound environment is beneficial for patients with post-stroke aphasia since the recovery rate is higher when standard care was combined with daily music listening.
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Affiliation(s)
| | - George Fotakopoulos
- Department of Neurosurgery, General Hospital of Pyrgos 'Andreas Papandreou', Sintriada, 27100, Pyrgos Ilias, Greece. .,, Pyrgos Ilias, Greece.
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The effect of software post-processing applications on identification of the penumbra and core within the ischaemic region in perfusion computed tomography. Pol J Radiol 2019; 84:e118-e125. [PMID: 31019604 PMCID: PMC6479142 DOI: 10.5114/pjr.2019.83182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 01/22/2019] [Indexed: 12/03/2022] Open
Abstract
Purpose Assessment of software applications designed for post-processing of CT imaging data and perfusion maps in terms of their ability to consistently define the penumbra and core in an ischemic area. Material and methods This study is based on measurements conducted in a group of 65 patients with neurological symptoms suggestive of ischaemia in the area of the MCA within 12 hours following onset of the first symptoms. Non-contrast and perfusion CT were performed during an emergency duty. The acquired data were processed using various programs to obtain defined ischaemic areas and parameters. Finally, the results obtained were compared to the distribution of penumbra and core within the ischaemic area received from different perfusion mapping programs. Results The programs designed to convert the acquired data and to map the distribution of perfusion were also assessed for their viability in dividing the ischaemic zone into penumbra and core. There was a statistically strong correlation (0.784-0.846) between results obtained by processing of imaging data with two different packages, and then by post-processing with one package, and a poor correlation (0.315-0.554) between results obtained by processing of data with the same package, and post-processing with two different packages designed for measuring penumbra and core areas. Conclusions The results obtained by processing of imaging data with different software applications and by post-processing with one program developed for identifying penumbra and core areas show a strong correlation. However, the results obtained by processing imaging data with the same software application and by post-processing with different programs measuring penumbra and core areas reveal poor correlation.
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Fotakopoulos G, Kotlia P. The Value of Exercise Rehabilitation Program Accompanied by Experiential Music for Recovery of Cognitive and Motor Skills in Stroke Patients. J Stroke Cerebrovasc Dis 2018; 27:2932-2939. [PMID: 30072173 DOI: 10.1016/j.jstrokecerebrovasdis.2018.06.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 06/17/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The aim of this study was to systematically assess the effects of exercise rehabilitation program accompanied by experiential music for clinical recovery. METHODS This was a prospective randomized study with 65 stroke survivor patients. All cases underwent a neuropsychological assessment first as a prescreening test, during the admission at the Rehabilitation center (baseline), and 6 months poststroke. All patients received standard treatment for stroke in terms of medical care and rehabilitation. Additionally, all patients were separated into 2 Groups: a music Group (daily listening to experiential/traditional music), and a control Group (CG) with no experiential/traditional music therapy (standard care only). Computed tomography perfusion and full neurological examination including GCS were assessment. As Recovery was defined the improvement of cognitive and motor skills of the limb in the affected site, with an increase of muscle strength at least by 1/5 and with emotional progress. RESULTS Statistically significant differences were found between the Group CG and the rest of the patients in respect of Lesion size (P = .001) and CBF in affected area (P = .001). Μultivariate analysis revealed that only Group and Lesion size were independent predictors for Recovery (odd ratio [OR][95%confidence interval]) .11(.001-.133) and .798(.668-.954) respectively. CONCLUSION The findings of this study suggest that the music-based exercise program has a positive effect on mood profile in stroke patients and Recovery rate is higher when exercise rehabilitation program was accompanied by an enriched sound environment with experiential music.
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Affiliation(s)
- George Fotakopoulos
- Department of Neurosurgery, University Hospital of Patras, Patra, Greece; Department of Neurosurgery, University Hospital of Thessaly, University Hospital of Larissa, Biopolis, 41110 Larissa, Thessaly, Greece
| | - Polikceni Kotlia
- Department of Head of Critical Care, University of Thessaly, University Hospital of Larissa, Biopolis, 41110, Larissa, Thessaly, Greece
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The value of computed tomography perfusion & transcranial Doppler in early diagnosis of cerebral vasospasm in aneurysmal & traumatic subarachnoid hemorrhage. Future Sci OA 2018; 4:FSO313. [PMID: 30057790 PMCID: PMC6060394 DOI: 10.4155/fsoa-2018-0015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 05/02/2018] [Indexed: 02/04/2023] Open
Abstract
Early detection and diagnosis of cerebral vasospasm in subarachnoid hemorrhage may be challenging both on clinical and radiographic grounds. In this respect we conducted a pilot study in order to assess the feasibility of the technique in the everyday setting of a tertiary hospital and to evaluate the diagnostic performance of different diagnostic computed tomography perfusion aspects in diagnosing the clinical outcome of patients with subarachnoid hemorrhage. Receiver-operating characteristic analysis showed that a cerebral blood flow value of <24.5 presented 67% sensitivity and 100% specificity to diagnose adverse ischemic events at 1 month (p = 0.041). These case series data provide evidence that computed tomography perfusion-derived cerebral blood flow is a measurable index that may detect the degree of cerebral ischemia in a very early stage. Early detection and diagnosis of cerebral vasospasm in subarachnoid hemorrhage is important but may be challenging both on clinical or radiographic grounds. This article provides evidence that computed tomography perfusion-derived cerebral blood flow is a measurable index that could detect the degree of cerebral ischemia in a very early stage in patients suffering with subarachnoid hemorrhage. Larger studies are needed in order to better define the role of computed tomography perfusion in early diagnosis of cerebral vasospasm.
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Bivard A, Spratt N, Miteff F, Levi C, Parsons MW. Tissue Is More Important than Time in Stroke Patients Being Assessed for Thrombolysis. Front Neurol 2018; 9:41. [PMID: 29467716 PMCID: PMC5808281 DOI: 10.3389/fneur.2018.00041] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/17/2018] [Indexed: 11/26/2022] Open
Abstract
Aim The relative prognostic importance of modern imaging profiles compared with standard clinical characteristics is uncertain in acute stroke patients. In this study, we aimed to compare baseline multimodal CT imaging measures with known clinical predictors of patient outcome at 3 months [modified Rankin scale (mRS)]. Methods We collected baseline, 24 h, and day 90 clinical and imaging data from acute ischemic stroke patients being assessed for thrombolytic therapy between 2010 and 2015 at a single center as part of a retrospective analysis. Results 561 patients presenting within 4.5 h of ischemic stroke onset who were eligible for thrombolysis based on standard clinical criteria were assessed. Acute infarct core volume on CTP was the strongest univariate predictor of patient outcome (mRS 0–2, R2 0.497, p < 0.001), followed by collateral grade (mRS 0–2, R2 0.281, p < 0.001). The strongest baseline clinical predictor of outcome was National Institutes of Health Stroke Scale (NIHSS) (mRS 0–2, R2 = 0.203, p < 0.001). Time to treatment (mRS 0–2, R2 0.096, p = 0.01) and age (mRS 0–2, R2 0.027, p = 0.013) were relatively weak univariate baseline clinical predictors of 3-month outcome. In multivariate analysis, acute infarct core volume and collateral grade were the only significant baseline predictors of 3-month disability (both p < 0.001). Conclusion In patients assessed for thrombolysis by combined clinical and multimodal CT criteria within 4.5 h of onset, the size of the CTP infarct core and collateral grade on multimodal CT were highly predictive of patient outcome. Standard clinical variables, including time to treatment and NIHSS, were not as strongly predictive as multimodal CT variables.
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Affiliation(s)
- Andrew Bivard
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Neil Spratt
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Ferdinand Miteff
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Christopher Levi
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Mark William Parsons
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
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El-Tawil S, Wardlaw J, Ford I, Mair G, Robinson T, Kalra L, Muir KW. Penumbra and re-canalization acute computed tomography in ischemic stroke evaluation: PRACTISE study protocol. Int J Stroke 2017; 12:671-678. [PMID: 28730951 DOI: 10.1177/1747493017696099] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Rationale Multimodal imaging, including computed tomography angiography and computed tomography perfusion imaging, yields additional information on intracranial vessels and brain perfusion and can differentiate between ischemic core and penumbra which may affect patient selection for intravenous thrombolysis. Hypothesis The use of multimodal imaging will increase the number of patients receiving intravenous thrombolysis and lead to better treatment outcomes. Sample size 400 patients. Methods and design PRACTISE is a prospective, multicenter, randomized, controlled trial in which patients presenting within 4.5 h of symptom onset are randomized to either the current evidence-based imaging (NCCT alone) or additional multimodal computed tomography imaging (NCCT + computed tomography angiography + computed tomography perfusion). Clinical decisions on intravenous recombinant tissue plasminogen activator are documented. Total imaging time in both arms and time to initiation of treatment delivery in those treated with intravenous recombinant tissue plasminogen activator, is recorded. Follow-up will include brain imaging at 24 h to document infarct size, the presence of edema and the presence of intra-cerebral hemorrhage. Clinical evaluations include NIHSS score at baseline, 24 h and day 7 ± 2, and mRS at day 90 to define functional outcomes. Study outcomes The primary outcome is the proportion of patients receiving intravenous recombinant tissue plasminogen activator. Secondary end-points evaluate times to decision-making, comparison of different image processing software and clinical outcomes at three months. Discussion Multimodal computed tomography is a widely available tool for patient selection for revascularization therapy, but it is currently unknown whether the use of additional imaging in all stroke patients is beneficial. The study opened for recruitment in March 2015 and will provide data on the value of multimodal imaging in treatment decisions for acute stroke.
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Affiliation(s)
- Salwa El-Tawil
- 1 Institute of Neuroscience & Psychology, Queen Elizabeth University Hospital, University of Glasgow, Glasgow, UK
| | - Joanna Wardlaw
- 2 Division of Neuroimaging Sciences, Western General Hospital, Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Ian Ford
- 3 Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Grant Mair
- 2 Division of Neuroimaging Sciences, Western General Hospital, Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Tom Robinson
- 4 Department of Cardiovascular Sciences, Ageing and Stroke Medicine Group, University of Leicester, Leicester, UK
| | - Lalit Kalra
- 5 Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neurosciences, King's College London, London, UK
| | - Keith W Muir
- 1 Institute of Neuroscience & Psychology, Queen Elizabeth University Hospital, University of Glasgow, Glasgow, UK
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Luby M, Warach SJ, Albers GW, Baron JC, Cognard C, Dávalos A, Donnan GA, Fiebach JB, Fiehler J, Hacke W, Lansberg MG, Liebeskind DS, Mattle HP, Oppenheim C, Schellinger PD, Wardlaw JM, Wintermark M. Identification of imaging selection patterns in acute ischemic stroke patients and the influence on treatment and clinical trial enrollment decision making. Int J Stroke 2017; 11:180-90. [PMID: 26783309 DOI: 10.1177/1747493015616634] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE For the STroke Imaging Research (STIR) and VISTA-Imaging Investigators The purpose of this study was to collect precise information on the typical imaging decisions given specific clinical acute stroke scenarios. Stroke centers worldwide were surveyed regarding typical imaging used to work up representative acute stroke patients, make treatment decisions, and willingness to enroll in clinical trials. METHODS STroke Imaging Research and Virtual International Stroke Trials Archive-Imaging circulated an online survey of clinical case vignettes through its website, the websites of national professional societies from multiple countries as well as through email distribution lists from STroke Imaging Research and participating societies. Survey responders were asked to select the typical imaging work-up for each clinical vignette presented. Actual images were not presented to the survey responders. Instead, the survey then displayed several types of imaging findings offered by the imaging strategy, and the responders selected the appropriate therapy and whether to enroll into a clinical trial considering time from onset, clinical presentation, and imaging findings. A follow-up survey focusing on 6 h from onset was conducted after the release of the positive endovascular trials. RESULTS We received 548 responses from 35 countries including 282 individual centers; 78% of the centers originating from Australia, Brazil, France, Germany, Spain, United Kingdom, and United States. The specific onset windows presented influenced the type of imaging work-up selected more than the clinical scenario. Magnetic Resonance Imaging usage (27-28%) was substantial, in particular for wake-up stroke. Following the release of the positive trials, selection of perfusion imaging significantly increased for imaging strategy. CONCLUSIONS Usage of vascular or perfusion imaging by Computed Tomography or Magnetic Resonance Imaging beyond just parenchymal imaging was the primary work-up (62-87%) across all clinical vignettes and time windows. Perfusion imaging with Computed Tomography or Magnetic Resonance Imaging was associated with increased probability of enrollment into clinical trials for 0-3 h. Following the release of the positive endovascular trials, selection of endovascular only treatment for 6 h increased across all clinical vignettes.
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Affiliation(s)
- Marie Luby
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, USA Department of Neurology and Neurotherapeutics, Seton/UT Southwestern Clinical Research Institute of Austin, UT Southwestern Medical Center, Austin, TX, USA
| | - Steven J Warach
- Dell Medical School, University of Texas Austin, Austin, TX, USA
| | | | - Jean-Claude Baron
- INSERM U894, Centre Hospitalier Sainte-Anne, Sorbonne Paris Cité, Paris, France Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | | | - Antoni Dávalos
- Hospital Universitari Germans Trias I Pujol, Badalona, Spain
| | - Geoffrey A Donnan
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Jochen B Fiebach
- Academic Neuroradiology, Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jens Fiehler
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | | | | | | | - Catherine Oppenheim
- Université Paris-Descartes, Sorbonne Paris Cité, Hôpital Sainte-Anne, INSERM U 894, Paris, France
| | | | - Joanna M Wardlaw
- Division of Neuroimaging Sciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Max Wintermark
- Stanford University School of Medicine, Stanford, CA, USA Department of Radiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
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Demaerschalk BM, Kleindorfer DO, Adeoye OM, Demchuk AM, Fugate JE, Grotta JC, Khalessi AA, Levy EI, Palesch YY, Prabhakaran S, Saposnik G, Saver JL, Smith EE. Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke. Stroke 2016; 47:581-641. [DOI: 10.1161/str.0000000000000086] [Citation(s) in RCA: 442] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose—
To critically review and evaluate the science behind individual eligibility criteria (indication/inclusion and contraindications/exclusion criteria) for intravenous recombinant tissue-type plasminogen activator (alteplase) treatment in acute ischemic stroke. This will allow us to better inform stroke providers of quantitative and qualitative risks associated with alteplase administration under selected commonly and uncommonly encountered clinical circumstances and to identify future research priorities concerning these eligibility criteria, which could potentially expand the safe and judicious use of alteplase and improve outcomes after stroke.
Methods—
Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge and, when appropriate, formulated recommendations using standard American Heart Association criteria. All members of the writing group had the opportunity to comment on and approved the final version of this document. The document underwent extensive American Heart Association internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.
Results—
After a review of the current literature, it was clearly evident that the levels of evidence supporting individual exclusion criteria for intravenous alteplase vary widely. Several exclusionary criteria have already undergone extensive scientific study such as the clear benefit of alteplase treatment in elderly stroke patients, those with severe stroke, those with diabetes mellitus and hyperglycemia, and those with minor early ischemic changes evident on computed tomography. Some exclusions such as recent intracranial surgery are likely based on common sense and sound judgment and are unlikely to ever be subjected to a randomized, clinical trial to evaluate safety. Most other contraindications or warnings range somewhere in between. However, the differential impact of each exclusion criterion varies not only with the evidence base behind it but also with the frequency of the exclusion within the stroke population, the probability of coexistence of multiple exclusion factors in a single patient, and the variation in practice among treating clinicians.
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18
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Exclusion of Isolated Cortical Swelling Can Increase Efficacy of Baseline Alberta Stroke Program Early CT Score in the Prediction of Prognosis in Acute Ischemic Stroke Patients Treated with Thrombolysis. J Stroke Cerebrovasc Dis 2015; 24:2754-8. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 08/02/2015] [Accepted: 08/04/2015] [Indexed: 11/18/2022] Open
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Breuer L, Knott M, Struffert T, Kloska S, Kurka N, Schwab S, Dörfler A, Köhrmann M, Engelhorn T. Limited versus Whole-Brain Perfusion for the Indication of Thrombolysis in the Extended Time Window of Acute Cerebral Ischemia. J Stroke Cerebrovasc Dis 2015; 24:2491-6. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.06.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 06/14/2015] [Indexed: 11/27/2022] Open
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20
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Bivard A, Levi C, Krishnamurthy V, McElduff P, Miteff F, Spratt NJ, Bateman G, Donnan G, Davis S, Parsons M. Perfusion computed tomography to assist decision making for stroke thrombolysis. Brain 2015; 138:1919-31. [PMID: 25808369 PMCID: PMC4572482 DOI: 10.1093/brain/awv071] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 01/21/2015] [Indexed: 11/13/2022] Open
Abstract
The use of perfusion imaging to guide selection of patients for stroke thrombolysis remains controversial because of lack of supportive phase three clinical trial evidence. We aimed to measure the outcomes for patients treated with intravenous recombinant tissue plasminogen activator (rtPA) at a comprehensive stroke care facility where perfusion computed tomography was routinely used for thrombolysis eligibility decision assistance. Our overall hypothesis was that patients with 'target' mismatch on perfusion computed tomography would have improved outcomes with rtPA. This was a prospective cohort study of consecutive ischaemic stroke patients who fulfilled standard clinical/non-contrast computed tomography eligibility criteria for treatment with intravenous rtPA, but for whom perfusion computed tomography was used to guide the final treatment decision. The 'real-time' perfusion computed tomography assessments were qualitative; a large perfusion computed tomography ischaemic core, or lack of significant perfusion lesion-core mismatch were considered relative exclusion criteria for thrombolysis. Specific volumetric perfusion computed tomography criteria were not used for the treatment decision. The primary analysis compared 3-month modified Rankin Scale in treated versus untreated patients after 'off-line' (post-treatment) quantitative volumetric perfusion computed tomography eligibility assessment based on presence or absence of 'target' perfusion lesion-core mismatch (mismatch ratio >1.8 and volume >15 ml, core <70 ml). In a second analysis, we compared outcomes of the perfusion computed tomography-selected rtPA-treated patients to an Australian historical cohort of non-contrast computed tomography-selected rtPA-treated patients. Of 635 patients with acute ischaemic stroke eligible for rtPA by standard criteria, thrombolysis was given to 366 patients, with 269 excluded based on visual real-time perfusion computed tomography assessment. After off-line quantitative perfusion computed tomography classification: 253 treated patients and 83 untreated patients had 'target' mismatch, 56 treated and 31 untreated patients had a large ischaemic core, and 57 treated and 155 untreated patients had no target mismatch. In the primary analysis, only in the target mismatch subgroup did rtPA-treated patients have significantly better outcomes (odds ratio for 3-month, modified Rankin Scale 0-2 = 13.8, P < 0.001). With respect to the perfusion computed tomography selected rtPA-treated patients (n = 366) versus the clinical/non-contrast computed tomography selected rtPA-treated patients (n = 396), the perfusion computed tomography selected group had higher adjusted odds of excellent outcome (modified Rankin Scale 0-1 odds ratio 1.59, P = 0.009) and lower mortality (odds ratio 0.56, P = 0.021). Although based on observational data sets, our analyses provide support for the hypothesis that perfusion computed tomography improves the identification of patients likely to respond to thrombolysis, and also those in whom natural history may be difficult to modify with treatment.
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Affiliation(s)
- Andrew Bivard
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, New South Wales, Australia
| | - Christopher Levi
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, New South Wales, Australia
| | - Venkatesh Krishnamurthy
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, New South Wales, Australia
| | - Patrick McElduff
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, New South Wales, Australia
| | - Ferdi Miteff
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, New South Wales, Australia
| | - Neil J Spratt
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, New South Wales, Australia
| | - Grant Bateman
- 2 Department of Radiology, John Hunter Hospital, University of Newcastle New South Wales, Australia
| | - Geoffrey Donnan
- 3 Melbourne Brain Centre, Florey Neuroscience Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Stephen Davis
- 3 Melbourne Brain Centre, Florey Neuroscience Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Mark Parsons
- 1 Department of Neurology, John Hunter Hospital, University of Newcastle, New South Wales, Australia
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Stoel BC, Marquering HA, Staring M, Beenen LF, Slump CH, Roos YB, Majoie CB. Automated brain computed tomographic densitometry of early ischemic changes in acute stroke. J Med Imaging (Bellingham) 2015; 2:014004. [PMID: 26158082 PMCID: PMC4478844 DOI: 10.1117/1.jmi.2.1.014004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 03/03/2015] [Indexed: 11/14/2022] Open
Abstract
The Alberta Stroke Program Early CT score (ASPECTS) scoring method is frequently used for quantifying early ischemic changes (EICs) in patients with acute ischemic stroke in clinical studies. Varying interobserver agreement has been reported, however, with limited agreement. Therefore, our goal was to develop and evaluate an automated brain densitometric method. It divides CT scans of the brain into ASPECTS regions using atlas-based segmentation. EICs are quantified by comparing the brain density between contralateral sides. This method was optimized and validated using CT data from 10 and 63 patients, respectively. The automated method was validated against manual ASPECTS, stroke severity at baseline and clinical outcome after 7 to 10 days (NIH Stroke Scale, NIHSS) and 3 months (modified Rankin Scale). Manual and automated ASPECTS showed similar and statistically significant correlations with baseline NIHSS ([Formula: see text] and [Formula: see text], respectively) and with follow-up mRS ([Formula: see text] and [Formula: see text]), except for the follow-up NIHSS. Agreement between automated and consensus ASPECTS reading was similar to the interobserver agreement of manual ASPECTS (differences [Formula: see text] point in 73% of cases). The automated ASPECTS method could, therefore, be used as a supplementary tool to assist manual scoring.
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Affiliation(s)
- Berend C. Stoel
- Leiden University Medical Center, Division of Image Processing, Department of Radiology, Albinusdreef 2 Leiden 2333 AA, The Netherlands
| | - Henk A. Marquering
- Academic Medical Center, Department of Radiology, Amsterdam, The Netherlands
- Academic Medical Center, Department of Biomedical Engineering and Physics, Amsterdam, The Netherlands
| | - Marius Staring
- Leiden University Medical Center, Division of Image Processing, Department of Radiology, Albinusdreef 2 Leiden 2333 AA, The Netherlands
| | - Ludo F. Beenen
- Academic Medical Center, Department of Radiology, Amsterdam, The Netherlands
| | - Cornelis H. Slump
- University of Twente, MIRA Institute for Biomedical Technology and Technical Medicine, Enschede, The Netherlands
| | - Yvo B. Roos
- Academic Medical Center, Department of Neurology, Amsterdam, The Netherlands
| | - Charles B. Majoie
- Academic Medical Center, Department of Radiology, Amsterdam, The Netherlands
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Dani KA, Warach S. Metabolic imaging of ischemic stroke: the present and future. AJNR Am J Neuroradiol 2014; 35:S37-43. [PMID: 24722308 DOI: 10.3174/ajnr.a3789] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Measures of cerebral metabolism may be useful in the selection of patients for reperfusion therapies and as end points in clinical trials. However, there are currently no clinically routine techniques that provide such data directly. We review how imaging modalities in current clinical use may provide surrogate markers of metabolic activity. Promising techniques for metabolic imaging that are currently in the pipeline are reviewed.
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Affiliation(s)
- K A Dani
- From the Institute of Neurosciences and Psychology (K.A.D.), University of Glasgow, Institute of Neurological Sciences, Glasgow, United Kingdom
| | - S Warach
- Department of Neurology and Neurotherapeutics (S.W.), UT Southwestern, Dallas, Texas.
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23
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3D movement correction of CT brain perfusion image data of patients with acute ischemic stroke. Neuroradiology 2014; 56:445-52. [PMID: 24715201 DOI: 10.1007/s00234-014-1358-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 03/26/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Head movement during CT brain perfusion (CTP) acquisition can deteriorate the accuracy of CTP analysis. Most CTP software packages can only correct in-plane movement and are limited to small ranges. The purpose of this study is to validate a novel 3D correction method for head movement during CTP acquisition. METHODS Thirty-five CTP datasets that were classified as defective due to head movement were included in this study. All CTP time frames were registered with non-contrast CT data using a 3D rigid registration method. Location and appearance of ischemic area in summary maps derived from original and registered CTP datasets were qualitative compared with follow-up non-contrast CT. A quality score (QS) of 0 to 3 was used to express the degree of agreement. Furthermore, experts compared the quality of both summary maps and assigned the improvement score (IS) of the CTP analysis, ranging from -2 (much worse) to 2 (much better). RESULTS Summary maps generated from corrected CTP significantly agreed better with appearance of infarct on follow-up CT with mean QS 2.3 versus mean QS 1.8 for summary maps from original CTP (P = 0.024). In comparison to original CTP data, correction resulted in a quality improvement with average IS 0.8: 17 % worsened (IS = -2, -1), 20 % remained unchanged (IS = 0), and 63 % improved (IS = +1, +2). CONCLUSION The proposed 3D movement correction improves the summary map quality for CTP datasets with severe head movement.
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Fahmi F, Marquering H, Streekstra G, Beenen L, Janssen N, Majoie C, vanBavel E. Automatic Detection of CT Perfusion Datasets Unsuitable for Analysis due to Head Movement of Acute Ischemic Stroke Patients. JOURNAL OF HEALTHCARE ENGINEERING 2014; 5:67-78. [DOI: 10.1260/2040-2295.5.1.67] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Kim BJ, Kim HJ, Lee DH, Kwon SU, Kim SJ, Kim JS, Kang DW. Diffusion-weighted image and fluid-attenuated inversion recovery image mismatch: unclear-onset versus clear-onset stroke. Stroke 2013; 45:450-5. [PMID: 24347423 DOI: 10.1161/strokeaha.113.002830] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE Mismatch in lesion visibility between diffusion-weighted image and fluid-attenuated inversion recovery image (DWI-FLAIR mismatch) has been proposed as a biomarker for the estimation of ischemic lesion age. The actual onset in some patients with unclear-onset stroke (UnCOS) may be close to the first-found abnormal time. We hypothesized that patients with UnCOS within a particular time window might have a similar DWI-FLAIR mismatch profile with patients with clear-onset stroke (COS). METHODS Patients who underwent MRI within 6 hours from first-found abnormal time were recruited retrospectively. Clinical characteristics and the proportion of DWI-FLAIR and perfusion-weighted image-DWI mismatch in each time window were compared between UnCOS and COS. RESULTS The final analysis included 259 patients (114 with UnCOS and 145 with COS). Patients with UnCOS were older and had more severe stroke at baseline. Risk factors, stroke subtypes, and perfusion-weighted image-DWI mismatch did not differ between the 2 groups. The proportion of patients with DWI-FLAIR mismatch in UnCOS did not differ from COS within 2 hours of first-found abnormal time (50.0% versus 51.5%; P=0.92), but it was significantly lower in UnCOS than in COS at 2 to 3 hours (16.1% versus 44.4%; P=0.02), 3 to 4 hours (13.8% versus 36.4%; P=0.04), and 4 to 5 hours (5.6% versus 29.6%; P=0.05). CONCLUSIONS The proportion of DWI-FLAIR mismatch in UnCOS within the first 2 hours from first-found abnormal time was similar with COS, but it sharply decreased beyond 2 hours. These data suggest that patients with UnCOS within 2 hours of symptom detection may be good candidates for multimodal imaging-based thrombolysis.
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Affiliation(s)
- Bum Joon Kim
- From the Departments of Neurology (B.J.K., S.U.K., J.S.K., D.-W.K.) and Radiology (D.H.L., S.J.K.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea; and Vision, Image, and Learning Laboratory, Asan Institute For Life Sciences, Asan Medical Center, Seoul, South Korea (H.-J.K., D.-W.K.)
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Fahmi F, Beenen L, Streekstra G, Janssen N, de Jong H, Riordan A, Roos Y, Majoie C, vanBavel E, Marquering H. Head movement during CT brain perfusion acquisition of patients with suspected acute ischemic stroke. Eur J Radiol 2013; 82:2334-41. [DOI: 10.1016/j.ejrad.2013.08.039] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 08/16/2013] [Accepted: 08/17/2013] [Indexed: 11/30/2022]
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Beaty CA, Arnaoutakis GJ, Grega MA, Robinson CW, George TJ, Baumgartner WA, Gottesman RF, McKhann GM, Cameron DE, Whitman GJ. The role of head computed tomography imaging in the evaluation of postoperative neurologic deficits in cardiac surgery patients. Ann Thorac Surg 2012; 95:548-54. [PMID: 23218967 DOI: 10.1016/j.athoracsur.2012.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 11/01/2012] [Accepted: 11/06/2012] [Indexed: 12/01/2022]
Abstract
BACKGROUND Computed tomography (CT) scans of the head without contrast are routinely obtained to evaluate neurologic deficits after cardiac surgery, but their utility is unknown. We evaluated our experience with this imaging modality to determine its value. METHODS We retrospectively identified cardiac surgery patients with postoperative neurologic deficits occurring during the first week after surgery between January 2000 and December 2012. Stroke was defined by neurologist's determination, whereas a nonfocal deficit (NFD) was defined by the presence of seizure, delirium, or cognitive impairment. We defined early noncontrast head CT as occurring within 7 days of surgery. Outcomes included positive findings on CT, in-hospital mortality, and length of stay. Multivariate logistic regression identified predictors of positive findings on head CT. RESULTS Within the population of 11,070 postoperative patients, 451 had early noncontrast head CT scans (4%). Two hundred two (44.7%) were associated with stroke, and 249 (55.2%) were associated with NFD. Among stroke patients, 40 of 202 (20%) showed acute infarction, 17 of 202 (8%) showed subacute infarction, and 5 of 202 (2%) showed hemorrhage. Among NFD patients, 1 of 248 (0.4%) showed acute infarction, 4 of 248 (1.6%) showed subacute infarction, and 1 of 248 (0.4%) showed hemorrhage. There was no difference in in-hospital mortality (stroke, 42 of 201 [21%] versus NFD, 41 of 248 [16%]; p = 0.2) or length of stay (stroke, 24 d versus NFD, 22 d; p = 0.5). On multivariable logistic regression, only focal deficits and aortic procedures predicted a positive finding on CT scan. CONCLUSIONS This study reviewed the utility of early postoperative noncontrast head CT in cardiac surgery patients. With focal neurologic deficits, this imaging modality was positive for approximately one third of patients, but rarely positive for NFD. Its use in this setting has limited utility.
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Affiliation(s)
- Claude A Beaty
- Division of Cardiac Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Rekik I, Allassonnière S, Carpenter TK, Wardlaw JM. Medical image analysis methods in MR/CT-imaged acute-subacute ischemic stroke lesion: Segmentation, prediction and insights into dynamic evolution simulation models. A critical appraisal. Neuroimage Clin 2012; 1:164-78. [PMID: 24179749 PMCID: PMC3757728 DOI: 10.1016/j.nicl.2012.10.003] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Revised: 10/08/2012] [Accepted: 10/09/2012] [Indexed: 12/30/2022]
Abstract
Over the last 15 years, basic thresholding techniques in combination with standard statistical correlation-based data analysis tools have been widely used to investigate different aspects of evolution of acute or subacute to late stage ischemic stroke in both human and animal data. Yet, a wave of biology-dependent and imaging-dependent issues is still untackled pointing towards the key question: "how does an ischemic stroke evolve?" Paving the way for potential answers to this question, both magnetic resonance (MRI) and CT (computed tomography) images have been used to visualize the lesion extent, either with or without spatial distinction between dead and salvageable tissue. Combining diffusion and perfusion imaging modalities may provide the possibility of predicting further tissue recovery or eventual necrosis. Going beyond these basic thresholding techniques, in this critical appraisal, we explore different semi-automatic or fully automatic 2D/3D medical image analysis methods and mathematical models applied to human, animal (rats/rodents) and/or synthetic ischemic stroke to tackle one of the following three problems: (1) segmentation of infarcted and/or salvageable (also called penumbral) tissue, (2) prediction of final ischemic tissue fate (death or recovery) and (3) dynamic simulation of the lesion core and/or penumbra evolution. To highlight the key features in the reviewed segmentation and prediction methods, we propose a common categorization pattern. We also emphasize some key aspects of the methods such as the imaging modalities required to build and test the presented approach, the number of patients/animals or synthetic samples, the use of external user interaction and the methods of assessment (clinical or imaging-based). Furthermore, we investigate how any key difficulties, posed by the evolution of stroke such as swelling or reperfusion, were detected (or not) by each method. In the absence of any imaging-based macroscopic dynamic model applied to ischemic stroke, we have insights into relevant microscopic dynamic models simulating the evolution of brain ischemia in the hope to further promising and challenging 4D imaging-based dynamic models. By depicting the major pitfalls and the advanced aspects of the different reviewed methods, we present an overall critique of their performances and concluded our discussion by suggesting some recommendations for future research work focusing on one or more of the three addressed problems.
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Affiliation(s)
- Islem Rekik
- BRIC, Edinburgh University, Department of Clinical Neurosciences, UK
- CMAP, Ecole Polytechnique, Route de Saclay, 91128 Palaiseau France
| | | | | | - Joanna M. Wardlaw
- BRIC, Edinburgh University, Department of Clinical Neurosciences, UK
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Affiliation(s)
- Mark W Parsons
- Department of Neurology, John Hunter Hospital/Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW 2305, Australia.
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Kim SJ, Ha YS, Ryoo S, Noh HJ, Ha SY, Bang OY, Kim GM, Chung CS, Lee KH. Sulcal effacement on fluid attenuation inversion recovery magnetic resonance imaging in hyperacute stroke: association with collateral flow and clinical outcomes. Stroke 2011; 43:386-92. [PMID: 22096035 DOI: 10.1161/strokeaha.111.638106] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The clinical significance of sulcal effacement has been widely investigated in CT studies, but the results are controversial. In this study, we evaluated the presence of perisylvian sulcal effacement (PSE) on fluid attenuation inversion recovery MRI and hypothesized that PSE may be related to collateral flow status together with hyperintense vessels on fluid attenuation inversion recovery in hyperacute stroke. In addition, we investigated whether an association between PSE and clinical outcome could be found in these patients. METHODS Consecutive patients with acute middle cerebral artery infarcts within 6 hours of symptom onset were included. All patients had internal carotid artery or middle cerebral artery occlusion and underwent MRI including FLAIR. The presence of PSE and hyperintense vessels on fluid attenuation inversion recovery and the collateral status and occurrence of early recanalization (ER) on conventional angiography were evaluated. RESULTS Of 139 patients, 79 (56.8%) had PSE. Multivariate testing revealed PSE was independently associated with collateral status. The association between hyperintense vessels and collaterals was different depending on PSE. Compared to PSE-positive and ER-negative patients, PSE-negative and ER-negative patients (odds ratio, 4.11; 95% confidence interval, 1.12-15.17) and PSE-negative and ER-positive patients (odds ratio, 34.62; 95% confidence interval, 5.75-208.60), but not PSE-positive and ER-positive patients, were more likely to experience favorable clinical outcomes (modified Rankin Scale score ≤ 2 at 3 months). CONCLUSIONS PSE is independently associated with collateral status in patients with acute middle cerebral artery stroke. Moreover, PSE in conjunction with recanalization status can predict clinical outcomes in these patients.
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Affiliation(s)
- Suk Jae Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Agarwal S, Jones P, Alawneh J, Antoun N, Barry P, Carrera E, Cotter P, O’Brien E, Salih I, Scoffings D, Baron JC, Warburton E. Does Perfusion Computed Tomography Facilitate Clinical Decision Making for Thrombolysis in Unselected Acute Patients with Suspected Ischaemic Stroke? Cerebrovasc Dis 2011; 32:227-33. [DOI: 10.1159/000329310] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 04/29/2011] [Indexed: 11/19/2022] Open
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Sun Z, Zhang X, Zhang Y, Guo H, Zhang J, Yu C. Estimation of the ischemic penumbra based on CT perfusion a pilot study. Acad Radiol 2010; 17:1535-42. [PMID: 20947391 DOI: 10.1016/j.acra.2010.08.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 07/05/2010] [Accepted: 08/03/2010] [Indexed: 10/18/2022]
Abstract
RATIONALE AND OBJECTIVES Ischemic penumbra (IP), the target of thrombolytic therapies, could be estimated by the mismatch region between magnetic resonance imaging (MRI) diffusion- and perfusion-defined abnormalities; however, the accuracy of this method has been challenged recently. In this study, we try to establish a method for calculating IP size based on computed tomography perfusion (CTP) and to observe the early evolution of IP in detail. MATERIALS AND METHODS The middle cerebral artery occlusion (MCAO) model in monkey was used to compare the accuracy in estimating the IP between CTP and MRI methods. A receiver operating characteristic (ROC) curve was performed to calculate the IP threshold of the different CTP parameters, and then the best parameter was obtained. The dynamic evolutions of estimated size of IP by these two methods were compared. RESULTS Among the three CTP parameters, relative cerebral blood flow (rCBF) had the highest sensitivity (83.3%) and specificity (98.5%) in estimating the IP. The optimal cutoff threshold of rCBF was 0.203. During the first 15 hours of the MCAO model, the estimated size of IP by the rCBF was larger than that of the MRI method; however, this relationship was reversed 15 hours later. CONCLUSION This study suggests that the rCBF method is more accurate in estimating the IP since previous studies have reported that the MRI method underestimated the exact IP in the early stage of ischemia and overestimated the exact IP in the later stages. Further experimental and clinical studies are needed to validate the conclusion.
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Furtado AD, Lau BC, Vittinghoff E, Dillon WP, Smith WS, Rigby T, Boussel L, Wintermark M. Optimal brain perfusion CT coverage in patients with acute middle cerebral artery stroke. AJNR Am J Neuroradiol 2009; 31:691-5. [PMID: 19942712 DOI: 10.3174/ajnr.a1880] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE PCT has emerged as an alternative to MR imaging for the assessment of patients with suspected acute stroke. However, 1 disadvantage of PCT is its limited anatomic coverage, which may impact the characterization of hemispheric ischemic strokes. The purpose of this study was to determine the optimal brain CT coverage required to accurately estimate the size of the infarct core relative to the MCA territory and the infarct-penumbra mismatch, by using a criterion standard of these parameters measured on PCT with 80-mm z-axis coverage. MATERIALS AND METHODS Fifty-one patients with acute ischemic hemispheric stroke underwent PCT scanning (2 boluses, total coverage of 80 mm, 16 x 5 mm sections) within the first 24 hours of symptom onset and a follow-up NCCT of the brain between 3 days and 3 months after the initial stroke CT study. The volumes of PCT infarct and penumbra for each possible extent of z-axis coverage derived from the individual PCT sections were recorded (beginning with 5 mm of z-axis coverage above the orbits and then increasing the coverage in 5-mm increments in the z-axis up to 80 mm above the orbits). The infarct-penumbra mismatch and the size of the infarction relative to the MCA territory were calculated for each extent of z-axis coverage. Using the 80-mm z-axis coverage as the criterion standard, we calculated the accuracy of the values of the relative PCT infarct size and mismatch that were obtained by using more limited z-axis coverage. The impact of different levels of PCT z-axis coverage on the eligibility for reperfusion treatment was assessed. RESULTS On the admission PCT, by using 80-mm of z-axis coverage, the mean perfusion infarct core volume was 45.9 +/- 44.0 cm(3) (range, 0-170 cm(3)) and the mean penumbra volume was 64.5 +/- 64.4 cm(3) (range, 0-226 cm(3)). The mean perfusion infarct core/MCA territory ratio was 19.6% +/- 16.2% (range, 0.1%-56%). The penumbra / (infarct + penumbra) ratio was 68.6% +/- 23.6% (range, 16.4%-100%). The final infarct volume on follow-up NCCT was 115.4 +/- 157.3 cm(3) (range, 1.79-647.4 cm(3)). The minimal z-axis PCT coverage required to obtain values similar to those obtained with 80-mm z-axis coverage was 75 mm for a mismatch of 0.5, fifty millimeters for a mismatch of 0.2, and 55 mm for a size of PCT infarct relative to the MCA territory. CONCLUSIONS Seventy-five millimeters is the minimal PCT coverage required to use PCT as a tool to select patients with acute stroke for reperfusion therapy by using a mismatch of 0.5. A z-axis coverage of 50 mm was sufficient for a mismatch of 0.2; and 55 mm, for the size of PCT infarct relative to MCA territory (one-third or more).
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Affiliation(s)
- A D Furtado
- Department of Radiology, University of California, San Francisco, 94143-0628, USA
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Puetz V, Dzialowski I, Hill MD, Demchuk AM. The Alberta Stroke Program Early CT Score in Clinical Practice: What have We Learned? Int J Stroke 2009; 4:354-64. [PMID: 19765124 DOI: 10.1111/j.1747-4949.2009.00337.x] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The introduction of brain imaging with computed tomography revolutionised the treatment of patients with acute ischaemic stroke. With the visual differentiation of haemorrhagic stroke from ischaemic stroke, thrombolytic therapy became feasible. The Alberta Stroke Program Early CT Score was devised to quantify the extent of early ischaemic changes in the middle cerebral artery territory on noncontrast computed tomography. With its systematic approach, the score is simple and reliable. However, the assessment of early ischaemic changes and Alberta Stroke Program Early CT scoring require training. The Alberta Stroke Program Early CT Score is a strong predictor of functional outcome. Furthermore, the effectiveness of intraarterial thrombolysis in patients with middle cerebral artery occlusion shows effect modification by the Alberta Stroke Program Early CT Score. This review summarises the Alberta Stroke Program Early CT Score methodology. We illustrate current knowledge regarding Alberta Stroke Program Early CT Score applied to clinical trials and comment on how Alberta Stroke Program Early CT Score may facilitate clinical treatment decision making and future trial design. Moreover, we introduce a modification of the Alberta Stroke Program Early CT Score methodology that disregards isolated cortical swelling, i.e. focal brain swelling without associated parenchymal hypoattenuation, as early ischaemic changes in the Alberta Stroke Program Early CT Score system.
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Affiliation(s)
- V. Puetz
- Department of Neurology, Dresden University Stroke Centre, University of Technology Dresden, Dresden, Germany
- Department of Clinical Neurosciences, Calgary Stroke Program, University of Calgary, Calgary, AB, Canada
| | - I. Dzialowski
- Department of Neurology, Dresden University Stroke Centre, University of Technology Dresden, Dresden, Germany
- Department of Clinical Neurosciences, Calgary Stroke Program, University of Calgary, Calgary, AB, Canada
| | - M. D. Hill
- Department of Clinical Neurosciences, Calgary Stroke Program, University of Calgary, Calgary, AB, Canada
| | - A. M. Demchuk
- Department of Clinical Neurosciences, Calgary Stroke Program, University of Calgary, Calgary, AB, Canada
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Imaging in Acute Stroke – a Personal View*. Clin Neuroradiol 2009; 19:20-30. [DOI: 10.1007/s00062-009-8030-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2008] [Accepted: 10/26/2008] [Indexed: 11/27/2022]
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Sherlock Holmes in the ER (the case of red and the head). Surv Ophthalmol 2009; 54:128-34. [PMID: 19171214 DOI: 10.1016/j.survophthal.2008.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
A 58-year-old woman presented with a problem with her peripheral vision. Computed tomography scan showed an occipital hemorrhagic stroke. She subsequently suffered gastrointestinal bleeding and at surgery biopsy of a portion of the middle colic artery aneurysm revealed changes consistent with polyarteritis nodosa.
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Ebinger M, De Silva DA, Christensen S, Parsons MW, Markus R, Donnan GA, Davis SM. Imaging the penumbra - strategies to detect tissue at risk after ischemic stroke. J Clin Neurosci 2008; 16:178-87. [PMID: 19097909 DOI: 10.1016/j.jocn.2008.04.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2007] [Revised: 03/05/2008] [Accepted: 04/06/2008] [Indexed: 10/21/2022]
Abstract
The aim of thrombolytic therapy after acute ischemic stroke is salvage of the ischemic penumbra. Several imaging techniques have been used to identify the penumbra in patients who may benefit from reperfusion beyond the currently narrow 3-hour time-window for thrombolysis. We discuss the advantages and disadvantages of positron emission tomography (PET), single photon emission computed tomography (SPECT), MRI and CT scans. We comment on concepts of clinical-imaging mismatch models and we explore the implications for clinical trials.
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Affiliation(s)
- M Ebinger
- Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria 3050, Australia
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Knoepfli AS, Sekoranja L, Bonvin C, Delavelle J, Kulcsar Z, Rüfenacht D, Yilmaz H, Sztajzel R, Altrichter S, Lövblad KO. Evaluation of perfusion CT and TIBI grade in acute stroke for predicting thrombolysis benefit and clinical outcome. J Neuroradiol 2008; 36:131-7. [PMID: 19062093 DOI: 10.1016/j.neurad.2008.10.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the prognostic accuracy of combining perfusion CT (PCT) and thrombolysis in brain ischemia (TIBI) ultrasonographic grade in the triage of stroke patients who will benefit from thrombolysis and in predicting the clinical outcome. METHODS We conducted a prospective study of all consecutive stroke patients admitted to our hospital from March 2003 to July 2007, presenting with signs of acute stroke within the therapeutic window, who had undergone either intravenous or combined intravenous and intra-arterial thrombolysis. All patients were evaluated by a complete stroke CT protocol, transcranial color-coded duplex sonographic monitoring, follow-up imaging (CT or MRI) and clinical outcome at 3 months, as assessed by the modified Rankin scale (mRS). RESULTS A total of 34 patients were included with a mean NIHSS on admission of 14.2. This study revealed that PCT had 95% sensitivity and 71% specificity in the evaluation of therapy benefit as well as 75% sensitivity and 39% specificity in predicting clinical outcome. The extent of ischemic tissue according to PCT and TIBI grade were significantly correlated (p<0.05). Using the MTT-TTP approach was an alternative to the classical MTT-CBV approach for determining tissue at risk. The clinical outcome assessed by the mRS was considered favorable (mRS 0-2) in 16 patients and unfavorable (mRS>2) in 18 patients. CONCLUSION PCT was the most accurate predictor of both thrombolytic therapy benefit and clinical outcome. The TIBI score was useful for determining whether or not to perform intravenous therapy alone or as a combined therapy.
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Affiliation(s)
- A-S Knoepfli
- Radiology Department, Geneva University Hospital, Switzerland
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