1
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Long J, Chen J, Huang G, Chen Z, Zhang H, Zhang Y, Duan Q, Wu B, He J. The differences of fibrinogen levels in various types of hemorrhagic transformations. Front Neurol 2024; 15:1364875. [PMID: 39119563 PMCID: PMC11306044 DOI: 10.3389/fneur.2024.1364875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 07/11/2024] [Indexed: 08/10/2024] Open
Abstract
Introduction Hemorrhagic transformation (HT) is a serious complication that can occur spontaneously after an acute ischemic stroke (AIS) or after a thrombolytic/mechanical thrombectomy. Our study aims to explore the potential correlations between fibrinogen levels and the occurrence of spontaneous HT (sHT) and HT after mechanical thrombectomy (tHT). Methods A total of 423 consecutive AIS patients diagnosed HT who did not undergone thrombolysis and 423 age- and sex-matched patients without HT (non-HT) were enrolled. Fibrinogen levels were measured within 24 h of admission after stroke. The cohorts were trisected according to fibrinogen levels. The HT were further categorized into hemorrhagic infarction (HI) or parenchymal hematoma (PH) based on their imaging characteristics. Results In sHT cohort, fibrinogen levels were higher in HT patients than non-HT patients (p < 0.001 versus p = 0.002). High fibrinogen levels were associated with the severity of HT. HT patients without atrial fibrillation (AF) had higher levels of fibrinogen compared to non-HT (median 3.805 vs. 3.160, p < 0.001). This relationship did not differ among AF patients. In tHT cohort, fibrinogen levels were lower in HT patients than non-HT patients (p = 0.002). Lower fibrinogen levels were associated with the severity of HT (p = 0.004). The highest trisection of fibrinogen both in two cohorts were associated with HT [sHT cohort: OR = 2.515 (1.339-4.725), p = 0.016; that cohort: OR = 0.238 (0.108-0.523), p = 0.003]. Conclusion Our study suggests that lower fibrinogen level in sHT without AF and higher fibrinogen level in tHT are associated with more severe HT.
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Affiliation(s)
- Jingfang Long
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- Department of Neurology, Wenzhou Central Hospital, Wenzhou, Zhejiang, China
| | - Jiahao Chen
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Guiqian Huang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- School of Mental Health, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zhen Chen
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Heyu Zhang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Ye Zhang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Qi Duan
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Beilan Wu
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jincai He
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
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Honig A, Percy J, Sepehry AA, Gomez AG, Field TS, Benavente OR. Hemorrhagic Transformation in Acute Ischemic Stroke: A Quantitative Systematic Review. J Clin Med 2022; 11:jcm11051162. [PMID: 35268253 PMCID: PMC8910828 DOI: 10.3390/jcm11051162] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 02/13/2022] [Accepted: 02/17/2022] [Indexed: 02/06/2023] Open
Abstract
The prevalence and risk factors of hemorrhagic transformation (HT) after acute ischemic stroke HT have not been adequately delineated. We performed a systematic review and meta-analysis to identify English-language prospective observational MEDLINE and EMBASE-listed reports of acute ischemic stroke with HT published from 1985–2017. Studies that used the ECASS-2 definitions of hemorrhagic transformation subtypes, hemorrhagic infarction (HI), and parenchymal hematoma (PH) were included. Patients treated with intravenous thrombolysis with tissue plasminogen activator (IV-tPA) were compared with those who did not receive thrombolysis. A total of 65 studies with 17,259 patients met inclusion criteria. Overall, HT prevalence was 27%; 32% in patients receiving IV-tPA vs. 20% in those without. Overall PH prevalence was 9%; 12% in IV-tPA treated patients vs. 5% in those without. HT was associated with a history of atrial fibrillation (OR 2.94) and use of anticoagulants (OR 2.47). HT patients had higher NIHSS (Hedge’s-G 0.96) and larger infarct volume (diffusion-weighted MRI, Hedge’s-G 0.8). In IV-tPA treated patients, PH correlated with antiplatelet (OR 3) and statin treatment (OR 4). HT (OR 3) and PH (OR 8) were associated with a poor outcome at 90-day (mRS 5–6). Hemorrhagic transformation is a frequent complication of acute ischemic stroke and is associated with poor outcome. Recognition of risk factors for HT and PH may reduce their incidence and severity.
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Affiliation(s)
- Asaf Honig
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel
- Correspondence:
| | - Jennifer Percy
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
| | - Amir A. Sepehry
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
- Clinical Psychology Program, Adler University, Vancouver, BC V6B 3J5, Canada
| | - Alejandra G. Gomez
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
| | - Thalia S. Field
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
| | - Oscar R. Benavente
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC V6T 2B5, Canada; (J.P.); (A.A.S.); (A.G.G.); (T.S.F.); (O.R.B.)
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3
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Tsivgoulis G, Kargiotis O, De Marchis G, Kohrmann M, Sandset EC, Karapanayiotides T, de Sousa DA, Sarraj A, Safouris A, Psychogios K, Vadikolias K, Leys D, Schellinger PD, Alexandrov AV. Off-label use of intravenous thrombolysis for acute ischemic stroke: a critical appraisal of randomized and real-world evidence. Ther Adv Neurol Disord 2021; 14:1756286421997368. [PMID: 33737956 PMCID: PMC7934037 DOI: 10.1177/1756286421997368] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 01/25/2021] [Indexed: 12/12/2022] Open
Abstract
Intravenous thrombolysis (IVT) represents the only systemic reperfusion therapy able to reverse neurological deficit in patients with acute ischemic stroke (AIS). Despite its effectiveness in patients with or without large vessel occlusion, it can be offered only to a minority of them, because of the short therapeutic window and additional contraindications derived from stringent but arbitrary inclusion and exclusion criteria used in landmark randomized controlled clinical trials. Many absolute or relative contraindications lead to disparities between the official drug label and guidelines or expert recommendations. Based on recent advances in neuroimaging and evidence from cohort studies, off-label use of IVT is increasingly incorporated into the daily practice of many stroke centers. They relate to extension of therapeutic time windows, and expansion of indications in co-existing conditions originally listed in exclusion criteria, such as use of alternative thrombolytic agents, pre-treatment with antiplatelets, anticoagulants or low molecular weight heparins. In this narrative review, we summarize recent randomized and real-world data on the safety and efficacy of off-label use of IVT for AIS. We also make some practical recommendations to stroke physicians regarding the off-label use of thrombolytic agents in complex and uncommon presentations of AIS or other conditions mimicking acute cerebral ischemia. Finally, we provide guidance on the risks and benefits of IVT in numerous AIS subgroups, where equipoise exists and guidelines and treatment practices vary.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, Iras 39, Gerakas Attikis, Athens 15344, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - Gianmarco De Marchis
- Neurology and Stroke Center, Department of Clinical Research, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Martin Kohrmann
- Department of Neurology, Universitätsklinikum Essen, Essen, Germany
| | | | - Theodore Karapanayiotides
- Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Diana Aguiar de Sousa
- Department of Neurosciences (Neurology), Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal
| | - Amrou Sarraj
- Department of Neurology, The University of Texas at Houston, Houston, TX, USA
| | - Apostolos Safouris
- Second Department of Neurology, National & Kapodistiran University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | | | - Konstantinos Vadikolias
- Department of Neurology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Didier Leys
- Department of Neurology (Stroke Unit), Lille Neuroscience and Cognition, Degenerative and Vascular Cognitive Disorders, University of Lille, INSERM (U-1172), Lille, France
| | - Peter D. Schellinger
- Department of Neurology, Johannes Wesling Medical Center Minden, UK RUB Minden, Germany
| | - Andrei V. Alexandrov
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
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4
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Matei N, Camara J, Zhang JH. The Next Step in the Treatment of Stroke. Front Neurol 2021; 11:582605. [PMID: 33551950 PMCID: PMC7862333 DOI: 10.3389/fneur.2020.582605] [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] [Received: 07/13/2020] [Accepted: 12/23/2020] [Indexed: 12/12/2022] Open
Abstract
Although many patients do not receive reperfusion therapy because of delayed presentation and/or severity and location of infarct, new reperfusion approaches are expanding the window of intervention. Novel application of neuroprotective agents in combination with the latest methods of reperfusion provide a path to improved stroke intervention outcomes. We examine why neuroprotective agents have failed to translate to the clinic and provide suggestions for new approaches. New developments in recanalization therapy in combination with therapeutics evaluated in parallel animal models of disease will allow for novel, intra-arterial deployment of therapeutic agents over a vastly expanded therapeutic time window and with greater likelihood success. Although the field of neuronal, endothelial, and glial protective therapies has seen numerous large trials, the application of therapies in the context of newly developed reperfusion strategies is still in its infancy. Given modern imaging developments, evaluation of the penumbra will likely play a larger role in the evolving management of stroke. Increasingly more patients will be screened with neuroimaging to identify patients with adequate collateral blood supply allowing for delayed rescue of the penumbra. These patients will be ideal candidates for therapies such as reperfusion dependent therapeutic agents that pair optimally with cutting-edge reperfusion techniques.
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Affiliation(s)
- Nathanael Matei
- Department of Ophthalmology, University of Southern California, Los Angeles, CA, United States
| | - Justin Camara
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, United States
| | - John H Zhang
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, United States.,Department of Anesthesiology, Loma Linda University, Loma Linda, CA, United States.,Department of Neurosurgery, Loma Linda University, Loma Linda, CA, United States
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5
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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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6
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Kim J, Kim CH, Kang J, Kwon OY. Predicting parenchymal hematoma associated with endovascular thrombectomy for acute occlusion of anterior circulation large vessel: the GuEss-MALiGn scale. JOURNAL OF NEUROCRITICAL CARE 2020. [DOI: 10.18700/jnc.190104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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7
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Chung JW, Kim BJ, Jeong HG, Seo WK, Kim GM, Jung C, Han MK, Bae HJ, Bang OY. Selection of Candidates for Endovascular Treatment: Characteristics According to Three Different Selection Methods. J Stroke 2019; 21:332-339. [PMID: 31590477 PMCID: PMC6780015 DOI: 10.5853/jos.2019.01578] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/03/2019] [Indexed: 12/18/2022] Open
Abstract
Background and Purpose To investigate the number and characteristics of patients eligible for endovascular treatment (EVT) determined using three different selection methods: clinical-core mismatch, target mismatch, and collateral status.
Methods Using the data of consecutive patients from two prospectively maintained registries of university medical centers, the number and characteristics of patients according to the three selection methods were investigated and their correlation was analyzed. Patients with anterior circulation stroke due to occlusion of the middle cerebral and/or internal carotid artery and a National Institute of Health Stroke Scale (NIHSS) score of ≥6 points, who arrived within 8 hours or between 6 and 12 hours of symptom onset and underwent magnetic resonance imaging prior to EVT, were included. Collateral status was assessed using magnetic resonance perfusion-derived collateral flow maps.
Results Three hundred thirty-five patients were investigated; the proportions of patients who were eligible and ineligible for EVT in all three selection methods were both small (n=85, 25.4%; n=54, 16.1%, respectively). The intercorrelation among the three selection methods was low (κ=0.235). The baseline NIHSS score and onset-to-selection time interval were associated with the presence of clinical-core mismatch, while the penumbra/core volume ratio and onset-to-selection time interval were related to target mismatch; none of these variables were associated with collateral status. The infarct core volume was associated with favorable profiles in all three selection methods.
Conclusions Although the application of individual selection methods resulted in favorable outcomes after EVT in clinical trials, there is a significant discrepancy in EVT eligibility depending on the selection method used.
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Affiliation(s)
- Jong-Won Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Han-Gil Jeong
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Woo-Keun Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gyeong-Moon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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8
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Boisseau W, Fahed R, Lapergue B, Desilles JP, Zuber K, Khoury N, Garcia J, Maïer B, Redjem H, Ciccio G, Smajda S, Escalard S, Taylor G, Mazighi M, Michel P, Gory B, Blanc R. Predictors of Parenchymal Hematoma After Mechanical Thrombectomy: A Multicenter Study. Stroke 2019; 50:2364-2370. [PMID: 31670928 DOI: 10.1161/strokeaha.118.024512] [Citation(s) in RCA: 50] [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
Background and Purpose Parenchymal hematoma (PH) is a rare but dreadful complication of acute ischemic stroke with
unclear underlying mechanisms. We aimed to study the incidence and predictors of PH after mechanical thrombectomy. Methods Data from a prospective observational multicenter registry was screened to identify acute ischemic stroke
patients with an anterior circulation large vessel occlusion who underwent mechanical thrombectomy. Clinical, imaging, and procedural characteristics were used for the analysis, including brain imaging systematically performed at 24 hours. PH occurrence was assessed according to ECASS (European Collaborative Acute Stroke Study) criteria. Univariate and multivariable analyses were performed to identify predictors of PH. Results A total of 1316 patients were included in the study. PH occurred in 153 out of 1316 patients (11.6%) and was
associated with a lower rate of favorable outcome and increased mortality. On multivariable analysis, age (per 1 year increase, odds ratio [OR], 1.01; 95% CI, 1.00–1.03; P=0.05), current smoking (OR, 2.02; 95% CI, 1.32–3.09; P<0.01), admission Alberta Stroke Program Early CT Score (per a decrease of 1 point, OR, 1.70; 95% CI, 1.18–2.44; P<0.01), general anesthesia (OR, 1.98; 95% CI, 1.36–2.90; P<0.001), angiographic poor collaterals (OR, 2.13; 95% CI, 1.36–3.33; P<0.001) and embolization in new territory (OR, 2.94; 95% CI, 1.70–5.10; P<0.001) were identified as independent predictors of PH. Conclusions PH occurred at a rate of 11.6% after mechanical thrombectomy, with high morbidity and mortality. Our
study identified clinical, radiological, and procedural predictors of PH occurrence that can serve as the focus of future periprocedural management studies with the aim of reducing its occurrence.
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Affiliation(s)
- William Boisseau
- Interventional Neuroradiology Unit, Fondation Rothschild Hospital, Paris, France (W.B., R.F., J.-P.D., K.Z., B.M., H.R., G.C., S.S., S.E., M.M., M.P., R.B.)
| | - Robert Fahed
- Interventional Neuroradiology Unit, Fondation Rothschild Hospital, Paris, France (W.B., R.F., J.-P.D., K.Z., B.M., H.R., G.C., S.S., S.E., M.M., M.P., R.B.)
| | | | - Jean-Philippe Desilles
- Interventional Neuroradiology Unit, Fondation Rothschild Hospital, Paris, France (W.B., R.F., J.-P.D., K.Z., B.M., H.R., G.C., S.S., S.E., M.M., M.P., R.B.).,Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France (J.-P.D., M.M., M.P., R.B.).,Université Paris Denis Diderot, Sorbonne Paris Cite, France (J.-P.D., M.M., M.P., R.B.)
| | - Kevin Zuber
- Interventional Neuroradiology Unit, Fondation Rothschild Hospital, Paris, France (W.B., R.F., J.-P.D., K.Z., B.M., H.R., G.C., S.S., S.E., M.M., M.P., R.B.)
| | - Naim Khoury
- HSHS Neuroscience Center, HSHS St John's Hospital, Springfield, IL (N.K.)
| | - Jeanne Garcia
- Neurovascular Unit, Foch Hospital, Suresnes, France (B.L., J.G.)
| | - Benjamin Maïer
- Interventional Neuroradiology Unit, Fondation Rothschild Hospital, Paris, France (W.B., R.F., J.-P.D., K.Z., B.M., H.R., G.C., S.S., S.E., M.M., M.P., R.B.)
| | - Hocine Redjem
- Interventional Neuroradiology Unit, Fondation Rothschild Hospital, Paris, France (W.B., R.F., J.-P.D., K.Z., B.M., H.R., G.C., S.S., S.E., M.M., M.P., R.B.)
| | - Gabriele Ciccio
- Interventional Neuroradiology Unit, Fondation Rothschild Hospital, Paris, France (W.B., R.F., J.-P.D., K.Z., B.M., H.R., G.C., S.S., S.E., M.M., M.P., R.B.)
| | - Stanislas Smajda
- Interventional Neuroradiology Unit, Fondation Rothschild Hospital, Paris, France (W.B., R.F., J.-P.D., K.Z., B.M., H.R., G.C., S.S., S.E., M.M., M.P., R.B.)
| | - Simon Escalard
- Interventional Neuroradiology Unit, Fondation Rothschild Hospital, Paris, France (W.B., R.F., J.-P.D., K.Z., B.M., H.R., G.C., S.S., S.E., M.M., M.P., R.B.)
| | - Guillaume Taylor
- Department of Intensive Care, Rothschild Foundation Hospital, Paris, France (G.T.)
| | - Mikael Mazighi
- Interventional Neuroradiology Unit, Fondation Rothschild Hospital, Paris, France (W.B., R.F., J.-P.D., K.Z., B.M., H.R., G.C., S.S., S.E., M.M., M.P., R.B.).,Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France (J.-P.D., M.M., M.P., R.B.).,Université Paris Denis Diderot, Sorbonne Paris Cite, France (J.-P.D., M.M., M.P., R.B.)
| | - Piotin Michel
- Interventional Neuroradiology Unit, Fondation Rothschild Hospital, Paris, France (W.B., R.F., J.-P.D., K.Z., B.M., H.R., G.C., S.S., S.E., M.M., M.P., R.B.).,Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France (J.-P.D., M.M., M.P., R.B.).,Université Paris Denis Diderot, Sorbonne Paris Cite, France (J.-P.D., M.M., M.P., R.B.)
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Nancy Hospital, France (B.G.).,University of Lorraine, INSERM U1254, IADI, Nancy, France (B.G.)
| | - Raphaël Blanc
- Interventional Neuroradiology Unit, Fondation Rothschild Hospital, Paris, France (W.B., R.F., J.-P.D., K.Z., B.M., H.R., G.C., S.S., S.E., M.M., M.P., R.B.).,Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France (J.-P.D., M.M., M.P., R.B.).,Université Paris Denis Diderot, Sorbonne Paris Cite, France (J.-P.D., M.M., M.P., R.B.)
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Wu B, Liu N, Wintermark M, Parsons MW, Chen H, Lin L, Zhou S, Hu G, Zhang Y, Hu J, Li Y, Su Z, Wu X, Zhu G. Optimal Delay Time of CT Perfusion for Predicting Cerebral Parenchymal Hematoma After Intra-Arterial tPA Treatment. Front Neurol 2018; 9:680. [PMID: 30186221 PMCID: PMC6110878 DOI: 10.3389/fneur.2018.00680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 07/27/2018] [Indexed: 11/20/2022] Open
Abstract
Background and Purpose: Cerebral hemorrhage is a serious potential complication of stroke revascularization, especially in patients receiving intra-arterial tissue-type plasminogen activator (tPA) therapy. We investigated the optimal pre-intervention delay time (DT) of computed tomography perfusion (CTP) measurement to predict cerebral parenchymal hematoma (PH) in acute ischemic stroke (AIS) patients after intra-arterial tissue plasminogen activator (tPA) treatment. Methods: The study population consisted of a series of patients with AIS who received intra-arterial tPA treatment and had CTP and follow-up computed tomography/magnetic resonance imaging (CT/MRI) to identify hemorrhagic transformation. The association of increasing DT thresholds (>2, >4, >6, >8, and >10 s) with PH was examined using receiver operating characteristic (ROC) analysis and logistic regression. Results: Of 94 patients, 23 developed PH on follow-up imaging. Receiver operating characteristic analysis revealed that the greatest area under the curve for predicting PH occurred at DT > 4 s (area under the curve, 0.66). At this threshold of > 4 s, DT lesion volume ≥ 30.85 mL optimally predicted PH with 70% sensitivity and 59% specificity. DT > 4 s volume was independently predictive of PH in a multivariate logistic regression model (P < 0.05). Conclusions: DT > 4 s was the parameter most strongly associated with PH. The volume of moderate, not severe, hypo-perfusion on DT is more strongly associated and may allow better prediction of PH after intra-arterial tPA thrombolysis.
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Affiliation(s)
- Bing Wu
- Department of Radiology, PLA Army General Hospital, Beijing, China
| | - Nan Liu
- Department of Neurology, PLA Army General Hospital, Beijing, China
| | - Max Wintermark
- Neuroradiology Section, Department of Radiology, Stanford University, Stanford, CA, United States
| | - Mark W Parsons
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia.,Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Hui Chen
- Department of Neurology, PLA Army General Hospital, Beijing, China
| | - Longting Lin
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Shuai Zhou
- Department of Radiology, PLA Army General Hospital, Beijing, China.,Inner Mongolia Medical University Hohhot, China
| | - Gang Hu
- Department of Radiology, PLA Army General Hospital, Beijing, China
| | - Yongwei Zhang
- Department of Neurology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jun Hu
- Department of Neurology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Ying Li
- Department of Neurology, PLA Army General Hospital, Beijing, China
| | | | - Xinhuai Wu
- Department of Radiology, PLA Army General Hospital, Beijing, China.,Inner Mongolia Medical University Hohhot, China
| | - Guangming Zhu
- Neuroradiology Section, Department of Radiology, Stanford University, Stanford, CA, United States
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10
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Severe cerebral hypovolemia on perfusion CT and lower body weight are associated with parenchymal haemorrhage after thrombolysis. Neuroradiology 2016; 59:23-29. [PMID: 28028565 DOI: 10.1007/s00234-016-1775-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 12/07/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Haemorrhagic transformation of acute ischemic stroke (AIS) and particularly parenchymal haemorrhage (PH) remains a feared complication of intravenous thrombolysis (IVT). We aimed to identify clinical and perfusion CT (PCT) variables which are independently associated with PHs. METHODS In this observational cohort study, based on the Acute Stroke Registry Analysis of Lausanne (ASTRAL) from 2003 to December 2013, we selected patients with AIS involving the middle cerebral artery (MCA) territory who were thrombolysed within 4.5 h of symptoms' onset and who had a good quality baseline PCT at the beginning of IVT. In addition to demographic, clinical, laboratory and non-contrast CT data, volumes of salvageable tissue and ischemic core on PCT, as well as absolute CBF and CBV values within the ischemic regions were compared in patients with and without PH in multivariate analysis. RESULTS Of the 190 included patients, 24 (12.6%) presented a PH (11 had PH1 and 13 had PH2). In multivariate analysis of the clinical and radiological variables, the lowest CBV in the core and lower body weight was both significantly associated with PH (p = 0.009 and p = 0.024, respectively). CONCLUSION In thrombolysed MCA strokes, maximal hypoperfusion severity depicted by lowest CBV values in the core region and lower body weight are independently correlated with PH. This information, if confirmed in other case series, may add to the stratification of revascularisation decisions in patients with a perceived high PH risk.
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11
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Son JP, Lee MJ, Kim SJ, Chung JW, Cha J, Kim GM, Chung CS, Lee KH, Bang OY. Impact of Slow Blood Filling via Collaterals on Infarct Growth: Comparison of Mismatch and Collateral Status. J Stroke 2016; 19:88-96. [PMID: 28030891 PMCID: PMC5307934 DOI: 10.5853/jos.2016.00955] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 08/30/2016] [Accepted: 09/22/2016] [Indexed: 12/28/2022] Open
Abstract
Background and Purpose Perfusion-diffusion mismatch has been evaluated to determine whether the presence of a target mismatch helps to identify patients who respond favorably to recanalization therapies. We compared the impact on infarct growth of collateral status and the presence of a penumbra, using magnetic resonance perfusion (MRP) techniques. Methods Consecutive patients who were candidates for recanalization therapy and underwent serial diffusion-weighted imaging (DWI) and MRP were enrolled. A collateral flow map derived from MRP source data was generated by automatic post-processing. The impact of a target mismatch (Tmax>6 s/apparent diffusion coefficient (ADC) volume≥1.8, ADC volume<70 mL; and Tmax>10 s for ADC volume<100 mL) on infarct growth was compared with MR-based collateral grading on day 7 DWI, using multivariate linear regression analysis. Results Among 73 patients, 55 (75%) showed a target mismatch, whereas collaterals were poor in 14 (19.2%), intermediate in 36 (49.3%), and good in 23 (31.5%) patients. After adjusting for initial severity of stroke, early recanalization (P<0.001) and the MR-based collateral grading (P=0.001), but not the presence of a target mismatch, were independently associated with infarct growth. Even in patients with a target mismatch and successful recanalization, the degree of infarct growth depended on the collateral status. Perfusion status at later Tmax time points (beyond the arterial phase) was more closely correlated with collateral status. Conclusions Patients with good collaterals show a favorable outcome in terms of infarct growth, regardless of the presence of a target mismatch pattern. The presence of slow blood filling predicts collateral status and infarct growth.
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Affiliation(s)
- Jeong Pyo Son
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, Korea.,Center for Neuroscience Imaging Research (CNIR), Institute for Basic Science (IBS), Suwon, Korea
| | - Mi Ji Lee
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Suk Jae Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong-Won Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jihoon Cha
- Department of Radioology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gyeong-Moon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chin-Sang Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Ho Lee
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Oh Young Bang
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, Korea.,Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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12
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Cheripelli BK, Huang X, MacIsaac R, Muir KW. Interaction of Recanalization, Intracerebral Hemorrhage, and Cerebral Edema After Intravenous Thrombolysis. Stroke 2016; 47:1761-7. [PMID: 27301943 DOI: 10.1161/strokeaha.116.013142] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 05/17/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Both intracerebral hemorrhage (ICH) and brain edema have been attributed to reperfusion after intravenous thrombolysis. We explored the interaction of recanalization and core size for imaging outcomes (ICH and vasogenic brain edema). METHODS In patients with anterior circulation occlusion given intravenous thrombolysis <4.5 hours and imaged with computed tomographic (CT) perfusion and CT angiography, we defined volumes of core (relative delay time >2 s and relative cerebral blood flow <40%) and penumbra (relative delay time >2 s). CT and CT angiography at 24 hours were reviewed for ICH (European Cooperative Acute Stroke Study [ECASS]-2 definition), early vasogenic edema (third International Stroke Trial [IST-3] criteria), and recanalization (thrombolysis in myocardial infarction 2-3). Independent effects of recanalization, core volume and potential interactions on edema, ICH and day 90 outcomes were estimated by logistic regression. RESULTS In 123 patients, there was a trend for recanalization to be associated with H1/2 ICH (odds ratio [OR], 2.3 [0.97-5.5]; P=0.06) but not with PH1/2 ICH (OR, 1.7 [0.33-8.8]; P=0.5), any edema, or significant brain edema (OR, 1.45 [0.4-4.9]; P=0.55). Ischemic core (>50 mL) was associated with any ICH (OR, 4.0 [1.6-9.5]; P=0.003), edema (OR, 5.4 [2-14]; P<0.01), and significant brain edema (OR, 17.4 [5.3-57]; P<0.01) but not with PH1/2 ICH (OR, 1.2 [0.23-6.5]; P=0.8), after controlling for recanalization. There was no significant interaction of recanalization and large core for any adverse outcomes. CONCLUSIONS Large ischemic core was associated with poorer outcomes and both early vasogenic brain edema and ICH, but recanalization on 24-hour CT angiography was associated with clinically favorable outcome. There was no significant interaction of recanalization and large core volume for any outcomes. The association of hemorrhage or brain edema with post-thrombolysis reperfusion is unclear.
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Affiliation(s)
- Bharath Kumar Cheripelli
- From the Institute of Neuroscience and Psychology (B.K.C., X.H., K.W.M.) and Institute of Cardiovascular and Medical Sciences (R.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow, Scotland, United Kingdom
| | - Xuya Huang
- From the Institute of Neuroscience and Psychology (B.K.C., X.H., K.W.M.) and Institute of Cardiovascular and Medical Sciences (R.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow, Scotland, United Kingdom
| | - Rachael MacIsaac
- From the Institute of Neuroscience and Psychology (B.K.C., X.H., K.W.M.) and Institute of Cardiovascular and Medical Sciences (R.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow, Scotland, United Kingdom
| | - Keith W Muir
- From the Institute of Neuroscience and Psychology (B.K.C., X.H., K.W.M.) and Institute of Cardiovascular and Medical Sciences (R.M.), University of Glasgow, Queen Elizabeth University Hospital, Glasgow, Scotland, United Kingdom.
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13
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Lee MJ, Son JP, Kim SJ, Ryoo S, Woo SY, Cha J, Kim GM, Chung CS, Lee KH, Bang OY. Predicting Collateral Status With Magnetic Resonance Perfusion Parameters. Stroke 2015; 46:2800-7. [DOI: 10.1161/strokeaha.115.009828] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 07/21/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Mi Ji Lee
- From the Departments of Neurology (M.J.L., S.J.K., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B.) and Radiology (J.C.), Samsung Medical Center, School of Medicine (M.J.L., S.J.K., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B., J.C.) and Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology (J.P.S., O.Y.B.), Sungkyunkwan University, Seoul, Korea; and Biostatistics Team, Samsung Biomedical Research Institute, Seoul, Korea (S.-Y.W.)
| | - Jeong Pyo Son
- From the Departments of Neurology (M.J.L., S.J.K., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B.) and Radiology (J.C.), Samsung Medical Center, School of Medicine (M.J.L., S.J.K., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B., J.C.) and Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology (J.P.S., O.Y.B.), Sungkyunkwan University, Seoul, Korea; and Biostatistics Team, Samsung Biomedical Research Institute, Seoul, Korea (S.-Y.W.)
| | - Suk Jae Kim
- From the Departments of Neurology (M.J.L., S.J.K., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B.) and Radiology (J.C.), Samsung Medical Center, School of Medicine (M.J.L., S.J.K., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B., J.C.) and Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology (J.P.S., O.Y.B.), Sungkyunkwan University, Seoul, Korea; and Biostatistics Team, Samsung Biomedical Research Institute, Seoul, Korea (S.-Y.W.)
| | - Sookyung Ryoo
- From the Departments of Neurology (M.J.L., S.J.K., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B.) and Radiology (J.C.), Samsung Medical Center, School of Medicine (M.J.L., S.J.K., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B., J.C.) and Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology (J.P.S., O.Y.B.), Sungkyunkwan University, Seoul, Korea; and Biostatistics Team, Samsung Biomedical Research Institute, Seoul, Korea (S.-Y.W.)
| | - Sook-Young Woo
- From the Departments of Neurology (M.J.L., S.J.K., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B.) and Radiology (J.C.), Samsung Medical Center, School of Medicine (M.J.L., S.J.K., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B., J.C.) and Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology (J.P.S., O.Y.B.), Sungkyunkwan University, Seoul, Korea; and Biostatistics Team, Samsung Biomedical Research Institute, Seoul, Korea (S.-Y.W.)
| | - Jihoon Cha
- From the Departments of Neurology (M.J.L., S.J.K., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B.) and Radiology (J.C.), Samsung Medical Center, School of Medicine (M.J.L., S.J.K., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B., J.C.) and Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology (J.P.S., O.Y.B.), Sungkyunkwan University, Seoul, Korea; and Biostatistics Team, Samsung Biomedical Research Institute, Seoul, Korea (S.-Y.W.)
| | - Gyeong-Moon Kim
- From the Departments of Neurology (M.J.L., S.J.K., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B.) and Radiology (J.C.), Samsung Medical Center, School of Medicine (M.J.L., S.J.K., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B., J.C.) and Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology (J.P.S., O.Y.B.), Sungkyunkwan University, Seoul, Korea; and Biostatistics Team, Samsung Biomedical Research Institute, Seoul, Korea (S.-Y.W.)
| | - Chin-Sang Chung
- From the Departments of Neurology (M.J.L., S.J.K., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B.) and Radiology (J.C.), Samsung Medical Center, School of Medicine (M.J.L., S.J.K., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B., J.C.) and Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology (J.P.S., O.Y.B.), Sungkyunkwan University, Seoul, Korea; and Biostatistics Team, Samsung Biomedical Research Institute, Seoul, Korea (S.-Y.W.)
| | - Kwang Ho Lee
- From the Departments of Neurology (M.J.L., S.J.K., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B.) and Radiology (J.C.), Samsung Medical Center, School of Medicine (M.J.L., S.J.K., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B., J.C.) and Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology (J.P.S., O.Y.B.), Sungkyunkwan University, Seoul, Korea; and Biostatistics Team, Samsung Biomedical Research Institute, Seoul, Korea (S.-Y.W.)
| | - Oh Young Bang
- From the Departments of Neurology (M.J.L., S.J.K., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B.) and Radiology (J.C.), Samsung Medical Center, School of Medicine (M.J.L., S.J.K., S.R., G.-M.K., C.-S.C., K.H.L., O.Y.B., J.C.) and Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology (J.P.S., O.Y.B.), Sungkyunkwan University, Seoul, Korea; and Biostatistics Team, Samsung Biomedical Research Institute, Seoul, Korea (S.-Y.W.)
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Gu F, Qin J, Chen R, Xu X. Post-thrombolysis hemorrhage in a patient with hypothyroidism and acute ischemic stroke: Case report. Neurol Neurochir Pol 2015; 49:290-4. [DOI: 10.1016/j.pjnns.2015.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 04/29/2015] [Accepted: 05/05/2015] [Indexed: 11/17/2022]
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15
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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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16
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Morgan CD, Stephens M, Zuckerman SL, Waitara MS, Morone PJ, Dewan MC, Mocco J. Physiologic imaging in acute stroke: Patient selection. Interv Neuroradiol 2015; 21:499-510. [PMID: 26063695 DOI: 10.1177/1591019915587227] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Treatment of acute stroke is changing, as endovascular intervention becomes an important adjunct to tissue plasminogen activator. An increasing number of sophisticated physiologic imaging techniques have unique advantages and applications in the evaluation, diagnosis, and treatment-decision making of acute ischemic stroke. In this review, we first highlight the strengths, weaknesses, and possible indications for various stroke imaging techniques. How acute imaging findings in each modality have been used to predict functional outcome is discussed. Furthermore, there is an increasing emphasis on using these state-of-the-art imaging modalities to offer maximal patient benefit through IV therapy, endovascular thrombolytics, and clot retrieval. We review the burgeoning literature in the determination of stroke treatment based on acute, physiologic imaging findings.
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Affiliation(s)
- Clinton D Morgan
- Department of Neurological Surgery, Vanderbilt University School of Medicine, USA
| | | | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University School of Medicine, USA
| | | | - Peter J Morone
- Department of Neurological Surgery, Vanderbilt University School of Medicine, USA
| | - Michael C Dewan
- Department of Neurological Surgery, Vanderbilt University School of Medicine, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mouth Sinai, USA
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17
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Mishra NK, Christensen S, Wouters A, Campbell BCV, Straka M, Mlynash M, Kemp S, Cereda CW, Bammer R, Marks MP, Albers GW, Lansberg MG. Reperfusion of very low cerebral blood volume lesion predicts parenchymal hematoma after endovascular therapy. Stroke 2015; 46:1245-9. [PMID: 25828235 DOI: 10.1161/strokeaha.114.008171] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 02/27/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND PURPOSE Ischemic stroke patients with regional very low cerebral blood volume (VLCBV) on baseline imaging have increased risk of parenchymal hemorrhage (PH) after intravenous alteplase-induced reperfusion. We developed a method for automated detection of VLCBV and examined whether patients with reperfused-VLCBV are at increased risk of PH after endovascular reperfusion therapy. METHODS Receiver operating characteristic analysis was performed to optimize a relative CBV threshold associated with PH in patients from the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution 2 (DEFUSE 2) study. Regional reperfused-VLCBV was defined as regions with low relative CBV on baseline imaging that demonstrated normal perfusion (Tmax <6 s) on coregistered early follow-up magnetic resonance imaging. The association between VLCBV, regional reperfused-VLCBV and PH was assessed in univariate and multivariate analyses. RESULTS In 91 patients, the greatest area under the curve for predicting PH occurred at an relative CBV threshold of <0.42 (area under the curve, 0.77). At this threshold, VLCBV lesion volume ≥3.55 mL optimally predicted PH with 94% sensitivity and 63% specificity. Reperfused-VLCBV lesion volume was more specific (0.74) and equally sensitive (0.94). In total, 18 patients developed PH, of whom 17 presented with VLCBV (39% versus 2%; P=0.001), all of them had regional reperfusion (47% versus 0%; P=0.01), and 71% received intravenous alteplase. VLCBV lesion (odds ratio, 33) and bridging with intravenous alteplase (odds ratio, 3.8) were independently associated with PH. In a separate model, reperfused-VLCBV remained the single independent predictor of PH (odds ratio, 53). CONCLUSIONS These results suggest that VLCBV can be used for risk stratification of patients scheduled to undergo endovascular therapy in trials and routine clinical practice.
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Affiliation(s)
- Nishant K Mishra
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.)
| | - Søren Christensen
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.)
| | - Anke Wouters
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.)
| | - Bruce C V Campbell
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.)
| | - Matus Straka
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.)
| | - Michael Mlynash
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.)
| | - Stephanie Kemp
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.)
| | - Carlo W Cereda
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.)
| | - Roland Bammer
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.)
| | - Michael P Marks
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.)
| | - Gregory W Albers
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.)
| | - Maarten G Lansberg
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA (N.K.M., S.C., M.S., M.M., S.K., C.W.C., G.W.A., M.G.L.); Department of Experimental Neurology, KU Leuven, Leuven, Belgium (A.W.); Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia (B.C.V.C.); Stroke Center, Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland (C.W.C.); and Department of Radiology, Stanford University Medical Center, CA (R.B., M.P.M.).
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Ibatullin MM, Kalinin MN, Kurado AT, Valeeva AA, Khasanova DR. [Multimodal imaging protocols and their predictive role in acute stroke functional outcome]. Zh Nevrol Psikhiatr Im S S Korsakova 2014; 114:9-15. [PMID: 25726796 DOI: 10.17116/jnevro20141141229-15] [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
Brain imaging 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 stroke functional outcome in the light of the aforementioned four Ps.
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Affiliation(s)
- M M Ibatullin
- GBOU VPO "Kazanskiĭ gosudarstvennyĭ meditsinskiĭ universitet"
| | - M N Kalinin
- GBOU VPO "Kazanskiĭ gosudarstvennyĭ meditsinskiĭ universitet"
| | - A T Kurado
- GAUZ "Mezhregional'nyĭ kliniko-diagnosticheskiĭ tsentr", Kazan'
| | - A A Valeeva
- GBOU VPO "Kazanskiĭ gosudarstvennyĭ meditsinskiĭ universitet"
| | - D R Khasanova
- GBOU VPO "Kazanskiĭ gosudarstvennyĭ meditsinskiĭ universitet"
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Yassi N, Parsons MW, Christensen S, Sharma G, Bivard A, Donnan GA, Levi CR, Desmond PM, Davis SM, Campbell BC. Prediction of Poststroke Hemorrhagic Transformation Using Computed Tomography Perfusion. Stroke 2013; 44:3039-43. [DOI: 10.1161/strokeaha.113.002396] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Nawaf Yassi
- From the Departments of Medicine and Neurology, Melbourne Brain Centre (N.Y., A.B., S.M.D., B.C.V.C.), and Department of Radiology (N.Y., S.C., G.S., P.M.D., B.C.V.C.), Royal Melbourne Hospital, and Florey Institute of Neuroscience and Mental Health (G.A.D.), University of Melbourne, Parkville, Victoria, Australia; and Priority Research Centre for Translational Neuroscience and Mental Health, University of Newcastle and Hunter Medical Research Institute, Newcastle, New South Wales, Australia (M.W.P
| | - Mark W. Parsons
- From the Departments of Medicine and Neurology, Melbourne Brain Centre (N.Y., A.B., S.M.D., B.C.V.C.), and Department of Radiology (N.Y., S.C., G.S., P.M.D., B.C.V.C.), Royal Melbourne Hospital, and Florey Institute of Neuroscience and Mental Health (G.A.D.), University of Melbourne, Parkville, Victoria, Australia; and Priority Research Centre for Translational Neuroscience and Mental Health, University of Newcastle and Hunter Medical Research Institute, Newcastle, New South Wales, Australia (M.W.P
| | - Søren Christensen
- From the Departments of Medicine and Neurology, Melbourne Brain Centre (N.Y., A.B., S.M.D., B.C.V.C.), and Department of Radiology (N.Y., S.C., G.S., P.M.D., B.C.V.C.), Royal Melbourne Hospital, and Florey Institute of Neuroscience and Mental Health (G.A.D.), University of Melbourne, Parkville, Victoria, Australia; and Priority Research Centre for Translational Neuroscience and Mental Health, University of Newcastle and Hunter Medical Research Institute, Newcastle, New South Wales, Australia (M.W.P
| | - Gagan Sharma
- From the Departments of Medicine and Neurology, Melbourne Brain Centre (N.Y., A.B., S.M.D., B.C.V.C.), and Department of Radiology (N.Y., S.C., G.S., P.M.D., B.C.V.C.), Royal Melbourne Hospital, and Florey Institute of Neuroscience and Mental Health (G.A.D.), University of Melbourne, Parkville, Victoria, Australia; and Priority Research Centre for Translational Neuroscience and Mental Health, University of Newcastle and Hunter Medical Research Institute, Newcastle, New South Wales, Australia (M.W.P
| | - Andrew Bivard
- From the Departments of Medicine and Neurology, Melbourne Brain Centre (N.Y., A.B., S.M.D., B.C.V.C.), and Department of Radiology (N.Y., S.C., G.S., P.M.D., B.C.V.C.), Royal Melbourne Hospital, and Florey Institute of Neuroscience and Mental Health (G.A.D.), University of Melbourne, Parkville, Victoria, Australia; and Priority Research Centre for Translational Neuroscience and Mental Health, University of Newcastle and Hunter Medical Research Institute, Newcastle, New South Wales, Australia (M.W.P
| | - Geoffrey A. Donnan
- From the Departments of Medicine and Neurology, Melbourne Brain Centre (N.Y., A.B., S.M.D., B.C.V.C.), and Department of Radiology (N.Y., S.C., G.S., P.M.D., B.C.V.C.), Royal Melbourne Hospital, and Florey Institute of Neuroscience and Mental Health (G.A.D.), University of Melbourne, Parkville, Victoria, Australia; and Priority Research Centre for Translational Neuroscience and Mental Health, University of Newcastle and Hunter Medical Research Institute, Newcastle, New South Wales, Australia (M.W.P
| | - Christopher R. Levi
- From the Departments of Medicine and Neurology, Melbourne Brain Centre (N.Y., A.B., S.M.D., B.C.V.C.), and Department of Radiology (N.Y., S.C., G.S., P.M.D., B.C.V.C.), Royal Melbourne Hospital, and Florey Institute of Neuroscience and Mental Health (G.A.D.), University of Melbourne, Parkville, Victoria, Australia; and Priority Research Centre for Translational Neuroscience and Mental Health, University of Newcastle and Hunter Medical Research Institute, Newcastle, New South Wales, Australia (M.W.P
| | - Patricia M. Desmond
- From the Departments of Medicine and Neurology, Melbourne Brain Centre (N.Y., A.B., S.M.D., B.C.V.C.), and Department of Radiology (N.Y., S.C., G.S., P.M.D., B.C.V.C.), Royal Melbourne Hospital, and Florey Institute of Neuroscience and Mental Health (G.A.D.), University of Melbourne, Parkville, Victoria, Australia; and Priority Research Centre for Translational Neuroscience and Mental Health, University of Newcastle and Hunter Medical Research Institute, Newcastle, New South Wales, Australia (M.W.P
| | - Stephen M. Davis
- From the Departments of Medicine and Neurology, Melbourne Brain Centre (N.Y., A.B., S.M.D., B.C.V.C.), and Department of Radiology (N.Y., S.C., G.S., P.M.D., B.C.V.C.), Royal Melbourne Hospital, and Florey Institute of Neuroscience and Mental Health (G.A.D.), University of Melbourne, Parkville, Victoria, Australia; and Priority Research Centre for Translational Neuroscience and Mental Health, University of Newcastle and Hunter Medical Research Institute, Newcastle, New South Wales, Australia (M.W.P
| | - Bruce C.V. Campbell
- From the Departments of Medicine and Neurology, Melbourne Brain Centre (N.Y., A.B., S.M.D., B.C.V.C.), and Department of Radiology (N.Y., S.C., G.S., P.M.D., B.C.V.C.), Royal Melbourne Hospital, and Florey Institute of Neuroscience and Mental Health (G.A.D.), University of Melbourne, Parkville, Victoria, Australia; and Priority Research Centre for Translational Neuroscience and Mental Health, University of Newcastle and Hunter Medical Research Institute, Newcastle, New South Wales, Australia (M.W.P
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Tu HTH, Campbell BCV, Christensen S, Desmond PM, De Silva DA, Parsons MW, Churilov L, Lansberg MG, Mlynash M, Olivot JM, Straka M, Bammer R, Albers GW, Donnan GA, Davis SM. Worse stroke outcome in atrial fibrillation is explained by more severe hypoperfusion, infarct growth, and hemorrhagic transformation. Int J Stroke 2013; 10:534-40. [PMID: 23489996 DOI: 10.1111/ijs.12007] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 09/06/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Atrial fibrillation is associated with greater baseline neurological impairment and worse outcomes following ischemic stroke. Previous studies suggest that greater volumes of more severe baseline hypoperfusion in patients with history of atrial fibrillation may explain this association. We further investigated this association by comparing patients with and without atrial fibrillation on initial examination following stroke using pooled multimodal magnetic resonance imaging and clinical data from the Echoplanar Imaging Thrombolytic Evaluation Trial and the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution studies. METHODS Echoplanar Imaging Thrombolytic Evaluation Trial was a trial of 101 ischemic stroke patients randomized to intravenous tissue plasminogen activator or placebo, and Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution was a prospective cohort of 74 ischemic stroke patients treated with intravenous tissue plasminogen activator at three to six hours following symptom onset. Patients underwent multimodal magnetic resonance imaging before treatment, at three to five days and three-months after stroke in Echoplanar Imaging Thrombolytic Evaluation Trial; before treatment, three to six hours after treatment and one-month after stroke in Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution. Patients were assessed with the National Institutes of Health Stroke Scale and the modified Rankin scale before treatment and at three-months after stroke. Patients were categorized into definite atrial fibrillation (present on initial examination), probable atrial fibrillation (history but no atrial fibrillation on initial examination), and no atrial fibrillation. Perfusion data were reprocessed with automated magnetic resonance imaging analysis software (RAPID, Stanford University, Stanford, CA, USA). Hypoperfusion volumes were defined using time to maximum delays in two-second increments from >4 to >8 s. Hemorrhagic transformation was classified according to the European Cooperative Acute Stroke Studies criteria. RESULTS Of the 175 patients, 28 had definite atrial fibrillation, 30 probable atrial fibrillation, 111 no atrial fibrillation, and six were excluded due to insufficient imaging data. At baseline, patients with definite atrial fibrillation had more severe hypoperfusion (median time to maximum >8 s, volume 48 vs. 29 ml, P = 0.02) compared with patients with no atrial fibrillation. At outcome, patients with definite atrial fibrillation had greater infarct growth (median volume 47 vs. 8 ml, P = 0.001), larger infarcts (median volume 75 vs. 23 ml, P = 0.001), more frequent parenchymal hematoma grade hemorrhagic transformation (30% vs. 10%, P = 0.03), worse functional outcomes (median modified Rankin scale score 4 vs. 3, P = 0.03), and higher mortality (36% vs. 16%, P = 0·.3) compared with patients with no atrial fibrillation. Definite atrial fibrillation was independently associated with increased parenchymal hematoma (odds ratio = 6.05, 95% confidence interval 1.60-22.83) but not poor functional outcome (modified Rankin scale 3-6, odds ratio = 0.99, 95% confidence interval 0.35-2.80) or mortality (odds ratio = 2.54, 95% confidence interval 0.86-7.49) three-months following stroke, after adjusting for other baseline imbalances. CONCLUSION Atrial fibrillation is associated with greater volumes of more severe baseline hypoperfusion, leading to higher infarct growth, more frequent severe hemorrhagic transformation and worse stroke outcomes.
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Affiliation(s)
- Hans T H Tu
- Department of Medicine and Neurology, The Royal Melbourne Hospital, University of Melbourne, Parkville, Vic, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, The Royal Melbourne Hospital, University of Melbourne, Parkville, Vic, Australia
| | - Soren Christensen
- Department of Radiology, The Royal Melbourne Hospital, University of Melbourne, Parkville, Vic, Australia
| | - Patricia M Desmond
- Department of Radiology, The Royal Melbourne Hospital, University of Melbourne, Parkville, Vic, Australia
| | - Deidre A De Silva
- Department of Neurology, Singapore General Hospital Campus, National Neuroscience Institute, Singapore
| | - Mark W Parsons
- Department of Neurology and Hunter Medical Research Institute, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Leonid Churilov
- Florey Neurosciences Institutes, The University of Melbourne, Parkville, Victoria, Australia
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences and the Stanford Stroke Center, Stanford University, Stanford, CA, USA
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences and the Stanford Stroke Center, Stanford University, Stanford, CA, USA
| | - Jean-Marc Olivot
- Department of Neurology and Neurological Sciences and the Stanford Stroke Center, Stanford University, Stanford, CA, USA
| | - Matus Straka
- Department of Neurology and Neurological Sciences and the Stanford Stroke Center, Stanford University, Stanford, CA, USA
| | - Roland Bammer
- Department of Neurology and Neurological Sciences and the Stanford Stroke Center, Stanford University, Stanford, CA, USA
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences and the Stanford Stroke Center, Stanford University, Stanford, CA, USA
| | - Geoffrey A Donnan
- Florey Neurosciences Institutes, The University of Melbourne, Parkville, Victoria, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, The Royal Melbourne Hospital, University of Melbourne, Parkville, Vic, Australia
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Campbell BCV, Christensen S, Parsons MW, Churilov L, 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. Advanced imaging improves prediction of hemorrhage after stroke thrombolysis. Ann Neurol 2013; 73:510-9. [PMID: 23444008 DOI: 10.1002/ana.23837] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 10/30/2012] [Accepted: 11/30/2012] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Very low cerebral blood volume (VLCBV), diffusion, and hypoperfusion lesion volumes have been proposed as predictors of hemorrhagic transformation following stroke thrombolysis. We aimed to compare these parameters, validate VLCBV in an independent cohort using DEFUSE study data, and investigate the interaction of VLCBV with regional reperfusion. METHODS The EPITHET and DEFUSE studies obtained diffusion and perfusion magnetic resonance imaging (MRI) in patients 3 to 6 hours from onset of ischemic stroke. EPITHET randomized patients to tissue plasminogen activator (tPA) or placebo, and all DEFUSE patients received tPA. VLCBV was defined as cerebral blood volume<2.5th percentile of brain contralateral to the infarct. Parenchymal hematoma (PH) was defined using European Cooperative Acute Stroke Study criteria. Reperfusion was assessed using subacute perfusion MRI coregistered to baseline imaging. RESULTS In DEFUSE, 69 patients were analyzed, including 9 who developed PH. The >2 ml VLCBV threshold defined in EPITHET predicted PH with 100% sensitivity, 72% specificity, 35% positive predictive value, and 100% negative predictive value. Pooling EPITHET and DEFUSE (163 patients, including 23 with PH), regression models using VLCBV (p<0.001) and tPA (p=0.02) predicted PH independent of clinical factors better than models using diffusion or time to maximum>8 seconds lesion volumes. Excluding VLCBV in regions without reperfusion improved specificity from 61 to 78% in the pooled analysis. INTERPRETATION VLCBV predicts PH after stroke thrombolysis and appears to be a more powerful predictor than baseline diffusion or hypoperfusion lesion volumes. Reperfusion of regions of VLCBV is strongly associated with post-thrombolysis PH. VLCBV may be clinically useful to identify patients at significant risk of hemorrhage following reperfusion.
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Affiliation(s)
- Bruce C V Campbell
- Departments of Medicine and Neurology, Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
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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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Abstract
Neonatal hypoxic-ischemic brain injury (HII) and arterial ischemic stroke (AIS) result in irreversibly injured (core) and salvageable (penumbral) tissue regions. Identification and reliable quantification of salvageable tissue is pivotal to any effective and safe intervention. Magnetic resonance imaging (MRI) is the current standard to distinguish core from penumbra using diffusion-perfusion mismatch (DPM). However, subtle MR signal variations between core-penumbral regions make their visual delineation difficult. We hypothesized that computational analysis of MRI data provides a more accurate assessment of core and penumbral tissue evolution in HII/AIS. We used two neonatal rat-pup models of HII/AIS (unilateral and global hypoxic-ischemia) and clinical data sets from neonates with AIS to test our noninvasive, automated computational approach, Hierarchical Region Splitting (HRS), to detect and quantify ischemic core-penumbra using only a single MRI modality (T2- or diffusion-weighted imaging, T2WI/DWI). We also validated our approach by comparing core-penumbral images (from HRS) to DPM with immunohistochemical validation of HII tissues. Our translational and clinical data results showed that HRS could accurately and reliably distinguish the ischemic core from penumbra and their spatiotemporal evolution, which may aid in the vetting and execution of effective therapeutic interventions as well as patient selection.
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Hoffmann A, Bredno J, Wendland MF, Derugin N, Hom J, Schuster T, Zimmer C, Su H, Ohara PT, Young WL, Wintermark M. MRI blood-brain barrier permeability measurements to predict hemorrhagic transformation in a rat model of ischemic stroke. Transl Stroke Res 2012; 3:508-16. [PMID: 24323835 DOI: 10.1007/s12975-012-0212-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 09/03/2012] [Indexed: 10/27/2022]
Abstract
Permeability imaging might add valuable information in the risk assessment of hemorrhagic transformation. This study evaluates the predictive value of blood-brain barrier permeability (BBBP) measurements extracted from dynamic contrast-enhanced MRI for hemorrhagic transformation in ischemic stroke. Spontaneously hypertensive and Wistar rats with 2 h filament occlusion of the right MCA underwent MRI during occlusion, at 4 and 24 h post reperfusion. BBBP was imaged by DCE imaging and quantified by Patlak analysis. Cresyl-violet staining was used to characterize hemorrhage in sacrificed rats at 24 h, immediately following the last imaging study. BBBP changes were evaluated at baseline, 4 and 24 h after reperfusion. Receiver-operating characteristic (ROC) analysis was performed to determine the most accurate BBBP threshold to predict hemorrhagic transformation. In animals showing macroscopic hemorrhage at 24 h, 95th BBBP percentile values ipsilateral were 0.323 [0.260, 0.387], 0.685 [0.385, 0.985], and 0.412 [0.210, 0.613] ml/min·100 g (marginal mean [95%CI]) during occlusion, at 4 and 24 h post reperfusion, respectively. The BBBP values on the infarcted and contralateral side were significantly different at 4 (p = 0.034) and 24 h post reperfusion (p = 0.031). The predictive value of BBBP in terms of macroscopic hemorrhage was highest 4 h after reperfusion (ROC area under the curve = 84 %) with a high negative predictive value (98.3 %) and limited positive predictive value (14.9 %) for a threshold of 0.35 ml/min·100g. Altered BBBP is a necessary but not sufficient condition to cause hemorrhagic transformation in rats with an infarct. Further research is needed to identify those additional risk factors that are required for hemorrhagic transformation to develop in the setting of ischemic stroke.
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Affiliation(s)
- Angelika Hoffmann
- Department of Radiology, Neuroradiology Division, University of Virginia, Box 800170, Charlottesville, VA, 22908, USA
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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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Guo G, Yang Y, Yang W. Validation of hyperintense middle cerebral artery sign in acute ischemic stroke: Comparison between magnetic resonance imaging and angiography. Neural Regen Res 2012; 7:229-34. [PMID: 25767505 PMCID: PMC4353121 DOI: 10.3969/j.issn.1673-5374.2012.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2011] [Accepted: 11/12/2011] [Indexed: 11/18/2022] Open
Abstract
We performed a retrospective analysis of non-contrast computed tomography (CT) scans, immediately subsequent magnetic resonance imaging (MRI), and cerebral angiography data from 30 consecutive patients with acute ischemic stroke within 6 hours after symptom onset. Results showed that eleven patients developed subsequent hemorrhagic transformation at follow-up. A hyperintense middle cerebral artery sign on MRI was found in six hemorrhagic patients, all of who had acute thrombosis formation on magnetic resonance angiography and digital subtraction angiography. No patients in the non-hemorrhagic group had hyperintense middle cerebral artery sign on MRI. The sensitivity, specificity, and positive predictive values of the hyperintense middle cerebral artery sign on MRI T1-weighted image for subsequent hemorrhagic transformation were 54.5%, 100%, and 100% respectively. Hyperdense middle cerebral artery sign on non-contrast CT was observed in nine patients, five of who developed hemorrhagic transformation. These data suggest that hyperintense middle cerebral artery sign on MRI T1-weighted image is a highly specific and moderately sensitive indicator of subsequent hemorrhagic transformation in patients after acute ischemic stroke, and its specificity is superior to CT.
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Affiliation(s)
- Gang Guo
- Department of Radiology, Xiamen Second Hospital, Teaching Hospital of Fujian Medical University, Xiamen 361021, Fujian Province, China
| | - Yonggui Yang
- Department of Radiology, Xiamen Second Hospital, Teaching Hospital of Fujian Medical University, Xiamen 361021, Fujian Province, China
| | - Weiqun Yang
- Department of Radiology, Xiamen Second Hospital, Teaching Hospital of Fujian Medical University, Xiamen 361021, Fujian Province, China
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Bang OY, Saver JL, Kim SJ, Kim GM, Chung CS, Ovbiagele B, Lee KH, Liebeskind DS. Collateral flow averts hemorrhagic transformation after endovascular therapy for acute ischemic stroke. Stroke 2011; 42:2235-9. [PMID: 21737798 DOI: 10.1161/strokeaha.110.604603] [Citation(s) in RCA: 207] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Collaterals sustain the ischemic penumbra to limit growth of the infarct core before revascularization, yet the impact of baseline collateral flow on hemorrhagic transformation (HT) after endovascular therapy remains unknown. METHODS A collaborative study from 2 stroke centers in distinct geographic regions included 222 consecutive patients who received endovascular therapy for acute cerebral ischemia. The influence of collaterals on HT was analyzed in distinct case scenarios relative to baseline collateral grade at angiography (0 to 1 versus 2 to 4) and recanalization (Thrombolysis in Myocardial Ischemia scale, 0 to 1 versus 2 to 3): good collaterals and successful recanalization (n=98), poor collaterals with successful recanalization (n=43), good collaterals and no recanalization(n=46), and poor collaterals and no recanalization (n=35). RESULTS HT after endovascular therapy occurred in 103 (46.4%) patients; 42 (18.9%) were symptomatic. HT was more frequently observed in patients with poor collaterals and recanalization than in other groups (P=0.048). When revascularization was achieved, patients with poorer collaterals were more likely to have symptomatic worsening with HT (r=-0.181, P=0.032). Multiple logistic regression analysis identified aggressive treatment (OR, 2.558 for Merci clot retrieval; 95% CI, 1.153 to 5.678; OR, 3.618 for combined fibrinolytics and mechanical therapy; 95% CI, 1.551 to 8.437; and OR, 2.085 for intravenous thrombolysis before endovascular therapy; 95% CI, 1.096 to 3.969), poor collaterals and recanalization (OR, 2.666; 95% CI, 1.163 to 6.113), and serum glucose levels (OR, 1.007; 95% CI, 1.000 to 1.014) as independent predictors of HT. CONCLUSIONS Angiographic grade of collateral flow strongly influences the rate of HT after therapeutic recanalization for acute ischemic stroke. Collateral status readily available from baseline angiography may therefore refine therapeutic decision-making in acute cerebral ischemia.
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Affiliation(s)
- Oh Young Bang
- Department of Neurology, UCLA Stroke Center, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea
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Fung SH, Roccatagliata L, Gonzalez RG, Schaefer PW. MR Diffusion Imaging in Ischemic Stroke. Neuroimaging Clin N Am 2011; 21:345-77, xi. [DOI: 10.1016/j.nic.2011.03.001] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Abstract
PURPOSE OF REVIEW Modern reperfusion therapy in acute ischemic stroke therapy is based on an 'as fast as possible' recanalization approach to obtain favorable clinical outcomes. However, arterial recanalization may be achieved without favorable clinical outcome, raising the question of the target population to be treated. We outline key issues that underline acute revascularization therapies. RECENT FINDINGS Intravenous (i.v.) thrombolysis remains the gold standard with the benefit of speed but lower recanalization rates of large artery occlusions as compared with intra-arterial routes. Conversely, intra-arterial therapies report higher recanalization rates, but are hampered by procedural delays and risks. Higher rates of recanalization in intra-arterial studies using clot-removal devices have not translated into improved patient functional outcome as compared with i.v. thrombolysis trials. Combined i.v.-intra-arterial therapy hold great promise with both the advantages of i.v. and intra-arterial routes. SUMMARY Endovascular therapy is potentially superior to i.v. tissue-type plasminogen activator with the development of new devices, which are now available, but none has been evaluated vs. i.v. thrombolysis. Future developments may include combined strategies or a 'pure' mechanical approach. The critical issue is time-to-reperfusion based on a brain imaging showing salvageable brain tissue with a reduced risk of adverse events associated with reperfusion. Current brain imaging techniques are probably not good enough to discriminate salvageable brain, and parenchymal lesion that may suffer from reperfusion injury.
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Diffusion-perfusion MRI for triaging transient ischemic attack and acute cerebrovascular syndromes. Curr Opin Neurol 2011; 24:44-9. [PMID: 21157338 DOI: 10.1097/wco.0b013e328341f8a5] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Time from symptom onset to treatment is considered to be the key variable that influences the indication of recanalization therapy for treatment of acute brain infarction. Symptom duration less than 24 h defines transient ischemic attack (TIA). The evolution of multimodal brain MRI demonstrates that neuroimaging findings of tissue injury may be more important predictors of clinical outcomes than arbitrary time thresholds. RECENT FINDINGS Preliminaries studies suggest that stroke victims with a significant penumbra estimated by the diffusion/perfusion mismatch on MRI benefit from thrombolysis beyond the currently recommended time window of 4.5 h. New software programs can automatically produce reliable perfusion and diffusion maps for use in clinical practice. Combined diffusion and perfusion MRI reveals an acute ischemic lesion in about 60% of TIA patients. Patients with transient symptoms and a restricted diffusion lesion on MRI are considered by the American Heart Association (AHA) scientific committee to have suffered a brain infarction and have a very high risk of early stroke recurrence. SUMMARY Multimodal MRI provides critical real-time information about ongoing tissue injury as well as the risk of additional ischemic damage. It is becoming an essential tool for the diagnosis, management and triage of acute TIA and brain infarction.
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Mlynash M, Lansberg MG, De Silva DA, Lee J, Christensen S, Straka M, Campbell BCV, Bammer R, Olivot JM, Desmond P, Donnan GA, Davis SM, Albers GW. Refining the definition of the malignant profile: insights from the DEFUSE-EPITHET pooled data set. Stroke 2011; 42:1270-5. [PMID: 21474799 DOI: 10.1161/strokeaha.110.601609] [Citation(s) in RCA: 175] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE To refine the definition of the malignant magnetic resonance imaging profile in acute stroke patients using baseline diffusion-weighted magnetic resonance imaging (DWI) and perfusion-weighted magnetic resonance imaging (PWI) findings from the pooled DEFUSE/EPITHET database. METHODS Patients presenting with acute stroke within 3 to 6 hours from symptom onset were treated with tissue plasminogen activator or placebo. Baseline and follow-up DWI and PWI images from both studies were reprocessed using the same software program. A receiver operating characteristic curve analysis was used to identify Tmax and DWI volumes that optimally predicted poor outcomes (modified Rankin Scale 5-6) at 90 days in patients who achieved reperfusion. RESULTS Sixty-five patients achieved reperfusion and 46 did not reperfuse. Receiver operating characteristic analysis identified a PWI (Tmax>8 s) volume of >85 mL as the optimal definition of the malignant profile. Eighty-nine percent of malignant profile patients had poor outcome with reperfusion versus 39% of patients without reperfusion (P=0.02). Parenchymal hematomas occurred more frequently in malignant profile patients who experienced reperfusion versus no reperfusion (67% versus 11%, P<0.01). DWI analysis identified a volume of 80 mL as the best DWI threshold, but this definition was less sensitive than were PWI-based definitions. CONCLUSIONS Stroke patients likely to suffer parenchymal hemorrhages and poor outcomes following reperfusion can be identified from baseline magnetic resonance imaging findings. The current analysis demonstrates that a PWI threshold (Tmax>8 s) of approximately 100 mL is appropriate for identifying these patients. Exclusion of malignant profile patients from reperfusion therapies may substantially improve the efficacy and safety of reperfusion therapies. Clinical Trial Registration Information- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00238537.
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Affiliation(s)
- Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, 780 Welch Road, Suite 205, Stanford, Stanford, CA, USA
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Current World Literature. Curr Opin Neurol 2011; 24:89-93. [DOI: 10.1097/wco.0b013e3283433a91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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