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Zheng C, Li R, Shen C, Hu Z, Qiu Z, Yang Q, Guo F. Leukoaraiosis in patients with tirofiban before endovascular thrombectomy: A post hoc analysis of a multicentre randomized clinical trial. J Formos Med Assoc 2024:S0929-6646(24)00391-7. [PMID: 39174395 DOI: 10.1016/j.jfma.2024.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 08/14/2024] [Accepted: 08/18/2024] [Indexed: 08/24/2024] Open
Abstract
BACKGROUND AND PURPOSE To evaluate the effectiveness and safety of intravenous tirofiban before endovascular thrombectomy in subgroups of acute ischemic stroke patients with different degrees of leukoaraiosis (LA). METHODS Patients of the RESCUE BT trial whose LA grade could be assessed were included. Eligible patients were dichotomized into two strata according to the van Swieten scale (VSS) score, absent-to-moderate LA (VSS score <3) and severe LA (VSS score ≥3). Furthermore, patients were divided into tirofiban and placebo groups in each stratum. The primary outcome was the 90-day modified Rankin Scale (mRS) score. Safety outcome was radiological intracranial hemorrhage within 48 h. RESULTS 861 patients were included, 439 patients with absent-to-moderate LA and 422 patients with severe LA. There were no significant differences in 90-day mRS score between the tirofiban and placebo groups in either stratum (absent-to-moderate LA: adjusted OR 0.92 (95%CI, 0.66-1.28), P = 0.62; severe LA: adjusted OR 0.99 (95% CI, 0.69-1.42), P = 0.96). In the severe LA stratum, the occurrence of radiologic intracranial hemorrhage was greater in the tirofiban group compared to the placebo group. (35.7% vs 26.4%; adjusted OR, 1.72 (95% CI, 1.12-2.66); P = 0.014). However, no difference was observed in the absent-to-moderate LA stratum (33.2% vs 29.3%; adjusted OR, 1.15 (95% CI, 0.76-1.75); P = 0.51). CONCLUSION There was no significant difference in disability severity at 90 days when treating AIS patients using intravenous tirofiban before endovascular therapy, in either absent-to-moderate or severe LA strata. It should be noted that intravenous tirofiban before endovascular therapy increases the incidence of radiologic intracranial hemorrhage in patients with severe LA.
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Affiliation(s)
- Chong Zheng
- Neurology Department, Longyan First Affiliated Hospital of Fujian Medical University, No. 105, Jiuyi North Road, Longyan 364000, China.
| | - Rongtong Li
- Neurology Department, Longyan First Affiliated Hospital of Fujian Medical University, No. 105, Jiuyi North Road, Longyan 364000, China
| | - Chaoxiong Shen
- Neurology Department, Longyan First Affiliated Hospital of Fujian Medical University, No. 105, Jiuyi North Road, Longyan 364000, China
| | - Zhizhou Hu
- Neurology Department, Longyan First Affiliated Hospital of Fujian Medical University, No. 105, Jiuyi North Road, Longyan 364000, China
| | - Zhongming Qiu
- Neurology Department, Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University) 183 Xinqiao Main Street, Shapingba District, Chongqing 400037, China
| | - Qingwu Yang
- Neurology Department, Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University) 183 Xinqiao Main Street, Shapingba District, Chongqing 400037, China
| | - Fang Guo
- Neurology Department, Longyan First Affiliated Hospital of Fujian Medical University, No. 105, Jiuyi North Road, Longyan 364000, China
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Arba F, Ferretti S, Leigh R, Fara A, Warach SJ, Luby M, Lees KR, Dawson J. Cerebral Small Vessel Disease and Infarct Growth in Acute Ischemic Stroke Treated with Intravenous Thrombolysis. Transl Stroke Res 2024:10.1007/s12975-024-01277-2. [PMID: 38963535 DOI: 10.1007/s12975-024-01277-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 06/03/2024] [Accepted: 06/29/2024] [Indexed: 07/05/2024]
Abstract
We investigated relations between cerebral small vessel disease (cSVD) markers and evolution of the ischemic tissue from ischemic core to final infarct in people with acute ischemic stroke treated with intravenous thrombolysis. Data from the Stroke Imaging Repository (STIR) and Virtual International Stroke Trials Archive (VISTA) were used. Any pre-existing lacunar infarcts and white matter hyperintensities (WMH) were assessed on magnetic resonance (MR) before thrombolytic therapy. Acute ischemic core and final infarct volume were then assessed by two independent radiologists. The relationship among baseline markers of cSVD, acute ischemic core volume, final infarct volume, infarct growth (IG = final infarct - ischemic core), and infarct growth ratio (IGR = final infarct/ischemic core) was then assessed using linear and ordinal regression adjusted for age, sex, onset-to-treatment time, and stroke severity. We included 165 patients, mean (± SD) age 69.5 (± 15.7) years, 74 (45%) males, mean (± SD) ischemic core volume 25.48 (± 42.22) ml, final infarct volume 52.06 (± 72.88) ml, IG 26.58 (± 51.02) ml, IGR 8.23 (± 38.12). Seventy (42%) patients had large vessel occlusion, 20 (12%) acute small subcortical infarct. WMHs were present in 131 (79%) and lacunar infarcts in 61 (37%) patients. Final infarct volumes were 53.8 ml and 45.2 ml (WMHs/no WMHs), p = 0.139, and 24.6 ml and 25.9 ml (lacunar infarcts/no lacunar infarcts), p = 0.842. In linear and ordinal regression analyses, presence of lacunar infarcts was associated with smaller IG (β = - 0.17; p = 0.024; cOR = 0.52; 95%CI = 0.28-0.96, respectively) and WMHs were associated with smaller IGR (β = - 0.30; p = 0.004; cOR = 0.27; 95%CI = 0.11-0.69, respectively). In people with acute ischemic stroke treated with intravenous thrombolysis, cSVD features were associated with smaller growth of the acute ischemic area, suggesting less salvageable tissue at time of reperfusion therapy.
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Affiliation(s)
- Francesco Arba
- Stroke Unit, Careggi University Hospital, Florence, Italy.
| | - Simone Ferretti
- NEUROFARBA Department, University of Florence, Careggi University Hospital, Florence, Italy
| | - Richard Leigh
- National Institute of Neurological Diseases and Stroke (NINDS), National Institutes of Health, Bethesda, MD, USA
| | - Andreia Fara
- National Institute of Neurological Diseases and Stroke (NINDS), National Institutes of Health, Bethesda, MD, USA
| | - Steven J Warach
- Department of Neurology, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Marie Luby
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Kennedy R Lees
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Zhu H, Liang W, Zhu J, He X, Zou P, Yang K, Li G, Liao B, Deng H, Liang Z, Zhao J, Zhao Z, Chen J, He Q, Ning W. Nomogram to predict ventilator-associated pneumonia in large vessel occlusion stroke after endovascular treatment: a retrospective study. Front Neurol 2024; 15:1351458. [PMID: 38803642 PMCID: PMC11129686 DOI: 10.3389/fneur.2024.1351458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/26/2024] [Indexed: 05/29/2024] Open
Abstract
Background Ventilator-Associated Pneumonia (VAP) severely impacts stroke patients' prognosis after endovascular treatment. Hence, this study created a nomogram to predict the occurrence of VAP after endovascular treatment. Methods The individuals with acute ischemic stroke and large vessel occlusion (AIS-LVO) who received mechanical ventilation and endovascular therapy between July 2020 and August 2023 were included in this retrospective study. The predictive model and nomogram were generated by performing feature selection optimization using the LASSO regression model and multifactor logistic regression analysis and assessed the evaluation, verification and clinical application. Results A total of 184 individuals (average age 61.85 ± 13.25 years, 73.37% male) were enrolled, and the rate of VAP occurrence was found to be 57.07%. Factors such as the Glasgow Coma Scale (GCS) score, duration of stay in the Intensive Care Unit (ICU), dysphagia, Fazekas scale 2 and admission diastolic blood pressure were found to be associated with the occurrence of VAP in the nomogram that demonstrating a strong discriminatory power with AUC of 0.862 (95% CI, 0.810-0.914), and a favorable clinical net benefit. Conclusion This nomogram, comprising GCS score, ICU duration, dysphagia, Fazekas scale 2 and admission diastolic blood pressure, can aid clinicians in predicting the identification of high-risk patients for VAP following endovascular treatment in large vessel occlusion stroke.
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Affiliation(s)
- Huishan Zhu
- Department of Neurology, Dongguan Hospital of Guangzhou University of Chinese Medicine, Dongguan, China
| | - Wenfei Liang
- Department of Neurology, Dongguan Hospital of Guangzhou University of Chinese Medicine, Dongguan, China
| | - Jingling Zhu
- Department of Neurology, Dongguan Hospital of Guangzhou University of Chinese Medicine, Dongguan, China
| | - Xiaohua He
- Department of Neurology, Dongguan Hospital of Guangzhou University of Chinese Medicine, Dongguan, China
| | - Pengjuan Zou
- Department of Neurology, Dongguan Hospital of Guangzhou University of Chinese Medicine, Dongguan, China
| | - Kangqiang Yang
- Department of Neurology, Dongguan Hospital of Guangzhou University of Chinese Medicine, Dongguan, China
| | - Guoshun Li
- Department of Neurology, Dongguan Hospital of Guangzhou University of Chinese Medicine, Dongguan, China
| | - Bin Liao
- Department of Neurology, Dongguan Hospital of Guangzhou University of Chinese Medicine, Dongguan, China
| | - Huiquan Deng
- Department of Neurology, Dongguan Hospital of Guangzhou University of Chinese Medicine, Dongguan, China
| | - Zichong Liang
- Department of Neurology, Dongguan Hospital of Guangzhou University of Chinese Medicine, Dongguan, China
| | - Jiasheng Zhao
- Department of Neurology, Dongguan Hospital of Guangzhou University of Chinese Medicine, Dongguan, China
| | - Zhan Zhao
- Department of Neurology, Dongguan Hospital of Guangzhou University of Chinese Medicine, Dongguan, China
| | - Jingyi Chen
- Department of Neurology, Dongguan Hospital of Guangzhou University of Chinese Medicine, Dongguan, China
| | - Qiuxing He
- Department of Neurology, Dongguan Hospital of Guangzhou University of Chinese Medicine, Dongguan, China
- School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, Guangdong, China
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Weimin Ning
- Department of Neurology, Dongguan Hospital of Guangzhou University of Chinese Medicine, Dongguan, China
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Clancy U, Kancheva AK, Valdés Hernández MDC, Jochems ACC, Muñoz Maniega S, Quinn TJ, Wardlaw JM. Imaging Biomarkers of VCI: A Focused Update. Stroke 2024; 55:791-800. [PMID: 38445496 DOI: 10.1161/strokeaha.123.044171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
Vascular cognitive impairment is common after stroke, in memory clinics, medicine for the elderly services, and undiagnosed in the community. Vascular disease is said to be the second most common cause of dementia after Alzheimer disease, yet vascular dysfunction is now known to predate cognitive decline in Alzheimer disease, and most dementias at older ages are mixed. Neuroimaging has a major role in identifying the proportion of vascular versus other likely pathologies in patients with cognitive impairment. Here, we aim to provide a pragmatic but evidence-based summary of the current state of potential imaging biomarkers, focusing on magnetic resonance imaging and computed tomography, which are relevant to diagnosing, estimating prognosis, monitoring vascular cognitive impairment, and incorporating our own experiences. We focus on markers that are well-established, with a known profile of association with cognitive measures, but also consider more recently described, including quantitative tissue markers of vascular injury. We highlight the gaps in accessibility and translation to more routine clinical practice.
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Affiliation(s)
- Una Clancy
- Centre for Clinical Brain Sciences and UK Dementia Research Institute, The University of Edinburgh, United Kingdom (U.C., M.d.C.V.H. A.C.C.J., S.M.M., J.M.W.)
| | - Angelina K Kancheva
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom (A.K.K., T.J.Q.)
| | - Maria Del C Valdés Hernández
- Centre for Clinical Brain Sciences and UK Dementia Research Institute, The University of Edinburgh, United Kingdom (U.C., M.d.C.V.H. A.C.C.J., S.M.M., J.M.W.)
| | - Angela C C Jochems
- Centre for Clinical Brain Sciences and UK Dementia Research Institute, The University of Edinburgh, United Kingdom (U.C., M.d.C.V.H. A.C.C.J., S.M.M., J.M.W.)
| | - Susana Muñoz Maniega
- Centre for Clinical Brain Sciences and UK Dementia Research Institute, The University of Edinburgh, United Kingdom (U.C., M.d.C.V.H. A.C.C.J., S.M.M., J.M.W.)
| | - Terence J Quinn
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom (A.K.K., T.J.Q.)
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences and UK Dementia Research Institute, The University of Edinburgh, United Kingdom (U.C., M.d.C.V.H. A.C.C.J., S.M.M., J.M.W.)
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Cougo P, Colares H, Farinhas JG, Hämmerle M, Neves P, Bezerra R, Balduino A, Wu O, Pontes-Neto OM. Subtle white matter intensity changes on fluid-attenuated inversion recovery imaging in patients with ischaemic stroke. Brain Commun 2024; 6:fcae089. [PMID: 38529359 PMCID: PMC10963121 DOI: 10.1093/braincomms/fcae089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 01/12/2024] [Accepted: 03/11/2024] [Indexed: 03/27/2024] Open
Abstract
Leukoaraiosis is a neuroimaging marker of small-vessel disease that is characterized by high signal intensity on fluid-attenuated inversion recovery MRI. There is increasing evidence from pathology and neuroimaging suggesting that the structural abnormalities that characterize leukoaraiosis are actually present within regions of normal-appearing white matter, and that the underlying pathophysiology of white matter damage related to small-vessel disease involves blood-brain barrier damage. In this study, we aim to verify whether leukoaraiosis is associated with elevated signal intensity on fluid-attenuated inversion recovery imaging, a marker of brain tissue free-water accumulation, in normal-appearing white matter. We performed a cross-sectional study of adult patients admitted to our hospital with a diagnosis of acute ischaemic stroke or transient ischaemic attack. Leukoaraiosis was segmented using a semi-automated method involving manual outlining and signal thresholding. White matter regions were segmented based on the probabilistic tissue maps from the International Consortium for Brain Mapping 152 atlas. Also, normal-appearing white matter was further segmented based on voxel distance from leukoaraiosis borders, resulting in five normal-appearing white matter strata at increasing voxel distances from leukoaraiosis. The relationship between mean normalized fluid-attenuated inversion recovery signal intensity on normal-appearing white matter and leukoaraiosis volume was studied in a multivariable statistical analysis using linear mixed modelling, having normal-appearing white matter strata as a clustering variable. One hundred consecutive patients meeting inclusion and exclusion criteria were selected for analysis (53% female, mean age 68 years). Mean normalized fluid-attenuated inversion recovery signal intensity on normal-appearing white matter was higher in the vicinity of leukoaraiosis and progressively lower at increasing distances from leukoaraiosis. In a multivariable analysis, the mean normalized fluid-attenuated inversion recovery signal intensity on normal-appearing white matter was positively associated with leukoaraiosis volume and age (B = 0.025 for each leukoaraiosis quartile increase; 95% confidence interval 0.019-0.030). This association was found similarly across normal-appearing white matter strata. Voxel maps of the mean normalized fluid-attenuated inversion recovery signal intensity on normal-appearing white matter showed an increase in signal intensity that was not adjacent to leukoaraiosis regions. Our results show that normal-appearing white matter exhibits subtle signal intensity changes on fluid-attenuated inversion recovery imaging that are related to leukoaraiosis burden. These results suggest that diffuse free-water accumulation is likely related to the aetiopathogenic processes underlying the development of white matter damage related to small-vessel disease.
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Affiliation(s)
- Pedro Cougo
- Instituto Americas, Neurology Division, Rio de Janeiro 22775-001, Brazil
- Hospital Samaritano Barra, Department of Neurology, Rio de Janeiro 22775-001, Brazil
| | - Heber Colares
- Hospital Samaritano Barra, Department of Radiology, Rio de Janeiro, 22775-001, Brazil
| | - João Gabriel Farinhas
- Instituto Americas, Neurology Division, Rio de Janeiro 22775-001, Brazil
- Hospital Samaritano Barra, Department of Neurology, Rio de Janeiro 22775-001, Brazil
| | - Mariana Hämmerle
- Hospital Samaritano Barra, Department of Neurology, Rio de Janeiro 22775-001, Brazil
| | - Pedro Neves
- Hospital Samaritano Barra, Department of Radiology, Rio de Janeiro, 22775-001, Brazil
| | - Raquel Bezerra
- Hospital Samaritano Barra, Department of Radiology, Rio de Janeiro, 22775-001, Brazil
| | - Alex Balduino
- Instituto Americas, Neurology Division, Rio de Janeiro 22775-001, Brazil
| | - Ona Wu
- Athinoula A. Martinos Centre for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA 02129, USA
| | - Octavio M Pontes-Neto
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto 14040-900, Brazil
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Sirimarco G, Strambo D, Nannoni S, Labreuche J, Cereda C, Dunet V, Puccinelli F, Saliou G, Meuli R, Eskandari A, Wintermark M, Michel P. Predicting Penumbra Salvage and Infarct Growth in Acute Ischemic Stroke: A Multifactor Survival Game. J Clin Med 2023; 12:4561. [PMID: 37510676 PMCID: PMC10380847 DOI: 10.3390/jcm12144561] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 06/28/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Effective treatment of acute ischemic stroke requires reperfusion of salvageable tissue. We investigated the predictors of penumbra salvage (PS) and infarct growth (IG) in a large cohort of stroke patients. METHODS In the ASTRAL registry from 2003 to 2016, we selected middle cerebral artery strokes <24 h with a high-quality CT angiography and CT perfusion. PS and IG were correlated in multivariate analyses with clinical, biochemical and radiological variables, and with clinical outcomes. RESULTS Among 4090 patients, 551 were included in the study, 50.8% male, mean age (±SD) 66.3 ± 14.7 years, mean admission NIHSS (±SD 13.3 ± 7.1) and median onset-to-imaging-time (IQR) 170 (102 to 385) minutes. Increased PS was associated with the following: higher BMI and lower WBC; neglect; larger penumbra; absence of early ischemic changes, leukoaraiosis and other territory involvement; and higher clot burden score. Reduced IG was associated with the following: non-smokers; lower glycemia; larger infarct core; absence of early ischemic changes, chronic vascular brain lesions, other territory involvement, extracranial arterial pathology and hyperdense middle cerebral artery sign; and higher clot burden score. When adding subacute variables, recanalization was associated with increased PS and reduced IG, and the absence of haemorrhage with reduced IG. Collateral status was not significantly associated with IG nor with PS. Increased PS and reduced IG correlated with better 3- and 12-month outcomes. CONCLUSION In our comprehensive analysis, multiple factors were found to be responsible for PS or IG, the strongest being radiological features. These findings may help to better select patients, particularly for more aggressive or late acute stroke treatment.
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Affiliation(s)
- Gaia Sirimarco
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
- Neurology Unit, Department of Internal Medicine, Riviera Chablais Hospital, 1847 Rennaz, Switzerland
| | - Davide Strambo
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Stefania Nannoni
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Julien Labreuche
- Statistical Unit, Regional House of Clinical Research, University of Lille, CHU Lille, EA 2694-Santé Publique: Épidémiologie et Qualité des Soins, 59000 Lille, France
| | - Carlo Cereda
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
- Stroke Center, Neurology Service, Ospedale Civico di Lugano, 6900 Lugano, Switzerland
| | - Vincent Dunet
- Diagnostic and Interventional Radiology Service, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Francesco Puccinelli
- Diagnostic and Interventional Radiology Service, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Guillaume Saliou
- Diagnostic and Interventional Radiology Service, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Reto Meuli
- Diagnostic and Interventional Radiology Service, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Ashraf Eskandari
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Max Wintermark
- Diagnostic and Interventional Radiology Service, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
- Department of Diagnostic and Interventional Radiology, Neuroradiology Division, Stanford University and Medical Center, Stanford, CA 94305, USA
| | - Patrik Michel
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
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Wang D, Yan D, Yan M, Li R, Jiang H, Wang J, Yang H. Leukoaraiosis severity is related to increased risk of early neurological deterioration in acute ischemic stroke: a retrospective observational study. Acta Neurol Belg 2023:10.1007/s13760-023-02249-3. [PMID: 37014516 DOI: 10.1007/s13760-023-02249-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 03/22/2023] [Indexed: 04/05/2023]
Abstract
OBJECTIVES The relationship between leukoaraiosis and early neurological deterioration in acute cerebral infarction patients remains controversial. We tried to determine whether an association existed between leukoaraiosis and early neurological deterioration in patients with acute ischemic stroke. MATERIALS AND METHODS We retrospectively enrolled acute cerebral infarction patients admitted to our our department within 4.5-72.0 h of symptom onset between January 2016 and March 2022. On the basis of the van Swieten scale, leukoaraiosis was evaluated as supratentorial white matter hypoattenuation on admission head CT and graded as 0 (absent), 1 (mild), 2 (moderate) and 3-4 (severe). Early neurological deterioration was defined as an increase in the National Institute of Health Stroke Scale score by > = 2 points in the total score, or > = 1 point in motor power within the first seven days after admission. RESULTS Among 736 patients, 522 (70.9%) patients had leukoaraiosis, and of these, 332 (63.6%) had mild leukoaraiosis, 41 (7.9%) had moderate leukoaraiosis, and 149 (28.5%) had severe leukoaraiosis. 118 (16.0%) patients experienced early neurological deterioration: 20 of the 214 (9.5%) patients without leukoaraiosis and 98 of the 522 (18.8%) patients with leukoaraiosis. In multiple regression analysis, we found van Swieten scale predicted early neurological deterioration independently (OR = 1.570; 95% CI: 1.226-2.012). CONCLUSIONS Leukoaraiosis is common in acute cerebral infarction patients and leukoaraiosis severity is related to increased risk of early neurological deterioration in the patients.
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Affiliation(s)
- Dan Wang
- Department of Neurology, Hubei NO. 3 People's Hospital of Jianghan University, 26 Zhongshan Road, Qiaokou District, Wuhan, China
| | - Dan Yan
- Department of Neurology, Hubei NO. 3 People's Hospital of Jianghan University, 26 Zhongshan Road, Qiaokou District, Wuhan, China
| | - Mingmin Yan
- Department of Neurology, Hubei NO. 3 People's Hospital of Jianghan University, 26 Zhongshan Road, Qiaokou District, Wuhan, China
| | - Ruifang Li
- Department of Neurology, Hubei NO. 3 People's Hospital of Jianghan University, 26 Zhongshan Road, Qiaokou District, Wuhan, China
| | - Haiwei Jiang
- Department of Neurology, Hubei NO. 3 People's Hospital of Jianghan University, 26 Zhongshan Road, Qiaokou District, Wuhan, China
| | - Juan Wang
- Department of Radiology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Hao Yang
- Department of Neurology, Hubei NO. 3 People's Hospital of Jianghan University, 26 Zhongshan Road, Qiaokou District, Wuhan, China.
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Elucidating the Role of Baseline Leukoaraiosis on Forecasting Clinical Outcome of Acute Ischemic Stroke Patients Undergoing Reperfusion Therapy. Neurol Int 2022; 14:923-942. [PMID: 36412696 PMCID: PMC9680372 DOI: 10.3390/neurolint14040074] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/06/2022] [Accepted: 11/08/2022] [Indexed: 11/12/2022] Open
Abstract
Stroke stands as a major cause of death and disability with increasing prevalence. The absence of clinical improvement after either intravenous thrombolysis (IVT) or mechanical thrombectomy (MT) represents a frequent concern in the setting of acute ischemic stroke (AIS). In an attempt to optimize overall stroke management, it is clinically valuable to provide important insight into functional outcomes after reperfusion therapy among patients presenting with AIS. The aim of the present review is to explore the predictive value of leukoaraiosis (LA) in terms of clinical response to revascularization poststroke. A literature research of two databases (MEDLINE and Scopus) was conducted in order to trace all relevant studies published between 1 January 2012 and 1 November 2022 that focused on the potential utility of LA severity regarding reperfusion status and clinical outcome after revascularization. A total of 37 articles have been traced and included in this review. LA burden assessment is indicative of functional outcome post-intervention and may be associated with hemorrhagic events' incidence among stroke individuals. Nevertheless, LA may not solely guide decision-making about treatment strategy poststroke. Overall, the evaluation of LA upon admission seems to have interesting prognostic potential and may substantially enhance individualized stroke care.
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Mechtouff L, Debs N, Frindel C, Bani-Sadr A, Bochaton T, Paccalet A, Crola Da Silva C, Buisson M, Amaz C, Berthezene Y, Eker OF, Bouin M, de Bourguignon C, Mewton N, Ovize M, Bidaux G, Nighoghossian N, Cho TH. Association of Blood Biomarkers of Inflammation With Penumbra Consumption After Mechanical Thrombectomy in Patients With Acute Ischemic Stroke. Neurology 2022; 99:e2063-e2071. [PMID: 36316128 DOI: 10.1212/wnl.0000000000201038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 06/15/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The objective of this study was to assess the relationship between blood biomarkers of inflammation and lesion growth within the penumbra in acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT). METHODS The HIBISCUS-STROKE cohort enrolled patients admitted in the Lyon Stroke Center for an anterior circulation AIS treated with MT after brain MRI assessment. Lesion growth within the penumbra was assessed on day 6 MRI using a voxel-based nonlinear coregistration method and dichotomized into low and high according to the median value. C-reactive protein, interleukin (IL)-6, IL-8, IL-10, monocyte chemoattractant protein-1, soluble tumor necrosis factor receptor I, soluble form suppression of tumorigenicity 2 (sST2), soluble P-selectin, vascular cellular adhesion molecule-1, and matrix metalloproteinase-9 were measured in sera at 4 time points within the first 48 hours. Reperfusion was considered as successful if Thrombolysis in Cerebral Infarction score was 2b/2c/3. A multiple logistic regression model was performed to detect any association between area under the curve (AUC) of these biomarkers within the first 48 hours and a high lesion growth within the penumbra. RESULTS Ninety patients were included. The median lesion growth within the penumbra was 2.3 (0.7-6.2) mL. On multivariable analysis, a high sST2 AUC (OR 3.77, 95% CI 1.36-10.46), a high baseline DWI volume (OR 3.65, 95% CI 1.32-10.12), and a lack of successful reperfusion (OR 0.19, 95% CI 0.04-0.92) were associated with a high lesion growth within the penumbra. When restricting analyses to patients with successful reperfusion (n = 76), a high sST2 AUC (OR 5.03, 95% CI 1.64-15.40), a high baseline DWI volume (OR 3.74, 95% CI 1.22-11.53), and a high penumbra volume (OR 3.25, 95% CI 1.10-9.57) remained associated with a high lesion growth within the penumbra. DISCUSSION High sST2 levels within the first 48 hours are associated with a high lesion growth within the penumbra.
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Affiliation(s)
- Laura Mechtouff
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France.
| | - Noelie Debs
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Carole Frindel
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Alexandre Bani-Sadr
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Thomas Bochaton
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Alexandre Paccalet
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Claire Crola Da Silva
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Marielle Buisson
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Camille Amaz
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Yves Berthezene
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Omer Faruk Eker
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Morgane Bouin
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Charles de Bourguignon
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Nathan Mewton
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Michel Ovize
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Gabriel Bidaux
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Norbert Nighoghossian
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Tae-Hee Cho
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
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10
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Sharif MS, Goldberg EB, Walker A, Hillis AE, Meier EL. The contribution of white matter pathology, hypoperfusion, lesion load, and stroke recurrence to language deficits following acute subcortical left hemisphere stroke. PLoS One 2022; 17:e0275664. [PMID: 36288353 PMCID: PMC9604977 DOI: 10.1371/journal.pone.0275664] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 09/21/2022] [Indexed: 11/05/2022] Open
Abstract
Aphasia, the loss of language ability following damage to the brain, is among the most disabling and common consequences of stroke. Subcortical stroke, occurring in the basal ganglia, thalamus, and/or deep white matter can result in aphasia, often characterized by word fluency, motor speech output, or sentence generation impairments. The link between greater lesion volume and acute aphasia is well documented, but the independent contributions of lesion location, cortical hypoperfusion, prior stroke, and white matter degeneration (leukoaraiosis) remain unclear, particularly in subcortical aphasia. Thus, we aimed to disentangle the contributions of each factor on language impairments in left hemisphere acute subcortical stroke survivors. Eighty patients with acute ischemic left hemisphere subcortical stroke (less than 10 days post-onset) participated. We manually traced acute lesions on diffusion-weighted scans and prior lesions on T2-weighted scans. Leukoaraiosis was rated on T2-weighted scans using the Fazekas et al. (1987) scale. Fluid-attenuated inversion recovery (FLAIR) scans were evaluated for hyperintense vessels in each vascular territory, providing an indirect measure of hypoperfusion in lieu of perfusion-weighted imaging. We found that language performance was negatively correlated with acute/total lesion volumes and greater damage to substructures of the deep white matter and basal ganglia. We conducted a LASSO regression that included all variables for which we found significant univariate relationships to language performance, plus nuisance regressors. Only total lesion volume was a significant predictor of global language impairment severity. Further examination of three participants with severe language impairments suggests that their deficits result from impairment in domain-general, rather than linguistic, processes. Given the variability in language deficits and imaging markers associated with such deficits, it seems likely that subcortical aphasia is a heterogeneous clinical syndrome with distinct causes across individuals.
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Affiliation(s)
- Massoud S. Sharif
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Emily B. Goldberg
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Alexandra Walker
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Argye E. Hillis
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Cognitive Science, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Erin L. Meier
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail:
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Uniken Venema SM, Dankbaar JW, van der Lugt A, Dippel DWJ, van der Worp HB. Cerebral Collateral Circulation in the Era of Reperfusion Therapies for Acute Ischemic Stroke. Stroke 2022; 53:3222-3234. [PMID: 35938420 DOI: 10.1161/strokeaha.121.037869] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Clinical outcomes of patients with acute ischemic stroke depend in part on the extent of their collateral circulation. A good collateral circulation has also been associated with greater benefit of intravenous thrombolysis and endovascular treatment. Treatment decisions for these reperfusion therapies are increasingly guided by a combination of clinical and imaging parameters, particularly in later time windows. Computed tomography and magnetic resonance imaging enable a rapid assessment of both the collateral extent and cerebral perfusion. Yet, the role of the collateral circulation in clinical decision-making is currently limited and may be underappreciated due to the use of rather coarse and rater-dependent grading methods. In this review, we discuss determinants of the collateral circulation in patients with acute ischemic stroke, report on commonly used and emerging neuroimaging techniques for assessing the collateral circulation, and discuss the therapeutic and prognostic implications of the collateral circulation in relation to reperfusion therapies for acute ischemic stroke.
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Affiliation(s)
- Simone M Uniken Venema
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, the Netherlands. (S.M.U.V., H.B.v.d.W.)
| | - Jan Willem Dankbaar
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, the Netherlands. (J.W.D.)
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center Rotterdam, the Netherlands. (A.v.d.L.)
| | - Diederik W J Dippel
- Department of Neurology, Erasmus Medical Center Rotterdam, the Netherlands. (D.W.J.D.)
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, the Netherlands. (S.M.U.V., H.B.v.d.W.)
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Dehondt JD, Holay Q, Brohee S, Mourre H, Hak JF, Osman O, Suissa L, Doche E. Diabetes is an Independent Growth Factor of Ischemic Stroke During Reperfusion Phase Leading to Poor Clinical Outcome. J Stroke Cerebrovasc Dis 2022; 31:106477. [PMID: 35472652 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 03/16/2022] [Accepted: 03/24/2022] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES Despite the success of recanalization by bridging therapy, about half of treated stroke patients remain disabled. While numerous reports propose clinical predictors of stroke clinical outcome in this context, we originally aimed to study pre-therapeutic factors influencing infarct growth (IG) and poor clinical outcome in strokes due to large vessel occlusion (LVO) successfully recanalized. MATERIALS AND METHODS We enrolled 87 consecutive successfully recanalized patients (mTICI: 2b/2c/3) by mechanical thrombectomy (±rt-PA) after stroke due to middle cerebral artery (M1) occlusion within 6 h according to AHA guidelines. IG was defined by subtracting the initial DWI volume to the final 24 h-TDM volume. Statistical associations between poor clinical outcome (mRS≥2), IG and pertinent clinico-radiological variables, were measured using logistic and linear regression models. RESULTS Among 87 enrolled patients (Age(y): 68.4 ± 17.5; NIHSS: 16.0 ± 5.4), 42/87 (48,28%) patients had a mRS ≥ 2 at 3 months. Diabetic history (OR: 3.70 CI95%[1.03;14.29] and initial NIHSS (/1 point: OR: 1.16 CI95%[1.05;1.27]) were independently associated with poor outcome. IG was significantly higher in stroke patients with poor outcome (+7.57 ± 4.52 vs -7.81 ± 1.67; p = 0.0024). Initial volumes were not significantly different (mRS≥2: 16.18 ± 2.67; mRS[0-1]: 14.70 ± 2.30; p = 0.6771). Explanatory variables of IG in linear regression were diabetic history (β: 21.26 CI95%[5.43; 37.09]) and NIHSS (β: 0.83 CI95%[0.02; 1.64]). IG was higher in diabetic stroke patients (23.54 ± 1.43 vs -6.20 ± 9.36; p = 0.0061). CONCLUSIONS We conclude that diabetes leads to continued IG after complete recanalization, conditioning clinical outcome in LVO strokes successfully recanalized by bridging therapy. We suggest that poor tissular reperfusion by diabetic microangiopathy could explain this result.
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Affiliation(s)
- Jean-Daniel Dehondt
- Stroke Unit, University Hospital of Marseille (AP-HM), Marseille, France; Center for Cardiovascular and Nutrition Research (C2VN), Aix Marseille University, Marseille, France
| | | | - Sacha Brohee
- Stroke Unit, University Hospital of Marseille (AP-HM), Marseille, France
| | - Hélène Mourre
- Stroke Unit, University Hospital of Marseille (AP-HM), Marseille, France
| | - Jean-François Hak
- Neuroradiology Department, University Hospital of Marseille (AP-HM), Marseille, France
| | - Ophélie Osman
- Stroke Unit, University Hospital of Marseille (AP-HM), Marseille, France
| | - Laurent Suissa
- Stroke Unit, University Hospital of Marseille (AP-HM), Marseille, France; Center for Cardiovascular and Nutrition Research (C2VN), Aix Marseille University, Marseille, France
| | - Emilie Doche
- Stroke Unit, University Hospital of Marseille (AP-HM), Marseille, France; Center for Cardiovascular and Nutrition Research (C2VN), Aix Marseille University, Marseille, France.
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Schilter M, Epstein A, Vynckier J, Mujanovic A, Belachew NF, Beyeler M, Siepen B, Goeldlin M, Scutelnic A, Seiffge DJ, Jung S, Gralla J, Dobrocky T, Arnold M, Kaesmacher J, Fischer U, Meinel TR. Chronic cerebral infarctions and white matter lesions link to long-term survival after a first ischemic event: A cohort study. J Neuroimaging 2022; 32:1134-1141. [PMID: 35922890 PMCID: PMC9804158 DOI: 10.1111/jon.13033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/15/2022] [Accepted: 07/23/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND PURPOSE To investigate the association of different phenotypes, count, and locations of chronic covert brain infarctions (CBI) with long-term mortality in patients with first-ever manifest acute ischemic stroke (AIS) or transient ischemic attack (TIA). Additionally, to analyze their potential interaction with white matter hyperintensities (WMH) and predictive value in addition to established mortality scores. METHODS Single-center cohort study including consecutive patients with first-ever AIS or TIA with available MRI imaging from January 2015 to December 2017. Blinded raters adjudicated CBI phenotypes and WMH (age-related white matter changes score) according to established definitions. We compared Cox regression models including prespecified established predictors of mortality using Harrell's C and likelihood ratio tests. RESULTS A total of 2236 patients (median [interquartile range] age: 71 [59-80] years, 43% female, National Institutes of Health Stroke Scale: 2 [1-6], median follow-up: 1436 days, 21% death during follow-up) were included. Increasing WMH (per point adjusted Hazard Ratio [aHR] = 1.29 [1.14-1.45]), but not CBI (aHR = 1.21 [0.99-1.49]), were independently associated with mortality. Neither CBI phenotype, count, nor location was associated with mortality and there was no multiplicative interaction between CBI and WMH (p > .1). As compared to patients without CBI or WMH, patients with moderate or severe WMH and additional CBI had the highest hazards of death (aHR = 1.62 [1.23-2.13]). The Cox regression model including CBI and WMH had a small but significant increment in Harrell's C when compared to the model including 14 clinical variables (0.831 vs. 0.827, p < .001). DISCUSSION WMH represent a strong surrogate biomarker of long-term mortality in first-ever manifest AIS or TIA patients. CBI phenotypes, count, and location seem less relevant. Incorporation of CBI and WMH slightly improves predictive capacity of established risk scores.
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Affiliation(s)
- Marina Schilter
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Alessandra Epstein
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Jan Vynckier
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Adnan Mujanovic
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Nebiyat Filate Belachew
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Morin Beyeler
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Bernhard Siepen
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Martina Goeldlin
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - David Julian Seiffge
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Simon Jung
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Tomas Dobrocky
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Urs Fischer
- Department of NeurologyBasel University Hospital, University of BaselBernSwitzerland
| | - Thomas Raphael Meinel
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
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14
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Ryu WS, Schellingerhout D, Hong KS, Jeong SW, Kim BJ, Kim JT, Lee KB, Park TH, Park SS, Park JM, Kang K, Cho YJ, Park HK, Lee BC, Yu KH, Oh MS, Lee SJ, Kim JG, Cha JK, Kim DH, Lee J, Han MK, Park MS, Choi KH, Nahrendorf M, Lee J, Bae HJ, Kim DE. Relation of Pre-Stroke Aspirin Use With Cerebral Infarct Volume and Functional Outcomes. Ann Neurol 2021; 90:763-776. [PMID: 34536234 PMCID: PMC9292882 DOI: 10.1002/ana.26219] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 01/13/2023]
Abstract
Objective We investigated (1) the associations of pre‐stroke aspirin use with thrombus burden, infarct volume, hemorrhagic transformation, early neurological deterioration (END), and functional outcome, and (2) whether stroke subtypes modify these associations in first‐ever ischemic stroke. Methods This multicenter magnetic resonance imaging (MRI)‐based study included 5,700 consecutive patients with acute first‐ever ischemic stroke, who did not undergo intravenous thrombolysis or endovascular thrombectomy, from May 2011 through February 2014. Propensity score‐based augmented inverse probability weighting was performed to estimate adjusted effects of pre‐stroke aspirin use. Results The mean age was 67 years (41% women), and 15.9% (n = 907) were taking aspirin before stroke. Pre‐stroke aspirin use (vs nonuse) was significantly related to a reduced infarct volume (by 30%), particularly in large artery atherosclerosis stroke (by 45%). In cardioembolic stroke, pre‐stroke aspirin use was associated with a ~50% lower incidence of END (adjusted difference = −5.4%, 95% confidence interval [CI] = −8.9 to −1.9). Thus, pre‐stroke aspirin use was associated with ~30% higher likelihood of favorable outcome (3‐month modified Rankin Scale score < 3), particularly in large artery atherosclerosis stroke and cardioembolic stroke (adjusted difference = 7.2%, 95% CI = 1.8 to 12.5 and adjusted difference = 6.4%, 95% CI = 1.7 to 11.1, respectively). Pre‐stroke aspirin use (vs nonuse) was associated with 85% less frequent cerebral thrombus‐related susceptibility vessel sign (SVS) in large artery atherosclerosis stroke (adjusted difference = −1.4%, 95% CI = −2.1 to −0.8, p < 0.001) and was associated with ~40% lower SVS volumes, particularly in cardioembolic stroke (adjusted difference = −0.16 cm3, 95% CI = −0.29 to −0.02, p = 0.03). Moreover, pre‐stroke aspirin use was not significantly associated with hemorrhagic transformation (adjusted difference = −1.1%, p = 0.09). Interpretation Pre‐stroke aspirin use associates with improved functional independence in patients with first‐ever ischemic large arterial stroke by reducing infarct volume and/or END, likely by decreasing thrombus burden, without increased risk of hemorrhagic transformation. ANN NEUROL 2021;90:763–776
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Affiliation(s)
- Wi-Sun Ryu
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, South Korea.,National Priority Research Center for Stroke, Goyang, South Korea
| | - Dawid Schellingerhout
- Departments of Radiology and Cancer Systems Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keun-Sik Hong
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang
| | - Sang-Wuk Jeong
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Hospital, Seoul, South Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, South Korea
| | - Sang-Soon Park
- Department of Neurology, Seoul Medical Center, Seoul, South Korea
| | - Jong-Moo Park
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu, South Korea
| | - Kyusik Kang
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea
| | - Yong-Jin Cho
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang
| | - Hong-Kyun Park
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Mi Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Soo Joo Lee
- Department of Neurology, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea
| | - Jae Guk Kim
- Department of Neurology, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Hospital, Daegu, South Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Man Seok Park
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
| | - Matthias Nahrendorf
- Center for Systems Biology and Department of Radiology, Massachusetts General Hospital Research Institute, Harvard Medical School, Boston, MA
| | - Juneyoung Lee
- Department of Biostatistics, Korea University, Seoul, South Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, South Korea.,National Priority Research Center for Stroke, Goyang, South Korea
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15
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Ingo C, Kurian S, Higgins J, Mahinrad S, Jenkins L, Gorelick P, Lloyd-Jones D, Sorond F. Vascular health and diffusion properties of normal appearing white matter in midlife. Brain Commun 2021; 3:fcab080. [PMID: 34494002 DOI: 10.1093/braincomms/fcab080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2021] [Indexed: 01/20/2023] Open
Abstract
In this study, we perform a region of interest diffusion tensor imaging and advanced diffusion complexity analysis of normal appearing white matter to determine the impact of vascular health on these diffusivity metrics in midlife adults. 77 participants (26 black, 35 female) at year 30 visit in the Coronary Artery Risk Development in Young Adults longitudinal study were scanned with an advanced diffusion-weighted imaging and fluid-attenuated inversion recovery protocol. Fractional anisotropy and non-linear diffusion complexity measures were estimated. Cumulative measures across 30 years (9 study visits) of systolic blood pressure, body mass index, glucose, smoking and cholesterol were calculated as the area under the curve from baseline up to year 30 examination. Partial correlation analyses assessed the association between cumulative vascular health measures and normal appearing white matter diffusion metrics in these participants. Midlife normal appearing white matter diffusion properties were significantly associated (P < 0.05) with cumulative exposure to vascular risk factors from young adulthood over the 30-year time period. Higher cumulative systolic blood pressure exposure was associated with increased complexity and decreased fractional anisotropy. Higher cumulative body mass index exposure was associated with decreased fractional anisotropy. Additionally, in the normal appearing white matter of black participants (P < 0.05), who exhibited a higher cumulative vascular risk exposure, fractional anisotropy was lower and complexity was higher in comparison to normal appearing white matter in white participants. Higher burden of vascular risk factor exposure from young adulthood to midlife is associated with changes in the diffusion properties of normal appearing white matter in midlife. These changes which may reflect axonal disruption, increased inflammation and/or increased glial proliferation, were primarily observed in both anterior and posterior normal appearing white matter regions of the corpus callosum. These results suggest that microstructural changes in normal appearing white matter are sensitive to vascular health during young adulthood and are possibly therapeutic targets in interventions focused on preserving white matter health across life.
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Affiliation(s)
- Carson Ingo
- Department of Neurology, Northwestern University, Chicago, IL, USA.,Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA
| | - Shawn Kurian
- Department of Neurology, Northwestern University, Chicago, IL, USA
| | - James Higgins
- Department of Radiology, Northwestern University, Chicago, IL, USA
| | - Simin Mahinrad
- Department of Neurology, Northwestern University, Chicago, IL, USA
| | - Lisanne Jenkins
- Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago, IL, USA
| | - Philip Gorelick
- Department of Neurology, Northwestern University, Chicago, IL, USA
| | - Donald Lloyd-Jones
- Department of Preventive Medicine, Northwestern University, Chicago, IL, USA
| | - Farzaneh Sorond
- Department of Neurology, Northwestern University, Chicago, IL, USA
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16
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Uniken Venema SM, Postma AA, van den Wijngaard IR, Vos JA, Lingsma HF, Bokkers RPH, Hofmeijer J, Dippel DWJ, Majoie CB, van der Worp HB. White Matter Lesions and Outcomes After Endovascular Treatment for Acute Ischemic Stroke: MR CLEAN Registry Results. Stroke 2021; 52:2849-2857. [PMID: 34078103 PMCID: PMC8378429 DOI: 10.1161/strokeaha.120.033334] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Cerebral white matter lesions (WMLs) have been associated with a greater risk of poor functional outcome after ischemic stroke. We assessed the relations between WML burden and radiological and clinical outcomes in patients treated with endovascular treatment in routine practice. Methods: We analyzed data from the MR CLEAN Registry (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischaemic Stroke in the Netherlands)—a prospective, multicenter, observational cohort study of patients treated with endovascular treatment in the Netherlands. WMLs were graded on baseline noncontrast computed tomography using a visual grading scale. The primary outcome was the score on the modified Rankin Scale at 90 days. Secondary outcomes included early neurological recovery, successful reperfusion (extended Thrombolysis in Cerebral Infarction ≥2b), futile recanalization (modified Rankin Scale score ≥3 despite successful reperfusion), and occurrence of symptomatic intracranial hemorrhage. We used multivariable logistic regression models to assess associations between WML severity and outcomes, taking the absence of WML on noncontrast computed tomography as the reference category. Results: Of 3180 patients included in the MR CLEAN Registry between March 2014 and November 2017, WMLs were graded for 3046 patients and categorized as none (n=1855; 61%), mild (n=608; 20%), or moderate to severe (n=588; 19%). Favorable outcome (modified Rankin Scale score, 0–2) was achieved in 838 patients (49%) without WML, 192 patients (34%) with mild WML, and 130 patients (24%) with moderate-to-severe WML. Increasing WML grades were associated with a shift toward poorer functional outcome in a dose-dependent manner (adjusted common odds ratio, 1.34 [95% CI, 1.13–1.60] for mild WML and 1.67 [95% CI, 1.39–2.01] for moderate-to-severe WML; Ptrend, <0.001). Increasing WML grades were associated with futile recanalization (Ptrend, <0.001) and were inversely associated with early neurological recovery (Ptrend, 0.041) but not with the probability of successful reperfusion or symptomatic intracranial hemorrhage. Conclusions: An increasing burden of WML at baseline is associated with poorer clinical outcomes after endovascular treatment for acute ischemic stroke but not with the probability of successful reperfusion or symptomatic intracranial hemorrhage.
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Affiliation(s)
- Simone M Uniken Venema
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, the Netherlands (S.M.U.V., H.B.v.d.W.)
| | - Alida A Postma
- Department of Radiology, Maastricht University Medical Center Plus, the Netherlands (A.A.P.).,School for Mental Health and Sciences, University of Maastricht, the Netherlands (A.A.P.)
| | - Ido R van den Wijngaard
- Department of Neurology, Haaglanden Medical Center, the Hague, the Netherlands (I.R.v.d.W.).,Department of Neurology, Leiden University Medical Center, the Netherlands (I.R.v.d.W.)
| | - Jan Albert Vos
- Department of Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands (J.A.V.)
| | - Hester F Lingsma
- Department of Public Health (H.F.L.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, the Netherlands (R.P.H.B.)
| | | | - Diederik W J Dippel
- Department of Neurology (D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Charles B Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, the Netherlands (C.B.M.)
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, the Netherlands (S.M.U.V., H.B.v.d.W.)
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17
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Ospel JM, Menon BK, Qiu W, Kashani N, Mayank A, Singh N, Cimflova P, Marko M, Nogueira RG, McTaggart RA, Demchuk AM, Poppe AY, Zerna C, Joshi M, Almekhlafi MA, Haussen D, Cutting S, Coutts SB, Roy D, Rohr A, Iancu D, Tymianski M, Hill MD, Goyal M. A Detailed Analysis of Infarct Patterns and Volumes at 24-hour Noncontrast CT and Diffusion-weighted MRI in Acute Ischemic Stroke Due to Large Vessel Occlusion: Results from the ESCAPE-NA1 Trial. Radiology 2021; 300:152-159. [PMID: 33973838 DOI: 10.1148/radiol.2021203964] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background The effect of infarct pattern on functional outcome in acute ischemic stroke is incompletely understood. Purpose To investigate the association of qualitative and quantitative infarct variables at 24-hour follow-up noncontrast CT and diffusion-weighted MRI with 90-day clinical outcome. Materials and Methods The Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke, or ESCAPE-NA1, randomized controlled trial enrolled patients with large-vessel-occlusion stroke undergoing mechanical thrombectomy from March 1, 2017, to August 12, 2019. In this post hoc analysis of the trial, qualitative infarct variables (predominantly gray [vs gray and white] matter involvement, corticospinal tract involvement, infarct structure [scattered vs territorial]) and total infarct volume were assessed at 24-hour follow-up noncontrast CT or diffusion-weighted MRI. White and gray matter infarct volumes were assessed in patients by using follow-up diffusion-weighted MRI. Infarct variables were compared between patients with and those without good outcome, defined as a modified Rankin Scale score of 0-2 at 90 days. The association of infarct variables with good outcome was determined with use of multivariable logistic regression. Separate regression models were used to report effect size estimates with adjustment for total infarct volume. Results Qualitative infarct variables were assessed in 1026 patients (mean age ± standard deviation, 69 years ± 13; 522 men) and quantitative infarct variables were assessed in a subgroup of 358 of 1026 patients (mean age, 67 years ± 13; 190 women). Patients with gray and white matter involvement (odds ratio [OR] after multivariable adjustment, 0.19; 95% CI: 0.14, 0.25; P < .001), corticospinal tract involvement (OR after multivariable adjustment, 0.06; 95% CI: 0.04, 0.10; P < .001), and territorial infarcts (OR after multivariable adjustment, 0.22; 95% CI: 0.14, 0.32; P < .001) were less likely to achieve good outcome, independent of total infarct volume. Conclusion Infarct confinement to the gray matter, corticospinal tract sparing, and scattered infarct structure at 24-hour noncontrast CT and diffusion-weighted MRI were highly predictive of good 90-day clinical outcome, independent of total infarct volume. Clinical trial registration no. NCT02930018 © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Mossa-Basha in this issue.
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Affiliation(s)
- Johanna M Ospel
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Bijoy K Menon
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Wu Qiu
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Nima Kashani
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Arnuv Mayank
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Nishita Singh
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Petra Cimflova
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Martha Marko
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Raul G Nogueira
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Ryan A McTaggart
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Andrew M Demchuk
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Alexandre Y Poppe
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Charlotte Zerna
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Manish Joshi
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Mohammed A Almekhlafi
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Diogo Haussen
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Shawna Cutting
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Shelagh B Coutts
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Daniel Roy
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Axel Rohr
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Dana Iancu
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Michael Tymianski
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Michael D Hill
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
| | - Mayank Goyal
- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
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- From the Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, 29th St NW, 1079 A, Calgary, AB, Canada T2N 2T9 (J.M.O., B.K.M., W.Q., N.K., A.M., N.S., P.C., M.M., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Radiology, University Hospital of Basel, Basel, Switzerland (J.M.O.); Department of Radiology, University of Calgary, Calgary, Alberta, Canada (B.K.M., N.K., A.M.D., C.Z., M.J., M.A.A., S.B.C., M.D.H., M.G.); Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.); International Clinical Research Center, St Anne's University Hospital Brno, Czech Republic (P.C.); Department of Neurology, Emory University School of Medicine, Atlanta, Ga (R.G.N., D.H.); Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (R.A.M.); Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (A.Y.P., D.R., D.I.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (S.C.); Department of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (A.R.); and NoNo, Toronto, Ontario, Canada (M.T.)
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18
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Hooper D, Nisar T, McCane D, Lee J, Ling KC, Vahidy F, Wong K, Wong S, Chiu D, Gadhia R. Severe Cerebral Small Vessel Disease Burden Is Associated With Poor Outcomes After Endovascular Thrombectomy in Acute Ischemic Stroke With Large Vessel Occlusion. Cureus 2021; 13:e13122. [PMID: 33728139 PMCID: PMC7935286 DOI: 10.7759/cureus.13122] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Despite recent advancements in the treatment of acute ischemic stroke (AIS) with large vessel occlusion (LVO), infarct progression over time and functional outcomes remain variable. This variation in outcomes may be partially attributed to an underlying state of chronic cerebral hypoperfusion and ischemia affecting small cerebral perforating arterioles, venules, and capillaries of the brain; broadly termed cerebral small vessel disease (CSVD). We investigated the association between CSVD burden and the degree of disability following successful recanalization with endovascular thrombectomy (EVT) in patients with AIS presenting with LVO. Methodology We conducted a single center retrospective analysis of all patients presenting with AIS LVO between May 2016 and May 2019. Patients who were premorbidly independent and presented within six hours from the last known well (LKW) with a proximal anterior circulation occlusion confirmed on computed tomography (CT) angiography of the head or neck were treated with EVT. Patients presenting after six hours and up to 24 hours from LKW with a target ischemic core to perfusion mismatch profile on CT or magnetic resonance (MR) perfusion, or a clinical imaging mismatch on MR diffusion-weighted imaging, were also treated. Patients with successful revascularization, defined as a thrombolysis in cerebral infarction score 2b or 3, were included and evaluated for CSVD burden. The presence of CSVD was quantified using the Fazekas scale (0-3). All patients were further evaluated for disability at 90 days using the modified Rankin Scale (mRS, range 0-6). An mRS score of ≤2 was defined as a good functional outcome. Results Of the 190 patients evaluated, absent (Fazekas grade 0), mild (Fazekas grade 1), moderate (Fazekas grade 2), and severe (Fazekas grade 3) CSVD was present in 33 (17.4%), 84 (44.2%), 35 (18.4%), and 38 (20.0%) patients, respectively. Patients with severe CSVD (Fazekas grade 3) were found to be older, had a higher presenting National Institute of Health Stroke Scale (NIHSS), and had greater proportions of preexisting atrial fibrillation and dementia compared to patients with no CSVD (Fazekas grade 0). Using a multivariate ordinal logistic regression model to adjust for age, presenting NIHSS, thrombus location, LKW to groin puncture time, use of tissue plasminogen activator, ischemic infarct volume, development of a symptomatic intracerebral hemorrhage, and treatment with hemicraniectomy, patients with Fazekas grade 3 were significantly more likely to have poor 90-day functional outcomes compared to patients with Fazekas grade 0 (odds ratio 10.25, 95% confidence interval [3.3-31.84]). Conclusions Based on our analytical cohort of AIS LVO patients treated with EVT, we found that patients with severe CSVD burden had worse functional outcomes at 90 days and increased mortality. These results provide evidence that the burden of CSVD may be considered an independent risk factor of poor clinical outcome and a predictor of mortality in patients with AIS presenting with LVO, despite successful radiographic recanalization with EVT.
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Affiliation(s)
| | - Tariq Nisar
- Statistics, Houston Methodist Neurological Institute, Houston, USA
| | - David McCane
- Neurology, Houston Methodist Hospital, Houston, USA
| | - Jason Lee
- Neurology, Houston Methodist Hospital, Houston, USA
| | | | - Farhaan Vahidy
- Statistics, Houston Methodist Neurological Institute, Houston, USA
| | - Kelvin Wong
- T.T. and W.F. Chao Center for BRAIN, Houston Methodist Neurological Institute, Houston, USA
| | - Stephen Wong
- T.T. and W.F. Chao Center for BRAIN, Houston Methodist Neurological Institute, Houston, USA
| | - David Chiu
- Neurology, Houston Methodist Hospital, Houston, USA
| | - Rajan Gadhia
- Neurology, Houston Methodist Hospital, Houston, USA
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19
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Wang F, Hua S, Zhang Y, Yu H, Zhang Z, Zhu J, Liu R, Jiang Z. Association Between Small Vessel Disease Markers, Medial Temporal Lobe Atrophy and Cognitive Impairment After Stroke: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2020; 30:105460. [PMID: 33227579 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105460] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/23/2020] [Accepted: 11/03/2020] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES Two-thirds of stroke survivors suffer from cognitive impairment, and up to one-third of them progress to dementia. However, the underlying pathogenesis is complex and controversial. Recent evidence has found that cerebral small vessel disease (SVD) markers and the Alzheimer's disease (AD) neuroimaging marker medial temporal lobe atrophy (MTLA), alone or in combination, contribute to the pathogenesis of poststroke cognitive impairment (PSCI). In the present systematic review and meta-analysis, we synthesized proof for these neuroimaging risk factors among stroke patients. MATERIALS AND METHODS PUBMED, MEDLINE, EMBASE and the Cochrane Library were searched for studies investigating imaging predictors of cognitive impairment or dementia following stroke. Meta-analysis was conducted to compute the odds ratios (ORs). RESULTS Thirteen studies were enrolled in the present study, and only ten of them, comprising 2713 stroke patients, were eligible for inclusion in the meta-analysis. MTLA was significantly correlated with PSCI (OR = 1.97, 95% CI: 1.48-2.62, I2 = 0.0%). In addition, white matter hyperintensities (WMH), as a neuroimaging marker of SVD, were associated with PSCI (OR = 1.17, 95% CI: 1.12-1.22, I2 = 0.0%). However, the presence of lacunar infarcts and enlarged perivascular spaces (EPVS) were not associated with the risk of PSCI. CONCLUSIONS The findings of the present study suggest that MTLA and WMH were associated with an increased risk of PSCI.
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Affiliation(s)
- Furu Wang
- Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Sunyu Hua
- Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Yue Zhang
- Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Hongchang Yu
- Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | | | - Jiangtao Zhu
- Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Rong Liu
- Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhen Jiang
- Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou, China.
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20
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Ryu WS, Jeong SW, Kim DE. Total small vessel disease burden and functional outcome in patients with ischemic stroke. PLoS One 2020; 15:e0242319. [PMID: 33180837 PMCID: PMC7660472 DOI: 10.1371/journal.pone.0242319] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 10/30/2020] [Indexed: 12/28/2022] Open
Abstract
Background Cerebral small vessel disease (SVD) is comprised of lacunes, cerebral microbleeds (CMBs), white matter hyperintensities (WMHs), and enlarged perivascular space (EPVS). We investigated the cumulative effect of SVD on 3-month functional outcome following ischemic stroke using the total SVD score. Methods The total SVD score of 477 acute ischemic stroke patients with adequate brain MRI was analyzed. We used multivariable ordinal logistic regression analysis to investigate the independent impact of total SVD score on ordinal modified Rankin Scale (mRS) score at 3-month after ischemic stroke. Results Mean age was 66±14 years, and 61% were men. The distribution of the total SVD score from 0 to 4 was 27%, 24%, 26%, 16%, and 7%, respectively. The proportion of mRS scores 2 or greater was 16% and 47% in total SVD score 0 and 4, respectively. Multivariable ordinal logistic regression analysis results showed that compared with the total SVD score of 0, total SVD scores of 2, 3, and 4 were independently associated with higher mRS scores with adjusted odds ratios (95% confidence intervals) of 1.68 (1.02–2.76), 2.24 (1.25–4.00), and 2.00 (1.02–4.29). Lacunes, CMBs, WMHs but not EPVS were associated with mRS scores at 3 months. However, the impact of each SVD marker on stroke outcome was smaller than that of the total SVD score. Conclusion We found an independent association between total SVD scores and functional outcome at 3 months following ischemic stroke. The total SVD score may be useful for stratification of patients who are at a high-risk of unfavorable outcomes.
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Affiliation(s)
- Wi-Sun Ryu
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
- Korean Brain MRI Data Center, Goyang, Republic of Korea
- * E-mail:
| | - Sang-Wuk Jeong
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
- Korean Brain MRI Data Center, Goyang, Republic of Korea
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
- Korean Brain MRI Data Center, Goyang, Republic of Korea
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21
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Koton S, Schneider AL, Windham BG, Mosley TH, Gottesman RF, Coresh J. Microvascular Brain Disease Progression and Risk of Stroke: The ARIC Study. Stroke 2020; 51:3264-3270. [PMID: 32998653 PMCID: PMC7769118 DOI: 10.1161/strokeaha.120.030063] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 08/07/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND PURPOSE Data on the significance of combined white matter hyperintensities (WMH)/lacunar brain infarcts, and their progression over time for the prediction of stroke are scarce. We studied associations between the progression in combined measures of microvascular brain disease and risk of stroke in the ARIC study (Atherosclerosis Risk in Communities). METHODS Prospective analysis of 907 stroke-free ARIC participants who underwent a brain magnetic resonance imaging (MRI) in 1993 to 1995, a second brain MRI in 2004 to 2006, and were subsequently followed for stroke incidence through December 31, 2017 (median [25%-75%] follow-up 12.6 [8.9-13.4] years). A combined measure of microvascular brain disease was defined at each visit and categorized by progression from first to second brain MRI as no progression; mild progression (increase of ≥1 unit in WMH grade or new lacune), and moderate progression (increase of ≥1 unit in WMH grade and new lacune). All definite/probable ischemic or hemorrhagic incident strokes occurring after this second MRI, and through 2017, were included. Associations between microvascular brain disease, progression in the combined measures, and stroke incidence were studied with Cox proportional hazard models, adjusting for age, sex, race, education level, time from first to second MRI, body mass index, smoking, hypertension, diabetes mellitus, and coronary heart disease. RESULTS At the second brain MRI (mean age 72), the distribution of the combined measure was 37% WMH grade <2 and no lacune; 57% WMH grade ≥2 or lacune; and 6% WMH grade ≥2 and lacune. No progression in the combined measures was observed in 38% of participants, 57% showed mild progression and 5% showed moderate progression. Sixty-four incident strokes occurred during the follow-up period. Compared with no change in the combined measure, moderate progression of microvascular brain disease was significantly associated with higher risk of stroke (adjusted hazard ratio, 3.00 [95% CI, 1.30-6.94]). CONCLUSIONS Progression of microvascular brain disease, manifesting as both new lacunes and increase in WMHs grade, is related to substantial increase in long-term risk of stroke.
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Affiliation(s)
- Silvia Koton
- Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, Maryland, USA
| | - Andrea L.C. Schneider
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, Maryland, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - B. Gwen Windham
- Department of Geriatric Medicine, University of Mississippi School of Medicine, Jackson, MI
| | - Thomas H. Mosley
- Memory Impairment and Neurodegenerative Dementia (MIND) Center, University of Mississippi Medical Center, Jackson, MS, USA
| | - Rebecca F. Gottesman
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, Maryland, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, Maryland, USA
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22
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Etherton MR, Fotiadis P, Giese AK, Iglesias JE, Wu O, Rost NS. White Matter Hyperintensity Burden Is Associated With Hippocampal Subfield Volume in Stroke. Front Neurol 2020; 11:588883. [PMID: 33193055 PMCID: PMC7649326 DOI: 10.3389/fneur.2020.588883] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/05/2020] [Indexed: 12/05/2022] Open
Abstract
White matter hyperintensities of presumed vascular origin (WMH) are a prevalent form of cerebral small-vessel disease and an important risk factor for post-stroke cognitive dysfunction. Despite this prevalence, it is not well understood how WMH contributes to post-stroke cognitive dysfunction. Preliminary findings suggest that increasing WMH volume is associated with total hippocampal volume in chronic stroke patients. The hippocampus, however, is a complex structure with distinct subfields that have varying roles in the function of the hippocampal circuitry and unique anatomical projections to different brain regions. For these reasons, an investigation into the relationship between WMH and hippocampal subfield volume may further delineate how WMH predispose to post-stroke cognitive dysfunction. In a prospective study of acute ischemic stroke patients with moderate/severe WMH burden, we assessed the relationship between quantitative WMH burden and hippocampal subfield volumes. Patients underwent a 3T MRI brain within 2–5 days of stroke onset. Total WMH volume was calculated in a semi-automated manner. Mean cortical thickness and hippocampal volumes were measured in the contralesional hemisphere. Total and subfield hippocampal volumes were measured using an automated, high-resolution, ex vivo computational atlas. Linear regression analyses were performed for predictors of total and subfield hippocampal volumes. Forty patients with acute ischemic stroke and moderate/severe white matter hyperintensity burden were included in this analysis. Median WMH volume was 9.0 cm3. Adjusting for intracranial volume and stroke laterality, age (β = −3.7, P < 0.001), hypertension (β = −44.7, P = 0.04), WMH volume (β = −0.89, P = 0.049), and mean cortical thickness (β = 286.2, P = 0.006) were associated with total hippocampal volume. In multivariable analysis, age (β = −3.3, P < 0.001) and cortical thickness (β = 205.2, P = 0.028) remained independently associated with total hippocampal volume. In linear regression for predictors of hippocampal subfield volume, increasing WMH volume was associated with decreased hippocampal-amygdala transition area volume (β = −0.04, P = 0.001). These finding suggest that in ischemic stroke patients, increased WMH burden is associated with selective hippocampal subfield degeneration in the hippocampal-amygdala transition area.
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Affiliation(s)
- Mark R Etherton
- Department of Neurology, J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Panagiotis Fotiadis
- Department of Neurology, J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Anne-Katrin Giese
- Department of Neurology, J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Juan E Iglesias
- Department of Radiology, Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States
| | - Ona Wu
- Department of Neurology, J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.,Department of Radiology, Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States
| | - Natalia S Rost
- Department of Neurology, J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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23
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Chen J, Koduri S, Dai S, Toyota Y, Hua Y, Chaudhary N, Pandey AS, Keep RF, Xi G. Intra-hematomal White Matter Tracts Act As a Scaffold for Macrophage Infiltration After Intracerebral Hemorrhage. Transl Stroke Res 2020; 12:858-865. [PMID: 33094829 DOI: 10.1007/s12975-020-00870-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/15/2020] [Accepted: 10/18/2020] [Indexed: 02/07/2023]
Abstract
Intracerebral hemorrhage (ICH) is a stroke subtype with high mortality and severe morbidity. Hemorrhages frequently develop within the white matter, but whether white matter fibers within the hematoma survive after ICH has not been well studied. The current study examines whether white matter fibers persist in the hematoma after ICH, fibers that might be impacted by evacuation, and their relationship to macrophage infiltration in a porcine model. Male piglets had 2.5 ml blood with or without CD47 blocking antibody injected into the right frontal lobe. Brains were harvested from 3 days to 2 months after ICH for brain histology. White matter fibers were detected within the hematoma 3 and 7 days after hemorrhage by brain histology and myelin basic protein immunohistochemistry. White matter still remained in the hematoma cavity at 2 months after ICH. Macrophage scavenger receptor-1 positive macrophages/microglia and heme oxygenase-1 positive cells infiltrated into the hematoma along the intra-hematomal white matter fibers at 3 and 7 days after ICH. Treatment with CD47 blocking antibody enhanced the infiltration of these cells. In conclusion, white matter fibers exist within the hematoma after ICH and macrophages/microglia may use such fibers as a scaffold to infiltrate into the hematoma and aid in hematoma clearance.
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Affiliation(s)
- Jingyin Chen
- Department of Neurosurgery, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA.,Department of Neurosurgery, the 2nd Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Sravanthi Koduri
- Department of Neurosurgery, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Shuhui Dai
- Department of Neurosurgery, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Yasunori Toyota
- Department of Neurosurgery, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Ya Hua
- Department of Neurosurgery, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Neeraj Chaudhary
- Department of Neurosurgery, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA.,Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA.,Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Richard F Keep
- Department of Neurosurgery, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Guohua Xi
- Department of Neurosurgery, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA.
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24
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Luijten SPR, Bos D, Compagne KCJ, Wolff L, Majoie CBLM, Roos YBWEM, van Zwam WH, van Oostenbrugge RJ, Dippel DWJ, van der Lugt A, van Es ACGM. Association of White Matter Lesions and Outcome After Endovascular Stroke Treatment. Neurology 2020; 96:e333-e342. [PMID: 33046611 DOI: 10.1212/wnl.0000000000010994] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 08/12/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the association between white matter lesions (WML) and functional outcome in patients with acute ischemic stroke (AIS) and the modification of the effect of endovascular treatment (EVT) by WML. METHODS We used data from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) trial and assessed severity of WML on baseline noncontrast CT imaging (NCCT; n = 473) according to the Van Swieten Scale. Poststroke functional outcome was assessed with the modified Rankin Scale. We investigated the association of WML with functional outcome using ordinal logistic regression models adjusted for age, sex, and other relevant cardiovascular and prognostic risk factors. In addition, an interaction term between treatment allocation and WML severity was used to assess treatment effect modification by WML. RESULTS We found an independent negative association between more severe WML and functional outcome (adjusted common odds ratio [acOR] 0.77 [95% confidence interval (CI) 0.66-0.90]). Patients with absent to moderate WML had similar benefit of EVT on functional outcome (acOR 1.93 [95% CI 1.31-2.84]) as patients with severe WML (acOR 1.95 [95% CI 0.90-4.20]). No treatment effect modification of WML was found (p for interaction = 0.85). CONCLUSIONS WML are associated with poor functional outcome after AIS, but do not modify the effect of EVT. CLASSIFICATION OF EVIDENCE Prognostic accuracy. This study provides Class II evidence that for patients with AIS, the presence of WML on baseline NCCT is associated with worse functional outcomes.
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Affiliation(s)
- Sven P R Luijten
- From the Departments of Radiology and Nuclear Medicine (S.P.R.L., D.B., K.C.J.C., L.W., A.v.d.L., A.C.G.M.v.E.), Neurology (K.C.J.C., D.W.J.D.), and Epidemiology (D.B.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology (C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Amsterdam University Medical Center, Location AMC, University of Amsterdam; and Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, the Netherlands.
| | - Daniel Bos
- From the Departments of Radiology and Nuclear Medicine (S.P.R.L., D.B., K.C.J.C., L.W., A.v.d.L., A.C.G.M.v.E.), Neurology (K.C.J.C., D.W.J.D.), and Epidemiology (D.B.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology (C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Amsterdam University Medical Center, Location AMC, University of Amsterdam; and Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, the Netherlands
| | - Kars C J Compagne
- From the Departments of Radiology and Nuclear Medicine (S.P.R.L., D.B., K.C.J.C., L.W., A.v.d.L., A.C.G.M.v.E.), Neurology (K.C.J.C., D.W.J.D.), and Epidemiology (D.B.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology (C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Amsterdam University Medical Center, Location AMC, University of Amsterdam; and Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, the Netherlands
| | - Lennard Wolff
- From the Departments of Radiology and Nuclear Medicine (S.P.R.L., D.B., K.C.J.C., L.W., A.v.d.L., A.C.G.M.v.E.), Neurology (K.C.J.C., D.W.J.D.), and Epidemiology (D.B.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology (C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Amsterdam University Medical Center, Location AMC, University of Amsterdam; and Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, the Netherlands
| | - Charles B L M Majoie
- From the Departments of Radiology and Nuclear Medicine (S.P.R.L., D.B., K.C.J.C., L.W., A.v.d.L., A.C.G.M.v.E.), Neurology (K.C.J.C., D.W.J.D.), and Epidemiology (D.B.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology (C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Amsterdam University Medical Center, Location AMC, University of Amsterdam; and Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, the Netherlands
| | - Yvo B W E M Roos
- From the Departments of Radiology and Nuclear Medicine (S.P.R.L., D.B., K.C.J.C., L.W., A.v.d.L., A.C.G.M.v.E.), Neurology (K.C.J.C., D.W.J.D.), and Epidemiology (D.B.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology (C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Amsterdam University Medical Center, Location AMC, University of Amsterdam; and Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, the Netherlands
| | - Wim H van Zwam
- From the Departments of Radiology and Nuclear Medicine (S.P.R.L., D.B., K.C.J.C., L.W., A.v.d.L., A.C.G.M.v.E.), Neurology (K.C.J.C., D.W.J.D.), and Epidemiology (D.B.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology (C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Amsterdam University Medical Center, Location AMC, University of Amsterdam; and Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, the Netherlands
| | - Robert J van Oostenbrugge
- From the Departments of Radiology and Nuclear Medicine (S.P.R.L., D.B., K.C.J.C., L.W., A.v.d.L., A.C.G.M.v.E.), Neurology (K.C.J.C., D.W.J.D.), and Epidemiology (D.B.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology (C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Amsterdam University Medical Center, Location AMC, University of Amsterdam; and Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, the Netherlands
| | - Diederik W J Dippel
- From the Departments of Radiology and Nuclear Medicine (S.P.R.L., D.B., K.C.J.C., L.W., A.v.d.L., A.C.G.M.v.E.), Neurology (K.C.J.C., D.W.J.D.), and Epidemiology (D.B.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology (C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Amsterdam University Medical Center, Location AMC, University of Amsterdam; and Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, the Netherlands
| | - Aad van der Lugt
- From the Departments of Radiology and Nuclear Medicine (S.P.R.L., D.B., K.C.J.C., L.W., A.v.d.L., A.C.G.M.v.E.), Neurology (K.C.J.C., D.W.J.D.), and Epidemiology (D.B.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology (C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Amsterdam University Medical Center, Location AMC, University of Amsterdam; and Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, the Netherlands
| | - Adriaan C G M van Es
- From the Departments of Radiology and Nuclear Medicine (S.P.R.L., D.B., K.C.J.C., L.W., A.v.d.L., A.C.G.M.v.E.), Neurology (K.C.J.C., D.W.J.D.), and Epidemiology (D.B.), Erasmus MC, University Medical Center, Rotterdam; Departments of Radiology (C.B.L.M.M.) and Neurology (Y.B.W.E.M.R.), Amsterdam University Medical Center, Location AMC, University of Amsterdam; and Departments of Radiology (W.H.v.Z.) and Neurology (R.J.v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, the Netherlands
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Abstract
ABSTRACT Cerebral small vessel disease (SVD) is a common global brain disease that causes cognitive impairment, ischemic or hemorrhagic stroke, problems with mobility, and neuropsychiatric symptoms. The brain damage, seen as focal white and deep grey matter lesions on brain magnetic resonance imaging (MRI) or computed tomography (CT), typically accumulates "covertly" and may reach an advanced state before being detected incidentally on brain scanning or causing symptoms. Patients have typically presented to different clinical services or been recruited into research focused on one clinical manifestation, perhaps explaining a lack of awareness, until recently, of the full range and complexity of SVD.In this review, we discuss the varied clinical presentations, established and emerging risk factors, relationship to SVD features on MRI or CT, and the current state of knowledge on the effectiveness of a wide range of pharmacological and lifestyle interventions. The core message is that effective assessment and clinical management of patients with SVD, as well as future advances in diagnosis, care, and treatment, will require a more "joined-up"' approach. This approach should integrate clinical expertise in stroke neurology, cognitive, and physical dysfunctions. It requires more clinical trials in order to improve pharmacological interventions, lifestyle and dietary modifications. A deeper understanding of the pathophysiology of SVD is required to steer the identification of novel interventions. An essential prerequisite to accelerating clinical trials is to improve the consistency, and standardization of clinical, cognitive and neuroimaging endpoints.
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Goyal M, Ospel JM, Menon B, Almekhlafi M, Jayaraman M, Fiehler J, Psychogios M, Chapot R, van der Lugt A, Liu J, Yang P, Agid R, Hacke W, Walker M, Fischer U, Asdaghi N, McTaggart R, Srivastava P, Nogueira RG, Moret J, Saver JL, Hill MD, Dippel D, Fisher M. Challenging the Ischemic Core Concept in Acute Ischemic Stroke Imaging. Stroke 2020; 51:3147-3155. [DOI: 10.1161/strokeaha.120.030620] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Endovascular treatment is a highly effective therapy for acute ischemic stroke due to large vessel occlusion and has recently revolutionized stroke care. Oftentimes, ischemic core extent on baseline imaging is used to determine endovascular treatment-eligibility. There are, however, 3 fundamental issues with the core concept: First, computed tomography and magnetic resonance imaging, which are mostly used in the acute stroke setting, are not able to precisely determine whether and to what extent brain tissue is infarcted (core) or still viable, due to variability in tissue vulnerability, the phenomenon of selective neuronal loss and lack of a reliable gold standard. Second, treatment decision-making in acute stroke is multifactorial, and as such, the relative importance of single variables, including imaging factors, is reduced. Third, there are often discrepancies between core volume and clinical outcome. This review will address the uncertainty in terminology and proposes a direction towards more clarity. This theoretical exercise needs empirical data that clarify the definitions further and prove its value.
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Affiliation(s)
- Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Canada. (M.G., J.M.O., B.M., M.A., M.D.H.)
- Department of Radiology, University of Calgary, Canada. (M.G., B.M., M.A., M.D.H.)
| | - Johanna M. Ospel
- Department of Clinical Neurosciences, University of Calgary, Canada. (M.G., J.M.O., B.M., M.A., M.D.H.)
- Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Switzerland (J.M.O., M.P.)
| | - Bijoy Menon
- Department of Clinical Neurosciences, University of Calgary, Canada. (M.G., J.M.O., B.M., M.A., M.D.H.)
- Department of Radiology, University of Calgary, Canada. (M.G., B.M., M.A., M.D.H.)
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, University of Calgary, Canada. (M.G., J.M.O., B.M., M.A., M.D.H.)
- Department of Radiology, University of Calgary, Canada. (M.G., B.M., M.A., M.D.H.)
| | - Mahesh Jayaraman
- Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (M.J., R.M.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (J.F.)
| | - Marios Psychogios
- Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Switzerland (J.M.O., M.P.)
| | - Rene Chapot
- Department of Neuroradiology, Alfred Krupp Krankenhaus, Essen, Germany (R.C.)
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, the Netherlands (A.v.d.L.)
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China (J.L.)
| | - Pengfei Yang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China (P.Y.)
| | - Ronit Agid
- Department of Medical Imaging, University of Toronto, Canada (R.A.)
| | - Werner Hacke
- Department of Neurology, University Hospital Heidelberg, Germany (W.H.)
| | - Melanie Walker
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle (M.W.)
| | - Urs Fischer
- Department of Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Switzerland (U.F.)
| | - Negar Asdaghi
- Department of Neurology, University of Miami Miller School of Medicine (N.A.)
| | - Ryan McTaggart
- Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (M.J., R.M.)
| | - Padma Srivastava
- Department of Neurology, All India Institute of Medicine, New Delhi, India (P.S.)
| | - Raul G. Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta (R.G.N.)
| | - Jacques Moret
- The Brain Vascular Center, Baujon University Hospital, Paris, France (J.M.)
| | - Jeffrey L. Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Michael D. Hill
- Department of Clinical Neurosciences, University of Calgary, Canada. (M.G., J.M.O., B.M., M.A., M.D.H.)
- Department of Radiology, University of Calgary, Canada. (M.G., B.M., M.A., M.D.H.)
| | - Diederik Dippel
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands (D.D.)
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (M.F.)
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27
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Liu L, Kurgan L, Wu FX, Wang J. Attention convolutional neural network for accurate segmentation and quantification of lesions in ischemic stroke disease. Med Image Anal 2020; 65:101791. [PMID: 32712525 DOI: 10.1016/j.media.2020.101791] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 06/26/2020] [Accepted: 07/17/2020] [Indexed: 10/23/2022]
Abstract
Ischemic stroke lesion and white matter hyperintensity (WMH) lesion appear as regions of abnormally signal intensity on magnetic resonance image (MRI) sequences. Ischemic stroke is a frequent cause of death and disability, while WMH is a risk factor for stroke. Accurate segmentation and quantification of ischemic stroke and WMH lesions are important for diagnosis and prognosis. However, radiologists have a difficult time distinguishing these two types of similar lesions. A novel deep residual attention convolutional neural network (DRANet) is proposed to accurately and simultaneously segment and quantify ischemic stroke and WMH lesions in the MRI images. DRANet inherits the advantages of the U-net design and applies a novel attention module that extracts high-quality features from the input images. Moreover, the Dice loss function is used to train DRANet to address data imbalance in the training data set. DRANet is trained and evaluated on 742 2D MRI images which are produced from the sub-acute ischemic stroke lesion segmentation (SISS) challenge. Empirical tests demonstrate that DRANet outperforms several other state-of-the-art segmentation methods. It accurately segments and quantifies both ischemic stroke lesion and WMH. Ablation experiments reveal that attention modules improve the predictive performance of DRANet.
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Affiliation(s)
- Liangliang Liu
- School of Computer Science and Engineering, Central South University, Changsha, 410083, P.R. China; Hunan Provincial Key Lab on Bioinformatics, Central South University, Changsha, 410083, P.R. China; Department of Network Center, Pingdingshan University, Pingdingshan, 467000, P.R. China
| | - Lukasz Kurgan
- Department of Computer Science, Virginia Commonwealth University, Richmond, VA, 23284, USA
| | - Fang-Xiang Wu
- Department of Mechanical Engineering and Division of Biomedical Engineering, University of Saskatchewan, Saskatoon, SK S7N5A9, Canada
| | - Jianxin Wang
- School of Computer Science and Engineering, Central South University, Changsha, 410083, P.R. China; Hunan Provincial Key Lab on Bioinformatics, Central South University, Changsha, 410083, P.R. China.
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28
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Giese AK, Schirmer MD, Dalca AV, Sridharan R, Donahue KL, Nardin M, Irie R, McIntosh EC, Mocking SJT, Xu H, Cole JW, Giralt-Steinhauer E, Jimenez-Conde J, Jern C, Kleindorfer DO, Lemmens R, Wasselius J, Lindgren A, Rundek T, Sacco RL, Schmidt R, Sharma P, Slowik A, Thijs V, Worrall BB, Woo D, Kittner SJ, McArdle PF, Mitchell BD, Rosand J, Meschia JF, Wu O, Golland P, Rost NS. White matter hyperintensity burden in acute stroke patients differs by ischemic stroke subtype. Neurology 2020; 95:e79-e88. [PMID: 32493718 PMCID: PMC7371377 DOI: 10.1212/wnl.0000000000009728] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 12/12/2019] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To examine etiologic stroke subtypes and vascular risk factor profiles and their association with white matter hyperintensity (WMH) burden in patients hospitalized for acute ischemic stroke (AIS). METHODS For the MRI Genetics Interface Exploration (MRI-GENIE) study, we systematically assembled brain imaging and phenotypic data for 3,301 patients with AIS. All cases underwent standardized web tool-based stroke subtyping with the Causative Classification of Ischemic Stroke (CCS). WMH volume (WMHv) was measured on T2 brain MRI scans of 2,529 patients with a fully automated deep-learning trained algorithm. Univariable and multivariable linear mixed-effects modeling was carried out to investigate the relationship of vascular risk factors with WMHv and CCS subtypes. RESULTS Patients with AIS with large artery atherosclerosis, major cardioembolic stroke, small artery occlusion (SAO), other, and undetermined causes of AIS differed significantly in their vascular risk factor profile (all p < 0.001). Median WMHv in all patients with AIS was 5.86 cm3 (interquartile range 2.18-14.61 cm3) and differed significantly across CCS subtypes (p < 0.0001). In multivariable analysis, age, hypertension, prior stroke, smoking (all p < 0.001), and diabetes mellitus (p = 0.041) were independent predictors of WMHv. When adjusted for confounders, patients with SAO had significantly higher WMHv compared to those with all other stroke subtypes (p < 0.001). CONCLUSION In this international multicenter, hospital-based cohort of patients with AIS, we demonstrate that vascular risk factor profiles and extent of WMH burden differ by CCS subtype, with the highest lesion burden detected in patients with SAO. These findings further support the small vessel hypothesis of WMH lesions detected on brain MRI of patients with ischemic stroke.
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Affiliation(s)
- Anne-Katrin Giese
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Markus D Schirmer
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Adrian V Dalca
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Ramesh Sridharan
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Kathleen L Donahue
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Marco Nardin
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Robert Irie
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Elissa C McIntosh
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Steven J T Mocking
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Huichun Xu
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - John W Cole
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Eva Giralt-Steinhauer
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Jordi Jimenez-Conde
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Christina Jern
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Dawn O Kleindorfer
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Robin Lemmens
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Johan Wasselius
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Arne Lindgren
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Tatjana Rundek
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Ralph L Sacco
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Reinhold Schmidt
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Pankaj Sharma
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Agnieszka Slowik
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Vincent Thijs
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Bradford B Worrall
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Daniel Woo
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Steven J Kittner
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Patrick F McArdle
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Braxton D Mitchell
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Jonathan Rosand
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - James F Meschia
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Ona Wu
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
| | - Polina Golland
- From the Department of Neurology (A.-K.G., M.D.S., K.L.D., M.N., J.R., O.W., N.S.R.), Massachusetts General Hospital, Harvard Medical School, Boston; Program in Medical and Population Genetics (A.K.-G, J.R.), Broad Institute of MIT and Harvard; Computer Science and Artificial Intelligence Lab (M.D.S., A.V.D., R. Sridharan, P.G.), Massachusetts Institute of Technology, Cambridge; Department of Population Health Sciences (M.D.S.), German Centre for Neurodegenerative Diseases, Bonn, Germany; Athinoula A. Martinos Center for Biomedical Imaging (A.V.D., R.I., E.C.M., S.J.T.M., J.R., O.W.), Department of Radiology, Massachusetts General Hospital, Charlestown; Division of Endocrinology, Diabetes and Nutrition (H.X., P.F.M., B.D.M.), Department of Medicine, University of Maryland School of Medicine; Department of Neurology (J.W.C., S.J.K.), University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore; Department of Neurology (E.G.-S., J.J.-C.), Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain; Institute of Biomedicine (C.J.), Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Neurology and Rehabilitation Medicine (D.O.K., D.W.), University of Cincinnati College of Medicine, OH; KU Leuven-University of Leuven (R.L.), Department of Neurosciences, Experimental Neurology; VIB (R.L.), Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Department of Neurology, Belgium; Department of Clinical Sciences Lund (J.W., A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L.), Neurology, Skåne University Hospital, Lund, Sweden; Department of Neurology (T.R., R.L.S.), Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL; Department of Neurology (R. Schmidt), Clinical Division of Neurogeriatrics, Medical University Graz, Austria; Institute of Cardiovascular Research (P.S.), Royal Holloway University of London, Egham, UK; Ashford and St Peter's Hospital (P.S.), UK; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Stroke Division (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne Heidelberg; Department of Neurology (V.T.), Austin Health, Heidelberg, Victoria, Australia; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Center for Genomic Medicine (J.R.), Massachusetts General Hospital; Henry and Allison McCance Center for Brain Health (J.R.), Boston, MA; and Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL
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Mutzenbach JS, Müller-Thies-Broussalis E, Killer-Oberpfalzer M, Griessenauer CJ, Hecker C, Moscote-Salazar LR, Paradaiser P, Pikija S. Severe Leukoaraiosis Is Associated with Poor Outcome after Successful Recanalization of M1 Middle Cerebral Artery Occlusion Strokes. Cerebrovasc Dis 2020; 49:253-261. [PMID: 32535590 DOI: 10.1159/000508209] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 04/25/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Severe leukoaraiosis (LA) is an established risk factor for poor outcome after mechanical thrombectomy (MT) for large vessel occlusion stroke. There is uncertainty whether this association also applies to successfully recanalized patients with M1 segment middle cerebral artery (MCA) occlusions. METHODS A retrospective single-centre study of patients with successful reperfusion (thrombolysis in cerebral infarction, TICI 2b or 3) after MT for an M1 MCA occlusion was performed over a 7-year period. LA score (LAS) was assessed using the age-related white matter change scale on pre-interventional brain imaging. RESULTS A total of 209 patients (median age 75.0 years) were included. LAS was assessed on pre-interventional imaging by computed tomography in 177 (84.7%) patients and magnetic resonance imaging in 32 (15.3%) patients. The median LAS was 1 (IQR 0-8), and severe LA consisted of the top 25 percentile, ranging from 9 to 24. Multivariable analysis demonstrated an association of severe LA (OR 0.32, 95% CI 0.12-0.88, p = 0.023), higher NIHSS on admission (OR 0.89, 95% CI 0.84-0.94, p < 0.001), advanced age (OR 0.97, 95% CI 0.95-1.00, p = 0.039), good leptomeningeal collaterals (OR 3.65, 95% CI 1.46-8.15, p = 0.001), and TICI 3 score (OR 3.26, 95% CI 10.52-7.01) with good clinical outcome after 3 months as measured with the modified Rankin scale. CONCLUSION Severe LA is associated with poor clinical outcome at 3 months in acute stroke patients undergoing MT due to emergent M1 MCA occlusion.
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Affiliation(s)
| | - Erasmia Müller-Thies-Broussalis
- Department of Neurology, Paracelsus Medical University, Salzburg, Austria.,Research Institute for Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Monika Killer-Oberpfalzer
- Department of Neurology, Paracelsus Medical University, Salzburg, Austria.,Research Institute for Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Christoph Johannes Griessenauer
- Research Institute for Neurointervention, Paracelsus Medical University, Salzburg, Austria.,Department of Neurosurgery, Geisinger, Danville, Pennsylvania, USA
| | - Constantin Hecker
- Department of Neurology, Paracelsus Medical University, Salzburg, Austria
| | | | - Pia Paradaiser
- Department of Neurology, Paracelsus Medical University, Salzburg, Austria
| | - Slaven Pikija
- Department of Neurology, Paracelsus Medical University, Salzburg, Austria
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Shang WJ, Shu LM, Zhou X, Liao HQ, Chen XH, Hong H, Chen HB. Association of FLAIR vascular hyperintensity and acute MCA stroke outcome changes with the severity of leukoaraiosis. Neurol Sci 2020; 41:3209-3218. [PMID: 32372196 DOI: 10.1007/s10072-020-04411-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 04/11/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The clinical significance of FLAIR vascular hyperintensity (FVH), a marker of collateral circulation in ischaemic stroke, remains controversial. We hypothesised that the association between FVH and outcomes varies with the severity of leukoaraiosis (LA), another marker of collaterals, and that their combined significance may vary with time. METHODS We included 459 consecutive patients with middle cerebral artery (MCA) stroke. Proximal and distal FVHs were distinguished based on location. LA was divided into two grades, according to Fazekas scores of 0-2 and 3-6. Symptom-to-MRI time was divided into two categories: ≤ 14 days and ≥ 15 days. RESULTS We found no difference in FVH proportion according to LA grade. Multivariate analysis revealed that LA and FVH status were independently associated with unfavourable outcomes (modified Rankin scale ≥ 2) in patients with symptom-to-MRI times ≤ 14 days (P = 0.008), but not in those with symptom-to-MRI times ≥15 days (P = 0.61). In the group with symptom-to-MRI times ≤14 days, patients with LA 3-6 and FVH(+) (OR, 3.044; 95% CI, 1.116-8.305) were more likely to have unfavourable clinical outcomes compared with patients with LA 0-2 and FVH(+) but not compared with those with LA 0-2 and FVH(-) or LA 3-6 and FVH(-). In addition, FVH location did not influence the relationship between FVH and outcomes. CONCLUSIONS The association between FVH and outcomes was influenced by the degree of LA in the acute but not in the subacute and chronic stages of MCA infarction. FVH predicts clinical outcomes independently only in those with more extensive LA.
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Affiliation(s)
- W J Shang
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, Guangdong Province, China
| | - L M Shu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, Guangdong Province, China.,Department of Neurology, The Seventh Affiliated Hospital, Sun Yat-sen University, NO. 628 Zhenyuan Road, Shenzhen, 518107, China
| | - X Zhou
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-Sen University, No. 2nd Zhongshan Road, Guangzhou, 510080, China
| | - H Q Liao
- Department of Neurology, The Seventh Affiliated Hospital, Sun Yat-sen University, NO. 628 Zhenyuan Road, Shenzhen, 518107, China
| | - X H Chen
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, Guangdong Province, China
| | - H Hong
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, Guangdong Province, China
| | - H B Chen
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, Guangdong Province, China.
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31
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Vagal V, Venema SU, Behymer TP, Mistry EA, Sekar P, Sawyer RP, Gilkerson L, Moomaw CJ, Haverbusch M, Coleman ER, Flaherty ML, Van Sanford C, Stanton RJ, Anderson C, Rosand J, Woo D. White Matter Lesion Severity is Associated with Intraventricular Hemorrhage in Spontaneous Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2020; 29:104661. [PMID: 32122778 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104661] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/15/2019] [Accepted: 01/10/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Intraventricular hemorrhage (IVH) and white matter lesion (WML) severity are associated with higher rates of death and disability in intracerebral hemorrhage (ICH). A prior report identified an increased risk of IVH with greater WML burden but did not control for location of ICH. We sought to determine whether a higher degree of WML is associated with a higher risk of IVH after controlling for ICH location. METHODS Utilizing the patient population from 2 large ICH studies; the Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS III) Study and the Ethnic/Racial Variations of Intracerebral Hemorrhage study, we graded WML using the Van Swieten Scale (0-1 for mild, 2 for moderate, and 3-4 for severe WML) and presence or absence of IVH in baseline CT scans. We used multivariable regression models to adjust for relevant covariates. RESULTS Among 3023 ICH patients, 1260 (41.7%) had presence of IVH. In patients with IVH, the proportion of severe WML (28.6%) was higher compared with patients without IVH (21.8%) (P < .0001). Multivariable analysis demonstrated that moderate-severe WML, deep ICH, and increasing ICH volume were independently associated with presence of IVH. We found an increased risk of IVH with moderate-severe WML (OR = 1.38; 95%Cl 1.03-1.86, P = .0328) in the subset of lobar hemorrhages. CONCLUSIONS Moderate to severe WML is a risk for IVH. Even in lobar ICH hemorrhages, severe WML leads to an independent increased risk for ventricular rupture.
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Affiliation(s)
- Vaibhav Vagal
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio.
| | - Simone U Venema
- Massachusetts General Hospital, Department of Neurology, Boston, Massachusetts
| | - Tyler P Behymer
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | - Eva A Mistry
- Vanderbilt University Medical Center, Department of Neurology, Nashville, Tennessee
| | - Padmini Sekar
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | - Russell P Sawyer
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | - Lee Gilkerson
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | - Charles J Moomaw
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | - Mary Haverbusch
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | | | | | | | - Robert J Stanton
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | | | - Jonathan Rosand
- Massachusetts General Hospital, Department of Neurology, Boston, Massachusetts
| | - Daniel Woo
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
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32
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Guo Y, Zhang S, Li M, Sun B, Shang X, Li S, Bai Y, Li Z, Zi W, Liu X. Leukoaraiosis and earlier neurological outcome after mechanical thrombectomy in acute ischemic stroke. J Neuroradiol 2020; 47:428-432. [PMID: 32035971 DOI: 10.1016/j.neurad.2019.10.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 10/17/2019] [Accepted: 10/21/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND PURPOSE The aim of the study was to evaluate whether leukoaraiosis (LA) severity is associated with earlier neurological outcome in acute stroke patients undergoing mechanical thrombectomy. MATERIALS AND METHODS In this retrospective multicenter study, we evaluated 273 acute stroke patients treated with mechanical thrombectomy. LA severity was graded as 0-2 (absent-to-moderate) versus 3-4 (severe) according to the van Swieten scale. The main clinical outcome was the proportion of early neurological improvement and early neurological deterioration. Early neurological improvement was defined as a decrease of≥4 points on the NIHSS, or an NIHSS score of zero 24hours after baseline assessment. Early neurological deterioration was defined as an increase of≥4 points on the NIHSS 24hours after baseline assessment. RESULTS There was a significantly lower early neurological improvement rate (17.1% versus 39.2%; P=0.006) and non-significantly higher early neurological deterioration rate (29.3% versus 17.7%; P=0.084) in patients with severe LA (sLA) compared with patients with absent-to-moderate LA. In multivariable analysis, sLA was inversely associated with early neurological improvement (OR, 0.31; 95% CI, 0.13-0.78; P=0.012). There was no significant association of sLA with early neurological deterioration. However, in patients without symptomatic intracranial hemorrhage, sLA was an independent predictor of early neurological deterioration (OR, 2.65; 95% CI, 1.09-6.45; P=0.032). CONCLUSIONS sLA is a significant negative predictor of early neurological improvement and is an independent predictor of early neurological deterioration in patients without symptomatic intracranial hemorrhage.
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Affiliation(s)
- Yongtao Guo
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, 305 East Zhongshan Road, 210002 Nanjing, Jiangsu, China; Department of Neurology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Nanjing Medical University, 223300 Huai'an, Jiangsu, China
| | - Shuai Zhang
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, 305 East Zhongshan Road, 210002 Nanjing, Jiangsu, China; Department of Neurology, the Affiliated Hospital of Yangzhou University, Yangzhou University, 225001 Yangzhou, Jiangsu, China
| | - Mingchao Li
- Department of Neurology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Nanjing Medical University, 223300 Huai'an, Jiangsu, China
| | - Bo Sun
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, 305 East Zhongshan Road, 210002 Nanjing, Jiangsu, China; Department of Neurology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Nanjing Medical University, 223300 Huai'an, Jiangsu, China
| | - Xianjin Shang
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, 305 East Zhongshan Road, 210002 Nanjing, Jiangsu, China; Department of Neurology, Yijishan Hospital of Wannan Medical College, 241001 Wuhu, Anhui, China
| | - Shun Li
- Department of Neurology, Jinling Hospital, Southern Medical University, 210002 Nanjing, Jiangsu, China
| | - Yongjie Bai
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, 305 East Zhongshan Road, 210002 Nanjing, Jiangsu, China; Department of Neurology, First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, 471003 Luoyang, China
| | - Zibao Li
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, 305 East Zhongshan Road, 210002 Nanjing, Jiangsu, China; Department of Neurology, Yijishan Hospital of Wannan Medical College, 241001 Wuhu, Anhui, China
| | - Wenjie Zi
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, 305 East Zhongshan Road, 210002 Nanjing, Jiangsu, China.
| | - Xinfeng Liu
- Department of Neurology, Jinling Clinical College of Nanjing Medical University, 305 East Zhongshan Road, 210002 Nanjing, Jiangsu, China; Department of Neurology, Jinling Hospital, Southern Medical University, 210002 Nanjing, Jiangsu, China.
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Ingo C, Lin C, Higgins J, Arevalo YA, Prabhakaran S. Diffusion Properties of Normal-Appearing White Matter Microstructure and Severity of Motor Impairment in Acute Ischemic Stroke. AJNR Am J Neuroradiol 2019; 41:71-78. [PMID: 31831465 DOI: 10.3174/ajnr.a6357] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/30/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The effect of white matter hyperintensities as measured by FLAIR MR imaging on functional impairment and recovery after ischemic stroke has been investigated thoroughly. However, there has been growing interest in investigating normal-appearing white matter microstructural integrity following ischemic stroke onset with techniques such as DTI. MATERIALS AND METHODS Fifty-two patients with acute ischemic stroke and 36 without stroke were evaluated with a DTI and FLAIR imaging protocol and clinically assessed for the severity of motor impairment using the Motricity Index within 72 hours of suspected symptom onset. RESULTS There were widespread decreases in fractional anisotropy and increases in mean diffusivity and radial diffusivity for the acute stroke group compared with the nonstroke group. There was a significant positive association between fractional anisotropy and motor function and a significant negative association between mean diffusivity/radial diffusivity and motor function. The normal-appearing white matter ROIs that were most sensitive to the Motricity Index were the anterior/posterior limb of the internal capsule in the infarcted hemisphere and the splenium of the corpus callosum, external capsule, posterior limb/retrolenticular part of the internal capsule, superior longitudinal fasciculus, and cingulum (hippocampus) of the intrahemisphere/contralateral hemisphere. CONCLUSIONS The microstructural integrity of normal-appearing white matter is a significant parameter to identify neural differences not only between those individuals with and without acute ischemic stroke but also correlated with the severity of acute motor impairment.
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Affiliation(s)
- C Ingo
- From the Departments of Neurology (C.I., Y.A.A.) .,Physical Therapy and Human Movement Sciences (C.I.)
| | - C Lin
- Department of Neurology (C.L.), University of Alabama at Birmingham, Birmingham, Alabama
| | - J Higgins
- Radiology (J.H.), Northwestern University, Chicago, Illinois
| | - Y A Arevalo
- From the Departments of Neurology (C.I., Y.A.A.)
| | - S Prabhakaran
- Department of Neurology (S.P.), University of Chicago Medical Center, Chicago, Illinois
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Mechtouff L, Nighoghossian N, Amaz C, Buisson M, Berthezène Y, Derex L, Ong E, Eker OF, Cho TH. White matter burden does not influence the outcome of mechanical thrombectomy. J Neurol 2019; 267:618-624. [DOI: 10.1007/s00415-019-09624-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/01/2019] [Accepted: 11/03/2019] [Indexed: 01/07/2023]
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Moulignier A, Savatovsky J, Assoumou L, Lescure FX, Lamirel C, Godin O, Valin N, Tubiana R, Canestri A, Roux P, Sadik JC, Salomon L, Abrivard M, Katlama C, Yazdanpanah Y, Pialoux G, Girard PM, Costagliola D. Silent Cerebral Small-Vessel Disease Is Twice as Prevalent in Middle-Aged Individuals With Well-Controlled, Combination Antiretroviral Therapy-Treated Human Immunodeficiency Virus (HIV) Than in HIV-Uninfected Individuals. Clin Infect Dis 2019; 66:1762-1769. [PMID: 29244126 DOI: 10.1093/cid/cix1075] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 12/12/2017] [Indexed: 02/07/2023] Open
Abstract
Background Silent cerebral small-vessel disease (CSVD) is defined as white matter hyperintensities, silent brain infarction, or microbleeds. CSVD is responsible for future vascular events, cognitive impairment, frailty, and shorter survival. CSVD prevalence among middle-aged people living with well-controlled human immunodeficiency virus (HIV) infection (PLHIV) is unknown. Methods The French National Agency for Research on AIDS and Viral Hepatitis (ANRS) EP51 Microvascular Brain Retina and Kidney Study (MicroBREAK; NCT02082574) is a cross-sectional study with prospective enrollment of treated PLHIV, ≥50 years old with viral load controlled for ≥12 months, and frequency age- and sex-matched HIV-uninfected controls (HUCs). It was designed to estimate CSVD prevalence on 3T magnetic resonance imaging (3D fluid-attenuated inversion recovery, transversal T2-weighted gradient-echo imaging and diffusion-weighted imaging), as diagnosed by 2 blinded neuroradiologists. A logistic regression model was used to assess the impact of HIV on CSVD after adjustment for traditional risk factors. Results Between June 2013 and May 2016, 456 PLHIV and 154 HUCs were recruited. Median age was 56 and 58 years, respectively (P = .001), among whom 84.9% and 77.3%, respectively (P = .030), were men. CSVD was detected in 51.5% of PLHIV and 36.4% of HUCs with an adjusted odds ratio (aOR) of 2.3. The HIV impact differed according to age, with aOR values of 5.3, 3.7, and 1.0 for age groups <54, 54-60, and >60 years, respectively (P = .022). Older age, hypertension, and lower CD4 cell count nadir were independently associated with a higher risk of CSVD among PLHIV. Conclusions HIV is an independent risk factor for CSVD. Despite sustained immunovirological control, the CSVD prevalence was twice as high among middle-aged PLHIV than HUCs. Clinical Trials Registration NCT02082574.
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Affiliation(s)
| | | | - Lambert Assoumou
- Sorbonne Universités, Institut national de la santé et de la recherche médicale (INSERM), UPMC Université Paris 06, Institut Pierre-Louis d'Epidémiologie et de Santé Publique (UMRS 1136)
| | - François-Xavier Lescure
- IAME, UMR 1137, INSERM, Université Paris Diderot, Sorbonne Paris Cité, Department of Infectious and Tropical Diseases, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris (AP-HP)
| | - Cédric Lamirel
- Fondation Adolphe de Rothschild, Department of Ophthalmology, Hôpital Bichat-Claude Bernard, AP-HP
| | - Ophelia Godin
- Sorbonne Universités, Institut national de la santé et de la recherche médicale (INSERM), UPMC Université Paris 06, Institut Pierre-Louis d'Epidémiologie et de Santé Publique (UMRS 1136)
| | - Nadia Valin
- Department of Infectious and Tropical Diseases, Hôpital Saint-Antoine, AP-HP
| | - Roland Tubiana
- Sorbonne Universités, Institut national de la santé et de la recherche médicale (INSERM), UPMC Université Paris 06, Institut Pierre-Louis d'Epidémiologie et de Santé Publique (UMRS 1136).,Department of Infectious and Tropical Diseases, Hôpital Pitié-Salpêtrière, AP-HP
| | - Ana Canestri
- Department of Infectious and Tropical Diseases, Hôpital Tenon, AP-HP
| | - Pascal Roux
- Department of Radiology, Fondation Adolphe de Rothschild
| | | | - Laurence Salomon
- Clinical Research Unit, Fondation Adolphe de Rothschild, Paris, France
| | - Marie Abrivard
- Clinical Research Unit, Fondation Adolphe de Rothschild, Paris, France
| | - Christine Katlama
- Sorbonne Universités, Institut national de la santé et de la recherche médicale (INSERM), UPMC Université Paris 06, Institut Pierre-Louis d'Epidémiologie et de Santé Publique (UMRS 1136).,Department of Infectious and Tropical Diseases, Hôpital Pitié-Salpêtrière, AP-HP
| | - Yazdan Yazdanpanah
- IAME, UMR 1137, INSERM, Université Paris Diderot, Sorbonne Paris Cité, Department of Infectious and Tropical Diseases, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris (AP-HP)
| | - Gilles Pialoux
- Department of Infectious and Tropical Diseases, Hôpital Tenon, AP-HP
| | - Pierre-Marie Girard
- Sorbonne Universités, Institut national de la santé et de la recherche médicale (INSERM), UPMC Université Paris 06, Institut Pierre-Louis d'Epidémiologie et de Santé Publique (UMRS 1136).,Department of Infectious and Tropical Diseases, Hôpital Saint-Antoine, AP-HP
| | - Dominique Costagliola
- Sorbonne Universités, Institut national de la santé et de la recherche médicale (INSERM), UPMC Université Paris 06, Institut Pierre-Louis d'Epidémiologie et de Santé Publique (UMRS 1136)
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Henninger N, Kaesmacher J. Mechanical thrombectomy in acute stroke: Paying attention to white matter hyperintensities. Neurology 2019; 93:691-692. [PMID: 31519777 DOI: 10.1212/wnl.0000000000008310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Nils Henninger
- From the Departments of Neurology (N.H.) and Psychiatry (N.H.), University of Massachusetts Medical School, Worcester; and University Institute of Diagnostic and Interventional Neuroradiology (J.K.) and University Institute of Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland.
| | - Johannes Kaesmacher
- From the Departments of Neurology (N.H.) and Psychiatry (N.H.), University of Massachusetts Medical School, Worcester; and University Institute of Diagnostic and Interventional Neuroradiology (J.K.) and University Institute of Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
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Uniken Venema SM, Marini S, Lena UK, Morotti A, Jessel M, Moomaw CJ, Kourkoulis C, Testai FD, Kittner SJ, Brouwers HB, James ML, Woo D, Anderson CD, Rosand J. Impact of Cerebral Small Vessel Disease on Functional Recovery After Intracerebral Hemorrhage. Stroke 2019; 50:2722-2728. [PMID: 31446887 DOI: 10.1161/strokeaha.119.025061] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background and Purpose- In this study, we aim to investigate the association of computed tomography-based markers of cerebral small vessel disease with functional outcome and recovery after intracerebral hemorrhage. Methods- Computed tomographic scans of patients in the ERICH study (Ethnic and Racial Variations of Intracerebral Hemorrhage) were evaluated for the extent of leukoaraiosis and cerebral atrophy using visual rating scales. Poor functional outcome was defined as a modified Rankin Scale (mRS) of ≥3. Multivariable logistic and linear regression models were used to explore the associations of cerebral small vessel disease imaging markers with poor functional outcome at discharge and, as a measure of recovery, change in mRS from discharge to 90 days poststroke. Results- After excluding in-hospital deaths, data from 2344 patients, 583 (24.9%) with good functional outcome (mRS of 0-2) at discharge and 1761 (75.1%) with poor functional outcome (mRS of 3-5) at discharge, were included. Increasing extent of leukoaraiosis (P for trend, 0.01) and only severe (grade 4) global atrophy (odds ratio, 2.02; 95% CI, 1.22-3.39, P=0.007) were independently associated with poor functional outcome at discharge. Mean (SD) mRS change from discharge to 90-day follow-up was 0.57 (1.18). Increasing extent of leukoaraiosis (P for trend, 0.002) and severe global atrophy (β [SE], -0.23 [0.115]; P=0.045) were independently associated with less improvement in mRS from discharge to 90 days poststroke. Conclusions- In intracerebral hemorrhage survivors, the extent of cerebral small vessel disease at the time of intracerebral hemorrhage is associated with poor functional outcome at hospital discharge and impaired functional recovery from discharge to 90 days poststroke.
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Affiliation(s)
- Simone M Uniken Venema
- From the Center for Genomic Medicine (S.M.U.V., S.M., U.K.L., C.K., C.D.A., J.R.), Massachusetts General Hospital, Boston
| | - Sandro Marini
- From the Center for Genomic Medicine (S.M.U.V., S.M., U.K.L., C.K., C.D.A., J.R.), Massachusetts General Hospital, Boston.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology (S.M., C.D.A., J.R.).,J.P. Kistler Stroke Research Center (S.M., M.J., C.D.A., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Umme K Lena
- From the Center for Genomic Medicine (S.M.U.V., S.M., U.K.L., C.K., C.D.A., J.R.), Massachusetts General Hospital, Boston
| | - Andrea Morotti
- Stroke Unit, Instituto Neurologico Nazionale a Carattere Scientifico (IRCCS) Mondino Foundation, Pavia, Italy (A.M.)
| | - Michael Jessel
- J.P. Kistler Stroke Research Center (S.M., M.J., C.D.A., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Charles J Moomaw
- Department Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH (C.J.M., D.W.)
| | - Christina Kourkoulis
- From the Center for Genomic Medicine (S.M.U.V., S.M., U.K.L., C.K., C.D.A., J.R.), Massachusetts General Hospital, Boston.,Henry and Allison McCance Center for Brain Health (C.K., C.D.A., J.R.), Massachusetts General Hospital, Boston
| | - Fernando D Testai
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago (F.D.T.)
| | - Steven J Kittner
- Department of Neurology, Baltimore Veterans Administration Medical Center, University of Maryland School of Medicine (S.J.K.)
| | - H Bart Brouwers
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands (H.B.B.)
| | - Michael L James
- Departments of Anesthesiology (M.L.J.), Brain Injury Translational Research Center, Duke University, Durham, NC.,Neurology (M.L.J.), Brain Injury Translational Research Center, Duke University, Durham, NC
| | - Daniel Woo
- Department Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH (C.J.M., D.W.)
| | - Christopher D Anderson
- Henry and Allison McCance Center for Brain Health (C.K., C.D.A., J.R.), Massachusetts General Hospital, Boston.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology (S.M., C.D.A., J.R.).,J.P. Kistler Stroke Research Center (S.M., M.J., C.D.A., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jonathan Rosand
- From the Center for Genomic Medicine (S.M.U.V., S.M., U.K.L., C.K., C.D.A., J.R.), Massachusetts General Hospital, Boston.,Henry and Allison McCance Center for Brain Health (C.K., C.D.A., J.R.), Massachusetts General Hospital, Boston.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology (S.M., C.D.A., J.R.).,J.P. Kistler Stroke Research Center (S.M., M.J., C.D.A., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
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Rocha EA, Ji R, Ay H, Li Z, Arsava EM, Silva GS, Sorensen AG, Wu O, Singhal AB. Reduced Ischemic Lesion Growth with Heparin in Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2019; 28:1500-1508. [PMID: 30935810 PMCID: PMC6544494 DOI: 10.1016/j.jstrokecerebrovasdis.2019.03.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/19/2019] [Accepted: 03/05/2019] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE The role of heparin in acute ischemic stroke is controversial. We investigated the effect of heparin on ischemic lesion growth. METHODS Data were analyzed on nonthrombolyzed ischemic stroke patients in whom diffusion-weighted imaging (DWI)/perfusion-weighted imaging (PWI) MRI was performed less than 12 hours of last known well and showed a PWI-DWI lesion mismatch, and who underwent follow-up neuroimaging at least 4 days after admission. Lesion growth was assessed by (1) absolute lesion growth and (2) percentage mismatch lost (PML). Univariate and multivariate regression analysis, and propensity score matching, were used to determine the effects of heparin on ischemic lesion growth. RESULTS Of the 113 patients meeting study criteria, 59 received heparin within 24 hours. Heparin use was associated with ∼5-fold reductions in PML (3.5% versus 19.2%, P = .002) and absolute lesion growth (4.7 versus 20.5 mL, P = .009). In multivariate regression models, heparin independently predicted reduced PML (P = .04) and absolute lesion growth (P = .04) in the entire cohort, and in multiple subgroups (patients with and without proximal artery occlusion; DWI volume greater than 5 mL; cardio-embolic mechanism; DEFUSE-3 target mismatch). In propensity score matching analysis where patients were matched by admission NIHSS, DWI volume and proximal artery occlusion, heparin remained an independent predictor of PML (P = .048) and tended to predict absolute lesion growth (P = .06). Heparin treatment did not predict functional outcome at discharge or 90 days. CONCLUSION Early heparin treatment in acute ischemic stroke patients with PWI-DWI mismatch attenuates ischemic lesion growth. Clinical trials with careful patient selection are warranted to investigate the potential ischemic protective effects of heparin.
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Affiliation(s)
- Eva A Rocha
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts; Department of Neurology, Universidade Federal de Sao Paulo, Sao Paulo, SP, Brazil
| | - Ruijun Ji
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts; Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hakan Ay
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts
| | - Zixiao Li
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts; Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | | | - Gisele S Silva
- Department of Neurology, Universidade Federal de Sao Paulo, Sao Paulo, SP, Brazil; Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | | | - Ona Wu
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts.
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Mikati AG, Mandelbaum M, Sapnar S, Puri AS, Silver B, Goddeau RP, Haussen DC, Moonis M, Jun-O'Connell AH, Henninger N. Impact of Leukoaraiosis Severity on the Association of Time to Successful Reperfusion with 90-Day Functional Outcome After Large Vessel Occlusion Stroke. Transl Stroke Res 2019; 11:39-49. [PMID: 30980282 DOI: 10.1007/s12975-019-00703-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/22/2019] [Accepted: 03/27/2019] [Indexed: 12/17/2022]
Abstract
The chance for a favorable outcome after mechanical thrombectomy (MT) for large vessel occlusion stroke decreases with the symptom onset-to-reperfusion time (OTR). Patients with severe leukoaraiosis are at increased risk for a poor outcome after MT. However, whether leukoaraiosis modulates to the association between OTR and 90-day functional outcome is uncertain. We retrospectively analyzed 144 consecutive patients with successful (TICI ≥ 2b/3) MT for anterior circulation large vessel occlusion within 24 h form OTR between January 2012 to November 2016. Leukoaraiosis was dichotomized to absent-to-mild (van Swieten scale score 0-2) versus moderate-to-severe (3-4) as assessed on admission head CT. Multiple linear, logistic, and ordinal regression analyses were used to determine the association between leukoaraiosis, OTR, and 90-day modified Rankin Scale (mRS) score, after adjustment for pertinent covariates. Leukoaraiosis was independently associated with the OTR on multivariable linear regression (p = 0.003). The association between OTR and 90-day outcome depended on the degree of pre-existing leukoaraiosis burden as shown by a significant leukoaraiosis-by-OTR interaction on multivariable logistic regression (OR 0.76, 95% CI 0.58-0.98, p = 0.037) and multivariable ordinal regression (OR 0.87, 95% CI 0.78-0.97, p = 0.011). Pre-existing leukoaraiosis is associated with the 90-day functional outcome after successful reperfusion and impacts the association between the OTR and 90-day mRS among patients undergoing MT. Patients with high leukoaraiosis burden need to present earlier than patients with low leukoaraiosis burden for a similar favorable outcome. Pending confirmation, these results may have important implications for optimizing patient selection for acute stroke therapies.
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Affiliation(s)
- Abdul Ghani Mikati
- Department of Neurology, University of Massachusetts Medical School, 55 Lake Ave, North Worcester, MA, 01655, USA
| | - Max Mandelbaum
- Department of Neurology, University of Massachusetts Medical School, 55 Lake Ave, North Worcester, MA, 01655, USA
| | - Shweta Sapnar
- Department of Neurology, University of Massachusetts Medical School, 55 Lake Ave, North Worcester, MA, 01655, USA
| | - Ajit S Puri
- Department of Radiology, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Neurosurgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Brian Silver
- Department of Neurology, University of Massachusetts Medical School, 55 Lake Ave, North Worcester, MA, 01655, USA
| | - Richard P Goddeau
- Department of Neurology, University of Massachusetts Medical School, 55 Lake Ave, North Worcester, MA, 01655, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University/Marcus Stroke and Neuroscience Center-Grady Memorial Hospital, Atlanta, GA, USA
| | - Majaz Moonis
- Department of Neurology, University of Massachusetts Medical School, 55 Lake Ave, North Worcester, MA, 01655, USA
| | - Adalia H Jun-O'Connell
- Department of Neurology, University of Massachusetts Medical School, 55 Lake Ave, North Worcester, MA, 01655, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Medical School, 55 Lake Ave, North Worcester, MA, 01655, USA. .,Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA.
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Li L, Li C. Microvascular complications of diabetes worsen long-term functional outcomes after acute ischemic stroke. J Int Med Res 2019; 46:3030-3041. [PMID: 30106326 PMCID: PMC6134682 DOI: 10.1177/0300060517734743] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Objective This study was performed to evaluate the potential predictors of poor outcomes associated with diabetes-specific microvascular pathologies and to analyze their influence on clinical outcomes by adjusting for other well-known prognostic factors in patients with acute ischemic stroke. Methods We analyzed 1389 consecutive adult patients with acute ischemic stroke and explored the relationship among clinical characteristics, laboratory measurements, imaging findings, and 6-month functional outcomes. Results The final study population comprised 216 patients with both acute ischemic stroke and diabetes mellitus who were followed up for 6 months. A multiple logistic regression analysis of poor outcomes revealed the following independent predictors: leukoaraiosis severity [odds ratio (OR), 7.38; 95% confidence interval (CI), 1.40–38.86, per 1-point increase), diabetic nephropathy (OR, 10.66; 95% CI, 1.10–103.43), and the admission National Institutes of Health stroke scale score (OR, 2.58; 95% CI, 1.36–4.92 per 1-point increase). In this model, admission hyperglycemia and intracerebral hemorrhagic transformation were not independent prognostic predictors. Conclusion Microvascular complications (such as nephropathy) caused by diabetes mellitus predict an unfavorable clinical outcome after acute ischemic stroke. Diabetic nephropathy may partly affect post-stroke prognosis by means of exacerbating leukoaraiosis.
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Affiliation(s)
- Longling Li
- Department of Neurology, The 2nd Affiliated Hospital of Chongqing Medical University, Linjianglu, Chongqing, China
| | - Changqing Li
- Department of Neurology, The 2nd Affiliated Hospital of Chongqing Medical University, Linjianglu, Chongqing, China
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Nikolopoulos D, Fanouriakis A, Boumpas DT. Cerebrovascular Events in Systemic Lupus Erythematosus: Diagnosis and Management. Mediterr J Rheumatol 2019; 30:7-15. [PMID: 32185337 PMCID: PMC7045913 DOI: 10.31138/mjr.30.1.7] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 02/22/2019] [Accepted: 02/25/2019] [Indexed: 02/06/2023] Open
Abstract
Stroke is a major cause of morbidity, mortality and disability in systemic lupus erythematosus (SLE). Patients with SLE have a two-fold increase in the risk of stroke with younger patients (ie, less than 50 years of age) having an ever-higher risk (up to 10-fold). Although the prognosis of SLE has improved, mortality due to cerebrovascular events (CVE) remains unchanged. Cerebrovascular disease may be directly attributed to the disease per se, as a manifestation of neuropsychiatric SLE, or be the result of traditional cardiovascular risk factors accompanying the disease. Elucidation of the underlying mechanism(s) of CVE is essential as it may guide the type of therapy (ie, antithrombotic or anticoagulant therapy versus immunosuppressive). Strokes attributed to lupus usually occur early in the course of the disease and are often accompanied by evidence of activity in other organs; those related to antiphospholipid antibodies can occur at any time, in patients with either active or inactive SLE. In this review, we discuss the epidemiology, work-up, management and primary prevention of CVE in patients with lupus. In view of the effectiveness of thrombolysis, physicians need to educate lupus patients and their families for the early recognition of the signs of stroke and the need to seek prompt attention. To this end acronyms, such as FAST (Facial drooping, Arm weakness, Speech difficulties and Time to call emergency service) can be used as a mnemonic to help detect and enhance responsiveness to the needs of a person having a stroke.
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Affiliation(s)
- Dionysis Nikolopoulos
- Rheumatology and Clinical Immunology Unit, 4th Department of Medicine, "Attikon" University Hospital, Athens, Greece.,Laboratory of Immune Regulation and Tolerance, Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, 4th Department of Medicine, "Attikon" University Hospital, Athens, Greece
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology Unit, 4th Department of Medicine, "Attikon" University Hospital, Athens, Greece.,Laboratory of Immune Regulation and Tolerance, Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece.,Medical School, University of Cyprus, Nicosia, Cyprus
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The global burden of cerebral small vessel disease related to neurological deficit severity and clinical outcomes of acute ischemic stroke after IV rt-PA treatment. Neurol Sci 2019; 40:1157-1166. [DOI: 10.1007/s10072-019-03790-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 02/22/2019] [Indexed: 12/18/2022]
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Georgakis MK, Duering M, Wardlaw JM, Dichgans M. WMH and long-term outcomes in ischemic stroke. Neurology 2019; 92:e1298-e1308. [DOI: 10.1212/wnl.0000000000007142] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 11/13/2018] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo investigate the relationship between baseline white matter hyperintensities (WMH) in patients with ischemic stroke and long-term risk of dementia, functional impairment, recurrent stroke, and mortality.MethodsFollowing the Meta-analysis of Observational Studies in Epidemiology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO protocol: CRD42018092857), we systematically searched Medline and Scopus for cohort studies of ischemic stroke patients examining whether MRI- or CT-assessed WMH at baseline are associated with dementia, functional impairment, recurrent stroke, and mortality at 3 months or later poststroke. We extracted data and evaluated study quality with the Newcastle–Ottawa scale. We pooled relative risks (RR) for the presence and severity of WMH using random-effects models.ResultsWe included 104 studies with 71,298 ischemic stroke patients. Moderate/severe WMH at baseline were associated with increased risk of dementia (RR 2.17, 95% confidence interval [CI] 1.72–2.73), cognitive impairment (RR 2.29, 95% CI 1.48–3.54), functional impairment (RR 2.21, 95% CI 1.83–2.67), any recurrent stroke (RR 1.65, 95% CI 1.36–2.01), recurrent ischemic stroke (RR 1.90, 95% CI 1.26–2.88), all-cause mortality (RR 1.72, 95% CI 1.47–2.01), and cardiovascular mortality (RR 2.02, 95% CI 1.44–2.83). The associations followed dose-response patterns for WMH severity and were consistent for both MRI- and CT-defined WMH. The results remained stable in sensitivity analyses adjusting for age, stroke severity, and cardiovascular risk factors, in analyses of studies scoring high in quality, and in analyses adjusted for publication bias.ConclusionsPresence and severity of WMH are associated with substantially increased risk of dementia, functional impairment, stroke recurrence, and mortality after ischemic stroke. WMH may aid clinical prognostication and the planning of future clinical trials.
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Naess H, Thomassen L, Waje-Andreassen U, Glad S, Kvistad CE. High risk of early neurological worsening of lacunar infarction. Acta Neurol Scand 2019; 139:143-149. [PMID: 30229856 DOI: 10.1111/ane.13029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/27/2018] [Accepted: 09/12/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE We aimed to evaluate factors associated with neurological worsening among patients with lacunar or non-lacunar infarction admitted within 3 hours and between 3 and 24 hours after stroke onset. METHODS All patients admitted to Haukeland university hospital between 2006 and 2016 with acute cerebral infarction on MRI and admission within 24 hours were included. Repeated National Institute of Health Stroke Scale (NIHSS) scoring was performed in all patients whenever possible. Neurological worsening during the hospital stay was defined as NIHSS score increase ≥3 compared to NIHSS score on admission. RESULTS In patients with lacunar infarction admitted within 3 hours of onset, neurological worsening was associated with low NIHSS score on admission, low body temperature, and leukoaraiosis, whereas only internal carotid artery stenosis or occlusion was associated with neurological worsening in non-lacunar infraction. For patients admitted 3-24 hours after onset, neurological worsening was associated with low body temperature, high systolic blood pressure, and short time from onset to admission in patients with lacunar infarction, whereas high systolic blood pressure, high NIHSS score on admission, middle cerebral artery occlusion, and high blood glucose were associated with neurological worsening in patients with non-lacunar infarction (all P < 0.05). CONCLUSIONS Lacunar infarctions with minor neurological deficits within 3 hours of stroke onset are at high risk of neurological worsening especially if concomitant low body temperature and leukoaraiosis.
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Affiliation(s)
- Halvor Naess
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
- Centre for age-related medicine; Stavanger University Hospital; Stavanger Norway
| | - Lars Thomassen
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - Ulrike Waje-Andreassen
- Department of Neurology; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - Solveig Glad
- Department of Neurology; Haukeland University Hospital; Bergen Norway
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45
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White Matter Integrity and Early Outcomes After Acute Ischemic Stroke. Transl Stroke Res 2019; 10:630-638. [PMID: 30693424 DOI: 10.1007/s12975-019-0689-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 01/02/2019] [Accepted: 01/17/2019] [Indexed: 10/27/2022]
Abstract
Chronic white matter structural injury is a risk factor for poor long-term outcomes after acute ischemic stroke (AIS). However, it is unclear how white matter structural injury predisposes to poor outcomes after AIS. To explore this question, in 42 AIS patients with moderate to severe white matter hyperintensity (WMH) burden, we characterized WMH and normal-appearing white matter (NAWM) diffusivity anisotropy metrics in the hemisphere contralateral to acute ischemia in relation to ischemic tissue and early functional outcomes. All patients underwent brain MRI with dynamic susceptibility contrast perfusion and diffusion tensor imaging within 12 h and at day 3-5 post stroke. Early neurological outcomes were measured as the change in NIH Stroke Scale score from admission to day 3-5 post stroke. Target mismatch profile, percent mismatch lost, infarct growth, and rates of good perfusion were measured to assess ischemic tissue outcomes. NAWM mean diffusivity was significantly lower in the group with early neurological improvement (ENI, 0.79 vs. 0.82 × 10-3, mm2/s; P = 0.02). In multivariable logistic regression, NAWM mean diffusivity was an independent radiographic predictor of ENI (β = - 17.6, P = 0.037). Median infarct growth was 118% (IQR 26.8-221.9%) despite good reperfusion being observed in 65.6% of the cohort. NAWM and WMH diffusivity metrics were not associated with target mismatch profile, percent mismatch lost, or infarct growth. Our results suggest that, in AIS patients, white matter structural integrity is associated with poor early neurological outcomes independent of ischemic tissue outcomes.
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Jiang J, Huang X, Zhang Y, Deng W, Shen F, Liu J. Total MRI burden of cerebral vessel disease correlates with the progression in patients with acute single small subcortical strokes. Brain Behav 2019; 9:e01173. [PMID: 30506998 PMCID: PMC6346414 DOI: 10.1002/brb3.1173] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/27/2018] [Accepted: 10/29/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The patients of single small subcortical strokes (SS) commonly have neurological worsening with risk factors, and mechanisms remain unclear. Asymptomatic lacunes, white matter lesions, cerebral microbleeds, and enlarged perivascular spaces are MRI markers of cerebral small vessel disease (cSVD). Previous studies mostly explored the association between the neurological deterioration and presence of above markers separately. The relationship between progressive single small SS and the simultaneous presence of multiple markers of cSVD has not been fully identified. We aimed to investigate whether total burden of cSVD detected with MRI was associated with progressive small SS in this study. METHODS Patients with single small SS (2.0 cm in diameter) were prospectively recruited during January 2016 and May 2018. Progression was defined as worsening by ≥1 point in National Institutes Health Stroke Scale (NIHSS) motor score within 72 hr from onset. The presence and burden of cSVD were determined by brain MRI, producing a score between 0 and 4. Besides, the patients' characteristics, clinical data, medical treatments during hospitalization stay were collected and statistically analyzed. Associations with progression were tested with forward stepwise regression analyses. RESULTS Fifty-seven (35.6%) patients underwent progression. No significant difference was observed in the distribution of any single vascular risk factor and its related laboratory data among these patients. After adjustment for age, sex, NIHSS score at admission, and time from stroke to MRI in separate models, severe WMHs (OR = 4.892; 95% CI = 2.011-11.904, p = 0.016), moderate- and high-grade basal ganglia EPVS (OR = 2.970; 95% CI = 1.861-6.121, p = 0.009), and total cSVD score (OR = 3.359; 95% CI = 2.016-5.599, p = 0.010) were associated with progression. CONCLUSION This study demonstrated that total MRI cSVD burden was independently associated with progression after single small subcortical strokes.
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Affiliation(s)
- Jingwen Jiang
- Department of Neurology, Ruijin Hospital North Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaojun Huang
- Department of Neurology, Ruijin Hospital North Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu Zhang
- Department of Neurology, Ruijin Hospital North Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weiping Deng
- Department of Neurology, Ruijin Hospital North Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fanxia Shen
- Department of Neurology, Ruijin Hospital North Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianrong Liu
- Department of Neurology, Ruijin Hospital North Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Yu Z, Zheng J, Guo R, Ma L, You C, Li H. Prognostic significance of leukoaraiosis in intracerebral hemorrhage: A meta-analysis. J Neurol Sci 2018; 397:34-41. [PMID: 30580053 DOI: 10.1016/j.jns.2018.12.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 11/27/2018] [Accepted: 12/16/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients with intracerebral hemorrhage (ICH) have high disability and mortality. Leukoaraiosis refers to the diffuse abnormalities of white matter on neuroimaging, which has been suggested to be with poor outcome in patients with ICH. This meta-analysis was performed to summarize the current evidence on the prognostic significance of leukoaraiosis in ICH patients. METHODS Databases were searched for published studies about leukoaraiosis and prognosis in patients with ICH. Data from eligible studies were extracted. Odds ratios (ORs) and their 95% confidence intervals (CIs) from each study were combined with DerSimonian-Laird method and random effect model for quantitative analysis. Begg's funnel plot was adopted to assess the publication bias. RESULTS A total of nine studies with 4948 patients were finally included in this meta-analysis. Six studies reported functional outcome, two studies reported mortality, and another study reported both functional outcome and mortality. The meta-analysis showed that leukoaraiosis was significantly associated with worse functional outcome in patients with ICH (OR = 1.40, 95%CI 1.17-1.68, P < .001). In addition, leukoaraiosis was also significantly associated with higher mortality in patients with ICH (OR = 1.59, 95%CI 1.21-2.08, P = .001). CONCLUSIONS Leukoaraiosis is significantly associated with both worse functional outcome and higher mortality in patients with ICH. Leukoaraiosis can be a useful imaging marker for predicting outcome in patients with ICH.
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Affiliation(s)
- Zhiyuan Yu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jun Zheng
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Rui Guo
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Chen X, Jin Y, Chen J, Chen X, Cao X, Yu L, Xu Y. Relationship between White Matter Hyperintensities and Hematoma Volume in Patients with Intracerebral Hematoma. Aging Dis 2018; 9:999-1009. [PMID: 30574413 PMCID: PMC6284763 DOI: 10.14336/ad.2018.0108] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 01/08/2018] [Indexed: 12/13/2022] Open
Abstract
The relationship of white-matter hyperintensity (WMH) to intracerebral hemorrhage (ICH) remains unclear. In this retrospective study, we investigated whether the severity and progression of WMH could be related to the hematoma volume and absorption in ICH. 2338 WMH patients with ICH aged≥40 years receiving brain computed tomography (CT) imaging within 12 hours of ICH symptom onset were screened, and 227 patients were included in the final study. The severity and progression of WMH were assessed using the software programs MRICRON and ITK-SNAP on brain magnetic resonance imaging (MRI) and the hematoma volumes and absorption with ITK-SNAP software on CT. We assessed the association of WMH severity with ICH volume in 227 patients at baseline. Totally 183 of 227 patients underwent repeated CT within 14 days of ICH onset. The relationship of WMH severity to ICH absorption was analyzed in 183 patients. Additionally, among all 227 patients, 37 subjected to another MRI before ICH onset were divided into two groups according to WMH progression: non-progression and progression groups. The link between WMH progression and hematoma volume was examined. The ICH volume was significantly larger in patients with the highest WMH scores than in those with the lowest WMH scores. Larger WMH volume was independently associated with larger ICH volume (odds ratio 1.00; 95% CI, 1.00 to 1.00; P = 0.049). There was a trend towards WMH progression being related to ICH volume (P =0.049). Contrastingly, the WMH volume was not linked with hematoma absorption (P = 0.79). In conclusion, we found that greater severity and progression of WMH were associated with larger ICH volume. Our findings suggest that WMH might provide important prognostic information about patients with ICH and may have implications for treatment stratification.
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Affiliation(s)
- Xuemei Chen
- 1Department of Neurology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China.,3Jiangsu Province Stroke Center for Diagnosis and Therapy, Nanjing 210008, China.,4Nanjing Neuropsychiatry Clinic Medical Center, Nanjing 210008, China
| | - Yuexinzi Jin
- 1Department of Neurology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Jian Chen
- 1Department of Neurology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Xin Chen
- 1Department of Neurology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Xiang Cao
- 2Department of Neurology, Affiliated Drum Tower Hospital, and Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing 210008, China.,3Jiangsu Province Stroke Center for Diagnosis and Therapy, Nanjing 210008, China.,4Nanjing Neuropsychiatry Clinic Medical Center, Nanjing 210008, China
| | - Linjie Yu
- 2Department of Neurology, Affiliated Drum Tower Hospital, and Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing 210008, China
| | - Yun Xu
- 1Department of Neurology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China.,2Department of Neurology, Affiliated Drum Tower Hospital, and Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing 210008, China.,3Jiangsu Province Stroke Center for Diagnosis and Therapy, Nanjing 210008, China.,4Nanjing Neuropsychiatry Clinic Medical Center, Nanjing 210008, China
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Cipolla MJ, Liebeskind DS, Chan SL. The importance of comorbidities in ischemic stroke: Impact of hypertension on the cerebral circulation. J Cereb Blood Flow Metab 2018; 38:2129-2149. [PMID: 30198826 PMCID: PMC6282213 DOI: 10.1177/0271678x18800589] [Citation(s) in RCA: 187] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Comorbidities are a hallmark of stroke that both increase the incidence of stroke and worsen outcome. Hypertension is prevalent in the stroke population and the most important modifiable risk factor for stroke. Hypertensive disorders promote stroke through increased shear stress, endothelial dysfunction, and large artery stiffness that transmits pulsatile flow to the cerebral microcirculation. Hypertension also promotes cerebral small vessel disease through several mechanisms, including hypoperfusion, diminished autoregulatory capacity and localized increase in blood-brain barrier permeability. Preeclampsia, a hypertensive disorder of pregnancy, also increases the risk of stroke 4-5-fold compared to normal pregnancy that predisposes women to early-onset cognitive impairment. In this review, we highlight how comorbidities and concomitant disorders are not only risk factors for ischemic stroke, but alter the response to acute ischemia. We focus on hypertension as a comorbidity and its effects on the cerebral circulation that alters the pathophysiology of ischemic stroke and should be considered in guiding future therapeutic strategies.
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Affiliation(s)
- Marilyn J Cipolla
- 1 Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - David S Liebeskind
- 2 Neurovascular Imaging Research Core and Stroke Center, Department of Neurology, University of California at Los Angeles, Los Angeles, CA, USA
| | - Siu-Lung Chan
- 1 Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, VT, USA
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Holmegaard L, Jensen C, Redfors P, Blomstrand C, Jern C, Jood K. Long-term progression of white matter hyperintensities in ischemic stroke. Acta Neurol Scand 2018; 138:548-556. [PMID: 30152523 DOI: 10.1111/ane.13019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 07/27/2018] [Accepted: 08/10/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Studies on long-term progression of white matter hyperintensities (WMH) after ischemic stroke are scarce. Here, we sought to investigate this progression and its predictors in a cohort presenting with ischemic stroke before 70 years of age. MATERIALS AND METHODS Participants in the Sahlgrenska Academy Study on Ischemic Stroke who underwent magnetic resonance imaging (MRI) of the brain at index stroke were examined by MRI again after 7 years (n = 188, mean age 53 years at index stroke, 35% females). WMH at index stroke and progression were assessed according to Fazekas' grades and the WMH change scale. Stroke subtype was classified according to TOAST. RESULTS Marked WMH at index stroke were present in 20% of the participants and were significantly associated with age, hypertension, and subtype. Progression of WMH after 7 years was observed in 63% and 35% of the participants for subcortical and periventricular locations, respectively. Significant independent predictors of progression were age and marked WMH at baseline for both locations, whereas no significant associations were detected for vascular risk factors or subtype in multivariable analyses. In participants with no or only mild WMH at baseline, 20% showed marked WMH at follow-up. Age and hypertension, but not subtype, were independently associated with this acquisition of marked WMH. CONCLUSIONS Age and marked WMH at index stroke, but not stroke subtype, predicted long-term WMH progression after ischemic stroke before 70 years of age, whereas age and hypertension predicted acquisition of marked WMH in those with no or only mild WMH at baseline.
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Affiliation(s)
- Lukas Holmegaard
- Department of Clinical Neuroscience; Institute of Neuroscience and Physiology; Sahlgrenska Academy at University of Gothenburg; Gothenburg Sweden
| | - Christer Jensen
- Department of Radiology; Institute of Clinical Sciences; Sahlgrenska Academy at University of Gothenburg; Gothenburg Sweden
| | - Petra Redfors
- Department of Clinical Neuroscience; Institute of Neuroscience and Physiology; Sahlgrenska Academy at University of Gothenburg; Gothenburg Sweden
| | - Christian Blomstrand
- Department of Clinical Neuroscience; Institute of Neuroscience and Physiology; Sahlgrenska Academy at University of Gothenburg; Gothenburg Sweden
| | - Christina Jern
- Department of Clinical Pathology and Genetics; Institute of Biomedicine; Sahlgrenska Academy at University of Gothenburg; Gothenburg Sweden
| | - Katarina Jood
- Department of Clinical Neuroscience; Institute of Neuroscience and Physiology; Sahlgrenska Academy at University of Gothenburg; Gothenburg Sweden
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