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Wen HF, Li Q, Wang PF, Li JL, Du JC. Endovascular thrombectomy in wake-up stroke guided by arterial spin-labeling and fluid-attenuated inversion recovery versus diffusion-weighted imaging mismatch on MRI. J Thromb Thrombolysis 2024; 57:797-804. [PMID: 38662115 DOI: 10.1007/s11239-024-02973-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/24/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVE This purpose of this study is to investigate the effectiveness and safety of utilizing the arterial spin-labeling (ASL) combined with diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) combined with DWI double mismatch in the endovascular treatment of patients diagnosed with wake-up stroke (WUS). METHODS In this single-center trial, patients diagnosed with WUS underwent thrombectomy if acute ischemic lesions were observed on DWI indicating large precerebral circulation occlusion. Patients with no significant parenchymal hypersignal on FLAIR and ASL imaging showing a hypoperfusion tissue to infarct core volume ratio of at least 1.2 were included. The participants were divided into groups receiving endovascular thrombectomy plus medical therapy or medical therapy alone, based on their subjective preference. Functional outcomes were assessed using the ordinal score on the modified Rankin scale (mRs) at 90 days, along with the rate of functional independence. RESULTS In this study, a total of 77 patients were included, comprising 38 patients in the endovascular therapy group and 39 patients in the medical therapy group. The endovascular therapy group exhibited more favorable changes in the distribution of functional prognosis measured by mRs at 90 days, compared to the medical therapy group (adjusted common odds ratio, 3.25; 95% CI, 1.03 to 10.26; P < 0.01). Additionally, the endovascular therapy group had a higher proportion of patients achieving functional independence (odds ratio, 4.0; 95% CI, 1.36 to 11.81; P < 0.01). Importantly, there were no significant differences observed in the incidence of intracranial hemorrhage or mortality rates between the two groups. CONCLUSION Guided by the ASL-DWI and FLAIR-DWI double mismatch, endovascular thrombectomy combined with standard medical treatment appears to yield superior functional outcomes in patients with WUS and large vessel occlusion compared to standard medical treatment alone.
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Affiliation(s)
- Hong-Feng Wen
- Department of Neurology, Aerospace Center Hospital, No. 15 Yuquan Road, Haidian District, Beijing, 100049, China
| | - Qin Li
- Department of Neurology, Aerospace Center Hospital, No. 15 Yuquan Road, Haidian District, Beijing, 100049, China
| | - Pei-Fu Wang
- Department of Neurology, Aerospace Center Hospital, No. 15 Yuquan Road, Haidian District, Beijing, 100049, China.
| | - Ji-Lai Li
- Department of Neurology, Aerospace Center Hospital, No. 15 Yuquan Road, Haidian District, Beijing, 100049, China
| | - Ji-Chen Du
- Department of Neurology, Aerospace Center Hospital, No. 15 Yuquan Road, Haidian District, Beijing, 100049, China.
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Ishizuka K, Saito M, Shibata N, Kitagawa K. Cytoskeletal protein breakdown and serum albumin extravasation in MRI DWI-T2WI mismatch area in acute murine cerebral ischemia. Neurosci Res 2023; 190:85-91. [PMID: 36375655 DOI: 10.1016/j.neures.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 10/12/2022] [Accepted: 11/10/2022] [Indexed: 11/13/2022]
Abstract
MRI diffusion-weighted imaging (DWI)-FLAIR mismatch is known as predictive of symptom onset within 4.5 h. This study assessed the breakdown of cytoskeletal protein and blood-brain barrier (BBB) in DWI-T2 mismatch. We employed occlusion of middle cerebral artery (MCAO) in C57BL/6 mice. We serially measured MRI including DWI and T2WI. After MRI, we prepared brain sections or samples and examined microtubule-associated protein 2 (MAP2) expression, alpha-fodrin degradation, extravasation of albumin and claudin-5 expression. In permanent or transient MCAO for 45 min, DWI hyperintensities was already found at 60 min without change of T2, showing DWI-T2 mismatch. In permanent MCAO, MAP2 expressions were preserved, and no extravasation of albumin was observed. In transient MCAO, MAP2 immunoreaction was already lost in the lateral part of the striatum. In both models, alpha-fodrin degradation was already detected. At 180 min, T2 hyperintensities appeared, where MAP2 signal was lost and albumin extravasation was found. At 24 h, hyperintensities of DWI and T2WI was found in the whole MCA territory, where MAP2 signal was completely lost with marked albumin extravasation and alpha-fodrin degradation. Immunoreaction for claudin-5 was preserved up to 180 min. DWI-T2 mismatch area may not always indicate intactness of cytoskeletal protein but shows preservation of BBB.
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Affiliation(s)
- Kentaro Ishizuka
- Department of Neurology, Tokyo Women's Medical University, Tokyo, Japan
| | - Moeko Saito
- Department of Neurology, Tokyo Women's Medical University, Tokyo, Japan
| | - Noriyuki Shibata
- Department of Pathology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazuo Kitagawa
- Department of Neurology, Tokyo Women's Medical University, Tokyo, Japan.
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Aoki J, Sakamoto Y, Suzuki K, Nishi Y, Kutsuna A, Takei Y, Sawada K, Kanamaru T, Abe A, Katano T, Takeshi Y, Nakagami T, Numao S, Kimura R, Suda S, Nishiyama Y, Kimura K. Fluid-Attenuated Inversion Recovery May Serve As a Tissue Clock in Patients Treated With Endovascular Thrombectomy. Stroke 2021; 52:2232-2240. [PMID: 33957776 DOI: 10.1161/strokeaha.120.033374] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Junya Aoki
- Department of Neurology, Nippon Medical School Graduate School of Medicine, Japan
| | - Yuki Sakamoto
- Department of Neurology, Nippon Medical School Graduate School of Medicine, Japan
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School Graduate School of Medicine, Japan
| | - Yuji Nishi
- Department of Neurology, Nippon Medical School Graduate School of Medicine, Japan
| | - Akihito Kutsuna
- Department of Neurology, Nippon Medical School Graduate School of Medicine, Japan
| | - Yukako Takei
- Department of Neurology, Nippon Medical School Graduate School of Medicine, Japan
| | - Kazutaka Sawada
- Department of Neurology, Nippon Medical School Graduate School of Medicine, Japan
| | - Takuya Kanamaru
- Department of Neurology, Nippon Medical School Graduate School of Medicine, Japan
| | - Arata Abe
- Department of Neurology, Nippon Medical School Graduate School of Medicine, Japan
| | - Takehiro Katano
- Department of Neurology, Nippon Medical School Graduate School of Medicine, Japan
| | - Yuho Takeshi
- Department of Neurology, Nippon Medical School Graduate School of Medicine, Japan
| | - Toru Nakagami
- Department of Neurology, Nippon Medical School Graduate School of Medicine, Japan
| | - Shinichiro Numao
- Department of Neurology, Nippon Medical School Graduate School of Medicine, Japan
| | - Ryutaro Kimura
- Department of Neurology, Nippon Medical School Graduate School of Medicine, Japan
| | - Satoshi Suda
- Department of Neurology, Nippon Medical School Graduate School of Medicine, Japan
| | - Yasuhiro Nishiyama
- Department of Neurology, Nippon Medical School Graduate School of Medicine, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School Graduate School of Medicine, Japan
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4
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Elsaid N, Mustafa W, Saied A. Radiological predictors of hemorrhagic transformation after acute ischemic stroke: An evidence-based analysis. Neuroradiol J 2020; 33:118-133. [PMID: 31971093 PMCID: PMC7140299 DOI: 10.1177/1971400919900275] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Hemorrhagic transformation (HT) is one of the most common adverse events related to acute ischemic stroke (AIS) that affects the treatment plan and clinical outcome. Identification of a sensitive radiological marker may influence the controversial thrombolytic decision in the setting of AIS and may at a minimum indicate more intensive monitoring or further prophylactic interventions. In this article we summarize possible radiological biomarkers and the role of different radiological modalities including computed tomography (CT), magnetic resonance imaging, angiography, and ultrasound in predicting HT. Different radiological indices of early ischemic changes, large ischemic lesion volume, severe blood flow restriction, blood-brain barrier disruption, poor collaterals and high blood flow velocities have been reported to be associated with higher risk of HT. The current levels of evidence of the available studies highlight the role of the different CT perfusion parameters in predicting HT. Further large standardized studies are recommended to compare the sensitivity and specificity of the different radiological markers combined and delineate the most reliable predictor.
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Affiliation(s)
- Nada Elsaid
- Department of Neurology, University of Mansoura
Faculty of Medicine, Egypt
| | - Wessam Mustafa
- Department of Neurology, University of Mansoura
Faculty of Medicine, Egypt
| | - Ahmed Saied
- Department of Neurology, University of Mansoura
Faculty of Medicine, Egypt
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Schwamm LH, Wu O, Song SS, Latour LL, Ford AL, Hsia AW, Muzikansky A, Betensky RA, Yoo AJ, Lev MH, Boulouis G, Lauer A, Cougo P, Copen WA, Harris GJ, Warach S. Intravenous thrombolysis in unwitnessed stroke onset: MR WITNESS trial results. Ann Neurol 2018; 83:980-993. [PMID: 29689135 DOI: 10.1002/ana.25235] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 04/08/2018] [Accepted: 04/12/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Most acute ischemic stroke (AIS) patients with unwitnessed symptom onset are ineligible for intravenous thrombolysis due to timing alone. Lesion evolution on fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) correlates with stroke duration, and quantitative mismatch of diffusion-weighted MRI with FLAIR (qDFM) might indicate stroke duration within guideline-recommended thrombolysis. We tested whether intravenous thrombolysis ≤4.5 hours from the time of symptom discovery is safe in patients with qDFM in an open-label, phase 2a, prospective study (NCT01282242). METHODS Patients aged 18 to 85 years with AIS of unwitnessed onset at 4.5 to 24 hours since they were last known to be well, treatable within 4.5 hours of symptom discovery with intravenous alteplase (0.9mg/kg), and presenting with qDFM were screened across 14 hospitals. The primary outcome was the risk of symptomatic intracranial hemorrhage (sICH) with preplanned stopping rules. Secondary outcomes included symptomatic brain edema risk, and functional outcomes of 90-day modified Rankin Scale (mRS). RESULTS Eighty subjects were enrolled between January 31, 2011 and October 4, 2015 and treated with alteplase at median 11.2 hours (IQR = 9.5-13.3) from when they were last known to be well. There was 1 sICH (1.3%) and 3 cases of symptomatic edema (3.8%). At 90 days, 39% of subjects achieved mRS = 0-1, as did 48% of subjects who had vessel imaging and were without large vessel occlusions. INTERPRETATION Intravenous thrombolysis within 4.5 hours of symptom discovery in patients with unwitnessed stroke selected by qDFM, who are beyond the recommended time windows, is safe. A randomized trial testing efficacy using qDFM appears feasible and is warranted in patients without large vessel occlusions. Ann Neurol 2018;83:980-993.
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Affiliation(s)
- Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Ona Wu
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA
| | - Shlee S Song
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Lawrence L Latour
- Acute Cerebrovascular Diagnostics Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Andria L Ford
- Department of Neurology, Washington University School of Medicine, St Louis, MO
| | - Amie W Hsia
- Acute Cerebrovascular Diagnostics Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD.,Comprehensive Stroke Center, MedStar Washington Hospital Center, Washington, DC
| | | | - Rebecca A Betensky
- Massachusetts General Hospital Biostatistics Center, Boston, MA.,Harvard T. H. Chan School of Public Health, Boston, MA
| | - Albert J Yoo
- Neuroendovascular Service, Texas Stroke Institute, Plano, TX.,Department of Radiology, Massachusetts General Hospital, Boston, MA
| | - Michael H Lev
- Department of Radiology, Massachusetts General Hospital, Boston, MA
| | - Gregoire Boulouis
- Department of Neurology, Massachusetts General Hospital, Boston, MA.,Department of Neuroradiology, Paris Descartes University, Saint Anne Hospital Center, Paris, France
| | - Arne Lauer
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Pedro Cougo
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - William A Copen
- Department of Radiology, Massachusetts General Hospital, Boston, MA
| | - Gordon J Harris
- Department of Radiology, Massachusetts General Hospital, Boston, MA
| | - Steven Warach
- Dell Medical School, University of Texas at Austin, Austin, TX
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Meisterernst J, Klinger-Gratz PP, Leidolt L, Lang MF, Schroth G, Mordasini P, Heldner MR, Mono ML, Kurmann R, Buehlmann M, Fischer U, Arnold M, Gralla J, Mattle HP, El-Koussy M, Jung S. Focal T2 and FLAIR hyperintensities within the infarcted area: A suitable marker for patient selection for treatment? PLoS One 2017; 12:e0185158. [PMID: 28957339 PMCID: PMC5619762 DOI: 10.1371/journal.pone.0185158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 09/07/2017] [Indexed: 12/03/2022] Open
Abstract
Background and purpose Some authors use FLAIR imaging to select patients for stroke treatment. However, the effect of hyperintensity on FLAIR images on outcome and bleeding has been addressed in only few studies with conflicting results. Methods 466 patients with anterior circulation strokes were included in this study. They all were examined with MRI before intravenous or endovascular treatment. Baseline data and 3 months outcome were recorded prospectively. Focal T2 and FLAIR hyperintensities within the ischemic lesion were evaluated by two raters, and the PROACT II classification was applied to assess bleeding complications on follow up imaging. Logistic regression analysis was used to determine predictors of bleeding complications and outcome and to analyze the influence of T2 or FLAIR hyperintensity on outcome. Results Focal hyperintensities were found in 142 of 307 (46.3%) patients with T2 weighted imaging and in 89 of 159 (56%) patients with FLAIR imaging. Hyperintensity in the basal ganglia, especially in the lentiform nucleus, on T2 weighted imaging was the only independent predictor of any bleeding after reperfusion treatment (33.8% in patients with vs. 18.2% in those without; p = 0.003) and there was a non-significant trend for more bleedings in patients with FLAIR hyperintensity within the basal ganglia (p = 0.069). However, there was no association of hyperintensity on T2 weighted or FLAIR images and symptomatic bleeding or worse outcome. Conclusion Our results question the assumption that T2 or FLAIR hyperintensities within the ischemic lesion should be used to exclude patients from reperfusion therapy, especially not from endovascular treatment.
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Affiliation(s)
- Julia Meisterernst
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Pascal P. Klinger-Gratz
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- Department of Radiology, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Lars Leidolt
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Matthias F. Lang
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gerhard Schroth
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Mirjam R. Heldner
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marie-Luise Mono
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Rebekka Kurmann
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Monika Buehlmann
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Heinrich P. Mattle
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marwan El-Koussy
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- * E-mail:
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7
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Fluid-Attenuated Inversion Recovery Hyperintensity Is Associated with Hemorrhagic Transformation following Reperfusion Therapy. J Stroke Cerebrovasc Dis 2017; 26:327-333. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.09.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 09/13/2016] [Accepted: 09/15/2016] [Indexed: 11/21/2022] Open
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8
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Verma RK, Gralla J, Klinger-Gratz PP, Schankath A, Jung S, Mordasini P, Zubler C, Arnold M, Buehlmann M, Lang MF, El-Koussy M, Hsieh K. Infarction Distribution Pattern in Acute Stroke May Predict the Extent of Leptomeningeal Collaterals. PLoS One 2015; 10:e0137292. [PMID: 26327519 PMCID: PMC4556517 DOI: 10.1371/journal.pone.0137292] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 08/16/2015] [Indexed: 11/25/2022] Open
Abstract
Objective The aim of this study was to evaluate whether the distribution pattern of early ischemic changes in the initial MRI allows a practical method for estimating leptomeningeal collateralization in acute ischemic stroke (AIS). Methods Seventy-four patients with AIS underwent MRI followed by conventional angiogram and mechanical thrombectomy. Diffusion restriction in Diffusion weighted imaging (DWI) and correlated T2-hyperintensity of the infarct were retrospectively analyzed and subdivided in accordance with Alberta Stroke Program Early CT score (ASPECTS). Patients were angiographically graded in collateralization groups according to the method of Higashida, and dichotomized in 2 groups: 29 subjects with collateralization grade 3 or 4 (well-collateralized group) and 45 subjects with grade 1 or 2 (poorly-collateralized group). Individual ASPECTS areas were compared among the groups. Results Means for overall DWI-ASPECTS were 6.34 vs. 4.51 (well vs. poorly collateralized groups respectively), and for T2-ASPECTS 9.34 vs 8.96. A significant difference between groups was found for DWI-ASPECTS (p<0.001), but not for T2-ASPECTS (p = 0.088). Regarding the individual areas, only insula, M1-M4 and M6 showed significantly fewer infarctions in the well-collateralized group (p-values <0.001 to 0.015). 89% of patients in the well-collateralized group showed 0–2 infarctions in these six areas (44.8% with 0 infarctions), while 59.9% patients of the poor-collateralized group showed 3–6 infarctions. Conclusion Patients with poor leptomeningeal collateralization show more infarcts on the initial MRI, particularly in the ASPECTS areas M1 to M4, M6 and insula. Therefore DWI abnormalities in these areas may be a surrogate marker for poor leptomeningeal collaterals and may be useful for estimation of the collateral status in routine clinical evaluation.
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Affiliation(s)
- Rajeev Kumar Verma
- University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
- Institute of Radiology, Tiefenau Hospital, Spital-Netz Bern, Bern, Switzerland
- * E-mail:
| | - Jan Gralla
- University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Pascal Pedro Klinger-Gratz
- University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Adrian Schankath
- University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Christoph Zubler
- University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
| | - Monika Buehlmann
- Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
| | - Matthias F. Lang
- University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Marwan El-Koussy
- University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Kety Hsieh
- University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
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Ibatullin MM, Kalinin MN, Curado AT, Khasanova DR. [Neurovisualisation predictors of malignant cerebral infarction and hemorrhagic transformation]. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:3-11. [PMID: 26120991 DOI: 10.17116/jnevro2015115323-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neuroimaging plays a central role in the assessment of patients with acute ischemic stroke. Within a few minutes, modern multimodal imaging protocols can provide one with comprehensive information about prognosis, management, and outcome of the disease, and may detect changes in the intracranial structures reflecting severity of the ischemic injury depicted by four Ps: parenchyma (of the brain), pipes (i.e., the cerebral blood vessels), penumbra, and permeability (of the blood brain barrier). In this article, we have reviewed neuroradiological predictors of malignant middle cerebral artery infarction and hemorrhagic transformation in light of the aforementioned four Ps.
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Affiliation(s)
| | | | - A T Curado
- Interregional Clinical Diagnostic Center, Kazan
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10
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Sun X, Berthiller J, Trouillas P, Derex L, Diallo L, Hanss M. Early fibrinogen degradation coagulopathy: A predictive factor of parenchymal hematomas in cerebral rt-PA thrombolysis. J Neurol Sci 2015; 351:109-114. [DOI: 10.1016/j.jns.2015.02.048] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 02/26/2015] [Accepted: 02/27/2015] [Indexed: 10/23/2022]
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11
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Hobohm C, Fritzsch D, Budig S, Classen J, Hoffmann K, Michalski D. Predicting intracerebral hemorrhage by baseline magnetic resonance imaging in stroke patients undergoing systemic thrombolysis. Acta Neurol Scand 2014; 130:338-45. [PMID: 25040041 PMCID: PMC4269181 DOI: 10.1111/ane.12272] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2014] [Indexed: 11/26/2022]
Abstract
Objectives Intracerebral hemorrhage (ICH) remains a serious complication in ischemic stroke patients undergoing systemic thrombolysis. Here, we examined whether the risk of treatment-associated hemorrhage can be predicted from magnetic resonance imaging (MRI) using fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted imaging (DWI) within 3 h after symptom onset. Methods In this single-center observational study involving 122 ischemic stroke patients between January 2005 and December 2008, the incidence of FLAIR-positive lesions within diffusion-restricted areas was determined on baseline MRI, which was carried out prior to treatment with tissue plasminogen activator (Actilyse®) within 3 h from symptom onset. The rate of ICH was assessed by computed tomography performed within 24 h after treatment. Relationships between FLAIR-positive lesions, DWI lesion size, proportion of FLAIR/DWI-positive lesions, and occurrence of bleeding were explored. Results Data from 97 patients were evaluated. FLAIR-positive lesions were present in 25 patients (25.8%) and ICH occurred in 32 patients (33.0%). FLAIR-positive lesions were associated with a bleeding rate of 80.0% compared with 16.7% in FLAIR-negative patients (P < 0.001; odds ratio 20.0, positive predictive value 0.8). DWI lesion size was significantly correlated with the rate of ICH (P = 0.001). In contrast, FLAIR/DWI proportion was not associated with ICH (P = 0.788). Conclusions In ischemic stroke patients within 3 h from symptom onset, the existence of FLAIR-positive lesions on pretreatment MRI is significantly associated with an increased bleeding risk due to systemic thrombolysis. Therefore, considering FLAIR-positive lesions on baseline MRI might guide treatment decisions in ischemic stroke.
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Affiliation(s)
- C. Hobohm
- Department of Neurology University of Leipzig Leipzig Germany
| | - D. Fritzsch
- Department of Neuroradiology University of Leipzig Leipzig Germany
| | - S. Budig
- Department of Neurology University of Leipzig Leipzig Germany
| | - J. Classen
- Department of Neurology University of Leipzig Leipzig Germany
| | - K.‐T. Hoffmann
- Department of Neuroradiology University of Leipzig Leipzig Germany
| | - D. Michalski
- Department of Neurology University of Leipzig Leipzig Germany
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12
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Kim BJ, Kang HG, Kim HJ, Ahn SH, Kim NY, Warach S, Kang DW. Magnetic resonance imaging in acute ischemic stroke treatment. J Stroke 2014; 16:131-45. [PMID: 25328872 PMCID: PMC4200598 DOI: 10.5853/jos.2014.16.3.131] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 09/15/2014] [Accepted: 09/16/2014] [Indexed: 11/11/2022] Open
Abstract
Although intravenous administration of tissue plasminogen activator is the only proven treatment after acute ischemic stroke, there is always a concern of hemorrhagic risk after thrombolysis. Therefore, selection of patients with potential benefits in overcoming potential harms of thrombolysis is of great importance. Despite the practical issues in using magnetic resonance imaging (MRI) for acute stroke treatment, multimodal MRI can provide useful information for accurate diagnosis of stroke, evaluation of the risks and benefits of thrombolysis, and prediction of outcomes. For example, the high sensitivity and specificity of diffusion-weighted image (DWI) can help distinguish acute ischemic stroke from stroke-mimics. Additionally, the lesion mismatch between perfusion-weighted image (PWI) and DWI is thought to represent potential salvageable tissue by reperfusion therapy. However, the optimal threshold to discriminate between benign oligemic areas and the penumbra is still debatable. Signal changes of fluid-attenuated inversion recovery image within DWI lesions may be a surrogate marker for ischemic lesion age and might indicate risks of hemorrhage after thrombolysis. Clot sign on gradient echo image may reflect the nature of clot, and their location, length and morphology may provide predictive information on recanalization by reperfusion therapy. However, previous clinical trials which solely or mainly relied on perfusion-diffusion mismatch for patient selection, failed to show benefits of MRI-based thrombolysis. Therefore, understanding the clinical implication of various useful MRI findings and comprehensively incorporating those variables into therapeutic decision-making may be a more reasonable approach for expanding the indication of acute stroke thrombolysis.
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Affiliation(s)
- Bum Joon Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun Goo Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Jin Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Ho Ahn
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Na Young Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Steven Warach
- Seton/University of Texas Southwestern Clinical Research Institute of Austin, TX, USA
| | - Dong-Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Jha R, Battey TWK, Pham L, Lorenzano S, Furie KL, Sheth KN, Kimberly WT. Fluid-attenuated inversion recovery hyperintensity correlates with matrix metalloproteinase-9 level and hemorrhagic transformation in acute ischemic stroke. Stroke 2014; 45:1040-5. [PMID: 24619394 DOI: 10.1161/strokeaha.113.004627] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE Matrix metalloproteinase-9 (MMP-9) is elevated in patients with acute stroke who later develop hemorrhagic transformation (HT). It is controversial whether early fluid-attenuated inversion recovery (FLAIR) hyperintensity on brain MRI predicts hemorrhagic transformation (HT). We assessed whether FLAIR hyperintensity was associated with MMP-9 and HT. METHODS We analyzed a prospectively collected cohort of acute stroke subjects with acute brain MRI images and MMP-9 values within the first 12 hours after stroke onset. FLAIR hyperintensity was measured using a signal intensity ratio between the stroke lesion and corresponding normal contralateral hemisphere. MMP-9 was measured using enzyme-linked immunosorbent assay. The relationships between FLAIR ratio (FR), MMP-9, and HT were evaluated. RESULTS A total of 180 subjects were available for analysis. Patients were imaged with brain MRI at 5.6±4.3 hours from last seen well time. MMP-9 blood samples were drawn within 7.7±4.0 hours from last seen well time. The time to MRI (r=0.17, P=0.027) and MMP-9 level (r=0.29, P<0.001) were each associated with FR. The association between MMP-9 and FR remained significant after multivariable adjustment (P<0.001). FR was also associated with HT and symptomatic hemorrhage (P=0.012). CONCLUSIONS FR correlates with both MMP-9 level and risk of hemorrhage. FLAIR changes in the acute phase of stroke may predict hemorrhagic transformation, possibly as a reflection of altered blood-brain barrier integrity.
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Affiliation(s)
- Ruchira Jha
- From the Department of Neurology, Massachusetts General Hospital, Boston, MA (R.J., T.W.K.B., L.P., W.T.K.); Department of Neurology and Psychiatry, Policlinico Umberto I Hospital, Sapienza University of Rome, Rome, Italy (S.L.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (K.L.F.); and Department of Neurology, Yale New Haven Hospital, New Haven, CT (K.N.S.)
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14
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Abstract
Cerebral ischemia manifests widely in patient symptoms. Along with the clinical examination, imaging serves as a powerful tool throughout the course of ischemia-from acute onset to evolution. A thorough understanding of imaging modalities, their strengths and their limitations, is essential for capitalizing on the benefit of this complementary source of information for understanding the mechanism of disease, making therapeutic decisions, and monitoring patient response over time.
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Affiliation(s)
- May Nour
- Department of Neurology, David Geffen School of Medicine, UCLA Stroke Center, University of California, RNRC, RM 4-126, Los Angeles, CA 90095, USA; Department of Radiology, Division of Interventional Neuroradiology, University of California, Los Angeles, 757 Westwood plaza Suite 2129, Los Angeles, CA 90095, USA
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15
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16
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Weiser RE, Sheth KN. Clinical Predictors and Management of Hemorrhagic Transformation. Curr Treat Options Neurol 2013; 15:125-49. [DOI: 10.1007/s11940-012-0217-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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17
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Hametner C, Ringleb PA, Hacke W, Kellert L. Selection of possible responders to thrombolytic therapy in acute ischemic stroke. Ann N Y Acad Sci 2012; 1268:120-6. [PMID: 22994230 DOI: 10.1111/j.1749-6632.2012.06747.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Ischemic stroke is one of the leading causes of death and morbidity worldwide, and systemic thrombolytic treatment is still the first-line therapy within 4.5 h from symptom onset. Selecting patients for treatment response is mandatory in any time window but challenging as well. The authors aim to support stroke physicians in their individual decision making. Besides evidence from clinical trials, some suggestions included here exclusively reflect the authors' opinions. This article presents clinical and imaging criteria of selecting patients reasonably, offering causal therapy to a growing number of patients.
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18
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Kufner A, Galinovic I, Brunecker P, Cheng B, Thomalla G, Gerloff C, Campbell BCV, Nolte CH, Endres M, Fiebach JB, Ebinger M. Early infarct FLAIR hyperintensity is associated with increased hemorrhagic transformation after thrombolysis. Eur J Neurol 2012; 20:281-5. [DOI: 10.1111/j.1468-1331.2012.03841.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 07/04/2012] [Indexed: 11/30/2022]
Affiliation(s)
- A. Kufner
- International Graduate Program Medical Neurosciences; Charité - Universitätsmedizin Berlin; Berlin; Germany
| | | | - P. Brunecker
- Center for Stroke Research Berlin; Berlin; Germany
| | - B. Cheng
- Department of Neurology; Center for Clinical Neurosciences; University Medical Center Hamburg; Eppendorf; Hamburg; Germany
| | - G. Thomalla
- Department of Neurology; Center for Clinical Neurosciences; University Medical Center Hamburg; Eppendorf; Hamburg; Germany
| | - C. Gerloff
- Department of Neurology; Center for Clinical Neurosciences; University Medical Center Hamburg; Eppendorf; Hamburg; Germany
| | - B. C. V. Campbell
- Department of Neurology; Royal Melbourne Hospital; University of Melbourne; Melbourne; Australia
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19
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Kang DW, Kwon JY, Kwon SU, Kim JS. Wake-up or unclear-onset strokes: are they waking up to the world of thrombolysis therapy? Int J Stroke 2012; 7:311-20. [PMID: 22510216 DOI: 10.1111/j.1747-4949.2012.00779.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Wake-up or unclear-onset strokes occur in up to one-fourth of patients with ischemic stroke. Although stroke severity and clinical outcomes appear to be poorer in wake-up strokes than nonwake-up strokes, many patients with wake-up strokes do not receive thrombolytic therapy because stroke onset time cannot be determined. Recent studies have suggested, however, that the actual onset time of wake-up stroke is close to the wake-up time. Furthermore, advanced imaging technologies may enable us to identify patients with favorable risk-benefit profiles for thrombolysis. Indeed, empirical thrombolytic treatments have suggested safety and feasibility of such therapy in these patients. Based on these promising results and the development of multimodal imaging methods, prospective thrombolysis trials using predefined imaging criteria are currently under way to test the safety and efficacy of thrombolysis in patients with wake-up or unclear-onset strokes. The establishment of optimal acute treatment strategies in this important yet so far neglected group of patients is eagerly awaited.
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Affiliation(s)
- Dong-Wha Kang
- Stroke Center and Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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20
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Ziegler A, Ebinger M, Fiebach JB, Audebert HJ, Leistner S. Judgment of FLAIR signal change in DWI-FLAIR mismatch determination is a challenge to clinicians. J Neurol 2011; 259:971-3. [PMID: 22037953 DOI: 10.1007/s00415-011-6284-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 10/04/2011] [Accepted: 10/07/2011] [Indexed: 10/15/2022]
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21
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Campbell BCV, Costello C, Christensen S, Ebinger M, Parsons MW, Desmond PM, Barber PA, Butcher KS, Levi CR, De Silva DA, Lansberg MG, Mlynash M, Olivot JM, Straka M, Bammer R, Albers GW, Donnan GA, Davis SM. Fluid-attenuated inversion recovery hyperintensity in acute ischemic stroke may not predict hemorrhagic transformation. Cerebrovasc Dis 2011; 32:401-5. [PMID: 21986096 DOI: 10.1159/000331467] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Accepted: 08/02/2011] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Fluid-attenuated inversion recovery (FLAIR) hyperintensity within an acute cerebral infarct may reflect delayed onset time and increased risk of hemorrhage after thrombolysis. Given the important implications for clinical practice, we examined the prevalence of FLAIR hyperintensity in patients 3-6 h from stroke onset and its relationship to parenchymal hematoma (PH). METHODS Baseline DWI and FLAIR imaging with subsequent hemorrhage detection (ECASS criteria) were prospectively obtained in patients 3-6 h after stroke onset from the pooled EPITHET and DEFUSE trials. FLAIR hyperintensity within the region of the acute DWI lesion was rated qualitatively (dichotomized as visually obvious or subtle (i.e. only visible after careful windowing)) and quantitatively (using relative signal intensity (RSI)). The association of FLAIR hyperintensity with hemorrhage was then tested alongside established predictors (very low cerebral blood volume (VLCBV) and diffusion (DWI) lesion volume) in logistic regression analysis. RESULTS There were 49 patients with pre-treatment FLAIR imaging (38 received tissue plasminogen activator (tPA), 5 developed PH). FLAIR hyperintensity within the region of acute DWI lesion occurred in 48/49 (98%) patients, was obvious in 18/49 (37%) and subtle in 30/49 (61%). Inter-rater agreement was 92% (κ = 0.82). The prevalence of obvious FLAIR hyperintensity did not differ between studies obtained in the 3-4.5 h and 4.5-6 h time periods (40% vs. 33%, p = 0.77). PH was poorly predicted by obvious FLAIR hyperintensity (sensitivity 40%, specificity 64%, positive predictive value 11%). In univariate logistic regression, VLCBV (p = 0.02) and DWI lesion volume (p = 0.03) predicted PH but FLAIR lesion volume (p = 0.87) and RSI (p = 0.11) did not. In ordinal logistic regression for hemorrhage grade adjusted for age and baseline stroke severity (NIHSS), increased VLCBV (p = 0.002) and DWI lesion volume (p = 0.003) were associated with hemorrhage but FLAIR lesion volume (p = 0.66) and RSI (p = 0.35) were not. CONCLUSIONS Visible FLAIR hyperintensity is almost universal 3-6 h after stroke onset and did not predict subsequent hemorrhage in this dataset. Our findings question the value of excluding patients with FLAIR hyperintensity from reperfusion therapies. Larger studies are required to clarify what implications FLAIR-positive lesions have for patient selection.
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Affiliation(s)
- Bruce C V Campbell
- Department of Medicine and Neurology, The Royal Melbourne Hospital, University of Melbourne, Parkville, Vic., Australia.
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22
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Abstract
Stroke, whether hemorrhagic or ischemic in nature, has the ability to lead to devastating and debilitating patient outcomes, which not only has direct implications from a healthcare standpoint, but its effects are longstanding and they impact the community as a whole. For decades, the goal of advancement and refinement in imaging modalities has been to develop the most precise, convenient, widely available and reproducible interpretable modality for the detection of stroke, not only in its hyperacute phase, but a method to be able to predict its evolution through the natural course of disease. Diagnosis is one of the most important initial roles, which imaging fulfills after the identification of existent pathology. However, imaging fulfills an even more important goal by using a combination of imaging modalities and their precise interpretation, which lends itself to understanding the mechanisms and pathophysiology of underlying disease, and therefore guides therapeutic decision-making in a patient-tailored fashion. This review explores the most commonly used brain imaging modalities, computer tomography, and magnetic resonance imaging, with an aim to demonstrate their dynamic use in uncovering stroke mechanism, facilitating prognostication, and potentially guiding therapy.
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Affiliation(s)
- May Nour
- University of California at Los Angeles Stroke Center, UCLA Medical Center, Los Angeles, CA 90095 USA
| | - David S. Liebeskind
- University of California at Los Angeles Stroke Center, UCLA Medical Center, Los Angeles, CA 90095 USA
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23
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Aoki J, Kimura K, Iguchi Y, Shibazaki K, Iwanaga T, Watanabe M, Kobayashi K, Sakai K, Sakamoto Y. Intravenous thrombolysis based on diffusion-weighted imaging and fluid-attenuated inversion recovery mismatch in acute stroke patients with unknown onset time. Cerebrovasc Dis 2011; 31:435-41. [PMID: 21346348 DOI: 10.1159/000323850] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Accepted: 12/16/2010] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Patients with unknown onset time would be able to receive intravenous thrombolysis when showing diffusion-weighted imaging (DWI)/fluid-attenuated inversion recovery (FLAIR) mismatch. METHODS Consecutive acute stroke patients with unknown onset time were prospectively enrolled. We defined patients as having unknown onset time when the last known normal time (LNT) was not consistent with the first found abnormal time (FAT). Only patients with anterior-circulation stroke and presence of arterial lesion were enrolled. Intravenous thrombolysis was conducted within 3 h from FAT if the patient showed DWI/FLAIR mismatch. RESULTS From June 2009 to May 2010, 10 patients [median age, 84 years (interquartile range, IQR, 64-90); National Institutes of Health Stroke Scale (NIHSS) score, 14 (IQR, 9-19)] were enrolled. Subjects included 4 patients who developed stroke during sleep, 5 with disturbance of consciousness, and 1 with aphasia. Median interval between LNT and thrombolysis was 5.6 h (IQR, 4.5-9.8) and median interval between FAT and thrombolysis was 2.5 h (IQR, 2.1-2.8). Three patients had internal carotid artery occlusion, 5 had M1 occlusion, and 2 had M2 occlusion. Early recanalization within 24 h was seen in 7 patients (complete recanalization, n = 4; partial recanalization, n = 3). No patients experienced symptomatic cerebral hemorrhage within 48 h. At day 7, 5 patients showed dramatic recovery (defined as ≥ 10-point reduction in total NIHSS score or score of 0 or 1). At 3 months, favorable outcome (modified Rankin scale score, 0-2) was seen in 4 patients. CONCLUSION Acute stroke patients with DWI/FLAIR mismatch may be able to safely receive intravenous thrombolysis.
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Affiliation(s)
- Junya Aoki
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki City, Japan.
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24
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25
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Use of magnetic resonance imaging to predict outcome after stroke: a review of experimental and clinical evidence. J Cereb Blood Flow Metab 2010; 30:703-17. [PMID: 20087362 PMCID: PMC2949172 DOI: 10.1038/jcbfm.2010.5] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Despite promising results in preclinical stroke research, translation of experimental data into clinical therapy has been difficult. One reason is the heterogeneity of the disease with outcomes ranging from complete recovery to continued decline. A successful treatment in one situation may be ineffective, or even harmful, in another. To overcome this, treatment must be tailored according to the individual based on identification of the risk of damage and estimation of potential recovery. Neuroimaging, particularly magnetic resonance imaging (MRI), could be the tool for a rapid comprehensive assessment in acute stroke with the potential to guide treatment decisions for a better clinical outcome. This review describes current MRI techniques used to characterize stroke in a preclinical research setting, as well as in the clinic. Furthermore, we will discuss current developments and the future potential of neuroimaging for stroke outcome prediction.
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Ebinger M, Galinovic I, Rozanski M, Brunecker P, Endres M, Fiebach JB. Fluid-Attenuated Inversion Recovery Evolution Within 12 Hours From Stroke Onset. Stroke 2010; 41:250-5. [DOI: 10.1161/strokeaha.109.568410] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
It has recently been proposed that fluid-attenuated inversion recovery (FLAIR) imaging may serve as a surrogate marker for time of symptom onset after stroke. We assessed the hypothesis that FLAIR imaging could be used to decide if an MRI was performed within 4.5 hours from symptom onset or later.
Methods—
All consecutive patients with presumed stroke who underwent an MRI within 12 hours after known symptom onset were included regardless of stroke subtype and severity between May 2008 and May 2009. Blinded to time of symptom onset, 2 raters judged the visibility of lesions on FLAIR. Apparent diffusion coefficient values, lesion volume on diffusion-weighted imaging, and relative signal intensity of FLAIR lesions were determined.
Results—
In 94 consecutive patients with stroke, we found that median time from symptom onset for FLAIR-positive patients (189 minutes; interquartile range, 110 to 369 minutes) was significantly longer compared with FLAIR-negative patients (103 minutes; interquartile range, 75 to 183 minutes;
P
=0.011). Negative FLAIR had a sensitivity of 46% and a specificity of 79% for allocating patients to a time window of less than 4.5 hours. FLAIR positivity increased with diffusion-weighted imaging lesion volume (
P
<0.001) but showed no correlation with apparent diffusion coefficient values (
P
=0.795). There was no significant correlation between relative signal intensity and time from symptom onset (Spearman correlation coefficient −0.152,
P
=0.128).
Conclusions—
Based on our findings, we cannot recommend the use of FLAIR visibility as an estimate of time from symptom onset within the first 4.5 hours.
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Affiliation(s)
- Martin Ebinger
- From the Center for Stroke Research Berlin (CSB; M. Ebinger, I.G., M.R., P.B., M. Endres, J.B.F.), Charité-Universitätsmedizin Berlin, Berlin, Germany; International Graduate Program Medical Neurosciences (I.G.), Charite-Universitätsmedizin Berlin, Berlin, Germany; and Klinik für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ivana Galinovic
- From the Center for Stroke Research Berlin (CSB; M. Ebinger, I.G., M.R., P.B., M. Endres, J.B.F.), Charité-Universitätsmedizin Berlin, Berlin, Germany; International Graduate Program Medical Neurosciences (I.G.), Charite-Universitätsmedizin Berlin, Berlin, Germany; and Klinik für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Michal Rozanski
- From the Center for Stroke Research Berlin (CSB; M. Ebinger, I.G., M.R., P.B., M. Endres, J.B.F.), Charité-Universitätsmedizin Berlin, Berlin, Germany; International Graduate Program Medical Neurosciences (I.G.), Charite-Universitätsmedizin Berlin, Berlin, Germany; and Klinik für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Brunecker
- From the Center for Stroke Research Berlin (CSB; M. Ebinger, I.G., M.R., P.B., M. Endres, J.B.F.), Charité-Universitätsmedizin Berlin, Berlin, Germany; International Graduate Program Medical Neurosciences (I.G.), Charite-Universitätsmedizin Berlin, Berlin, Germany; and Klinik für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- From the Center for Stroke Research Berlin (CSB; M. Ebinger, I.G., M.R., P.B., M. Endres, J.B.F.), Charité-Universitätsmedizin Berlin, Berlin, Germany; International Graduate Program Medical Neurosciences (I.G.), Charite-Universitätsmedizin Berlin, Berlin, Germany; and Klinik für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen B. Fiebach
- From the Center for Stroke Research Berlin (CSB; M. Ebinger, I.G., M.R., P.B., M. Endres, J.B.F.), Charité-Universitätsmedizin Berlin, Berlin, Germany; International Graduate Program Medical Neurosciences (I.G.), Charite-Universitätsmedizin Berlin, Berlin, Germany; and Klinik für Neurologie (M. Endres), Charité-Universitätsmedizin Berlin, Berlin, Germany
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Affiliation(s)
- Sung-Il Sohn
- Department of Neurology, Keimyung University School of Medicine, Korea.
| | - A-Hyun Cho
- Department of Neurology, The Catholic University of Korea, St. Mary's Hospital, Seoul, Korea.
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