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Pikija S, Magdic J, Liebeskind DS, Karamyan A, Bubel N, McCoy MR, Sellner J. Sigmoid Sinus Characteristics Correlate with Early Clinical and Imaging Surrogates in Anterior Circulation Ischemic Stroke. Mol Neurobiol 2016; 54:5583-5589. [PMID: 27613283 PMCID: PMC5533853 DOI: 10.1007/s12035-016-0091-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 08/30/2016] [Indexed: 11/11/2022]
Abstract
Cerebral venous outflow may play a decisive role in acute ischemic stroke. Here, we assessed the relation of cerebral sinus vein characteristics with clinical and imaging surrogates of early outcome in acute ischemic stroke. We evaluated cerebral vein characteristics in 212 patients with the middle cerebral artery (MCA) occlusive stroke confirmed by CT angiography CTA within 6 h from symptom onset. Readout parameters included volume and density of the sigmoid sinus (SS) and density of the superior sagittal sinus (SupSagS). These were correlated with early clinical outcome defined as hospital death (HD), final infarct volume (FIV), and National Institute of Health Stroke Scale (NIHSS) at discharge. We found a correlation for the volume of the right SS and the FIV when the M1 segment of the MCA of either side was occluded (p = 0.002, Rho = 0.206, n = 134). A decrease in SS density was more pronounced in the subgroup with unfavorable outcome (NIHSS > 15 + HD) but only when the left hemisphere was affected (p = 0.026, n = 101). On stepwise logistic regression analysis, adjusted for on-admission NIHSS, age at presentation, and FIV, smaller SS volume was independently associated with lower odds for hospital death (n = 183, OR 0.13, 95 % CI 0.02–0.94, p = 0.043). A larger right SS and a decrease in density increase the risk of unfavorable early clinical and imaging outcome in AIS. This finding of an outflow pattern independent of the stroke site implicates an involvement of the cerebral venous drainage system in the pathophysiology of ischemic stroke.
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Affiliation(s)
- Slaven Pikija
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Jozef Magdic
- Department of Neurology, Univerzitetni Klinični Center Maribor, Maribor, Slovenia
| | - David S Liebeskind
- Neurovascular Imaging Research Core and UCLA Stroke Center, University of California, Los Angeles, CA, USA
| | - Arthur Karamyan
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Nele Bubel
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Mark R McCoy
- Division of Neuroradiology, Christian Doppler Medical Center, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria. .,Department of Neurology, Klinikum rechts der Isar, Technische Universität München, München, Germany.
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Abstract
Numerous acute ischemic stroke trials have recently published detailed results, providing an opportunity to consider the role of collaterals in stroke pathophysiology and their influential effect on patient outcomes. Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke (SENTIS), the largest randomized controlled trial of device therapy to date, tested the potential augmentation of collateral perfusion. SYNTHESIS Expansion, Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE), and Interventional Management of Stroke (IMS) III chronicled the saga of endovascular therapy trialed against medical treatment for acute ischemic stroke. These recent randomized studies, however, largely neglect current device technology available for endovascular therapy as advanced by the TREVO2 and SOLITAIRE™(TM) FR With the Intention For Thrombectomy (SWIFT) studies. Such exhaustive efforts in recent trials have failed to introduce a new treatment for stroke that unequivocally improves patient outcomes. Collateral perfusion is widely recognized to vary across individuals in any population and exerts a dramatic effect on baseline variables including the time course of ischemic injury, stroke severity, imaging findings, and therapeutic opportunities. Similarly, collaterals have been recognized to influence recanalization, reperfusion, hemorrhagic transformation, and subsequent neurological outcomes after stroke. Collateral lessons may be gleaned from these trials, to expand consideration of overall study results and perhaps most importantly, alter ongoing and new trials in development. Detailed analyses of available information on collaterals from these trials demonstrate that collaterals may be more influential than the choice of treatment modality or intervention.
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Naggara O, Raymond J, Domingo Ayllon M, Al-Shareef F, Touzé E, Chenoufi M, Gerber S, Mellerio C, Zuber M, Meder JF, Mas JL, Oppenheim C. T2* "susceptibility vessel sign" demonstrates clot location and length in acute ischemic stroke. PLoS One 2013; 8:e76727. [PMID: 24146915 PMCID: PMC3795632 DOI: 10.1371/journal.pone.0076727] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 08/26/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES The aim of our study was to evaluate, in acute ischemic stroke patients, the diagnostic accuracy of the MRI susceptibility vessel sign (SVS) against catheter angiography (DSA) for the detection of the clot and its value in predicting clot location and length. MATERIALS AND METHODS We identified consecutive patients (2006-2012) admitted to our center, where 1.5 T MRI is systematically implemented as first-line diagnostic work-up, with: (1) pre-treatment 6-mm-thick multislice 2D T2* sequence; (2) delay from MRI-to-DSA <3 hrs; (3) no fibrinolysis between MRI and DSA. The location and length of SVS on T2* was independently assessed by three readers, and compared per patient, per artery and per segment, to DSA findings, obtained by two different readers. Clot length measured on T2* and DSA were compared using intra-class correlation coefficient (ICC), Bland & Altman test and Passing & Bablok regression analysis. RESULTS On DSA, a clot was present in 85 patients, in 126 of 1190 (10.6%) arteries and 175 of 1870 (9.4%) segments. Sensitivity of the SVS, as sensed by the used protocol at 1.5 T, was 81.1% (69 of 85 patients) and was higher in anterior (55 of 63, 87.3%), than in posterior circulation stroke (14 of 22, 63.6%, p=0.02). Sensitivity/specificity was 69.8/99.6% (per artery) and 76.6/99.7% (per segment). Positive (PPV) and negative predictive value (NPV) and accuracy were all >94%. Inter- and intra-observer ICC was excellent for clot length as measured on T2* (ĸ ≥ 0.97) and as measured on DSA (ĸ ≥ 0.94). Correlation between T2* and DSA for clot length was excellent (ICC: 0.88, 95%CI: 0.81-0.92; Bland & Altman: mean bias of 1.6% [95%CI: -4.7 to 7.8%], Passing & Bablok: 0.91). CONCLUSIONS SVS is a specific marker of clot location in the anterior and posterior circulation. Clot length greater than 6 mm can be reliably measured on T2*.
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Affiliation(s)
- Olivier Naggara
- Department of Neuroradiology, Université Paris-Descartes, INSERM UMR 894, Centre Hospitalier Sainte-Anne, Paris, Ile de France, France
- * E-mail:
| | - Jean Raymond
- Department of Radiology, The International Consortium of Neuroendovascular Centres, Interventional Neuroradiology Research Unit, University of Montreal, Notre-Dame Hospital, Montreal, QC, Canada
| | - Montserrat Domingo Ayllon
- Department of Neuroradiology, Université Paris-Descartes, INSERM UMR 894, Centre Hospitalier Sainte-Anne, Paris, Ile de France, France
| | - Fawaz Al-Shareef
- Department of Neuroradiology, Université Paris-Descartes, INSERM UMR 894, Centre Hospitalier Sainte-Anne, Paris, Ile de France, France
| | - Emmanuel Touzé
- Department of Neurology, Université Paris-Descartes, INSERM UMR 894, Centre Hospitalier Sainte-Anne, Paris, Ile de France, France
| | - Meriem Chenoufi
- Department of Neuroradiology, Université Paris-Descartes, INSERM UMR 894, Centre Hospitalier Sainte-Anne, Paris, Ile de France, France
| | - Sophie Gerber
- Department of Radiology, Saint Joseph Hospital, Paris, France
| | - Charles Mellerio
- Department of Neuroradiology, Université Paris-Descartes, INSERM UMR 894, Centre Hospitalier Sainte-Anne, Paris, Ile de France, France
| | - Matthieu Zuber
- Department of Neurology, Saint Joseph Hospital, Paris, Ile de France, France
| | - Jean Francois Meder
- Department of Neuroradiology, Université Paris-Descartes, INSERM UMR 894, Centre Hospitalier Sainte-Anne, Paris, Ile de France, France
| | - Jean-Louis Mas
- Department of Neurology, Université Paris-Descartes, INSERM UMR 894, Centre Hospitalier Sainte-Anne, Paris, Ile de France, France
| | - Catherine Oppenheim
- Department of Neuroradiology, Université Paris-Descartes, INSERM UMR 894, Centre Hospitalier Sainte-Anne, Paris, Ile de France, France
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Liebeskind DS, Sanossian N, Yong WH, Starkman S, Tsang MP, Moya AL, Zheng DD, Abolian AM, Kim D, Ali LK, Shah SH, Towfighi A, Ovbiagele B, Kidwell CS, Tateshima S, Jahan R, Duckwiler GR, Viñuela F, Salamon N, Villablanca JP, Vinters HV, Marder VJ, Saver JL. CT and MRI early vessel signs reflect clot composition in acute stroke. Stroke 2011; 42:1237-43. [PMID: 21393591 DOI: 10.1161/strokeaha.110.605576] [Citation(s) in RCA: 394] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to provide the first correlative study of the hyperdense middle cerebral artery sign (HMCAS) and gradient-echo MRI blooming artifact (BA) with pathology of retrieved thrombi in acute ischemic stroke. METHODS Noncontrast CT and gradient-echo MRI studies before mechanical thrombectomy in 50 consecutive cases of acute middle cerebral artery ischemic stroke were reviewed blinded to clinical and pathology data. Occlusions retrieved by thrombectomy underwent histopathologic analysis, including automated quantitative and qualitative rating of proportion composed of red blood cells (RBCs), white blood cells, and fibrin on microscopy of sectioned thrombi. RESULTS Among 50 patients, mean age was 66 years and 48% were female. Mean (SD) proportion was 61% (±21) fibrin, 34% (±21) RBCs, and 4% (±2) white blood cells. Of retrieved clots, 22 (44%) were fibrin-dominant, 13 (26%) RBC-dominant, and 15 (30%) mixed. HMCAS was identified in 10 of 20 middle cerebral artery stroke cases with CT with mean Hounsfield Unit density of 61 (±8 SD). BA occurred in 17 of 32 with gradient-echo MRI. HMCAS was more commonly seen with RBC-dominant and mixed than fibrin-dominant clots (100% versus 67% versus 20%, P=0.016). Mean percent RBC composition was higher in clots associated with HMCAS (47% versus 22%, P=0.016). BA was more common in RBC-dominant and mixed clots compared with fibrin-dominant clots (100% versus 63% versus 25%, P=0.002). Mean percent RBC was greater with BA (42% versus 23%, P=0.011). CONCLUSIONS CT HMCAS and gradient-echo MRI BA reflect pathology of occlusive thrombus. RBC content determines appearance of HMCAS and BA, whereas absence of HMCAS or BA may indicate fibrin-predominant occlusive thrombi.
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