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Mouchtouris N, Ailes I, Gooch R, Raimondo C, Oghli YS, Tjoumakaris S, Jabbour P, Rosenwasser R, Alizadeh M. Quantifying blood-brain barrier permeability in patients with ischemic stroke using non-contrast MRI. Magn Reson Imaging 2024; 109:165-172. [PMID: 38513785 DOI: 10.1016/j.mri.2024.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/17/2024] [Accepted: 03/18/2024] [Indexed: 03/23/2024]
Abstract
Increased blood-brain barrier permeability (BBBP) after ischemic stroke predisposes patients to hemorrhagic conversion. While altered BBBP can impact patient recovery, it is not routinely assessed during the workup of acute ischemic stroke (AIS). We study the effectiveness of the non-contrast MRI sequences diffusion-prepared pseudocontinuous arterial spin labeling (DP-pCASL) and Neurite Orientation Dispersion and Density Imaging (NODDI) in assessing BBBP and correlating to tissue microstructure after ischemic insult. Twelve patients with AIS were prospectively enrolled to undergo our multimodal MR imaging, which generated the DP-pCASL-derived cerebral blood flow (CBF), arterial transit time (ATT), and water exchange rate (kw) and the NODDI-derived b0, mean diffusivity (MD), orientation dispersion index (ODI), intracellular volume fraction (ICVF), and isotropic volume fraction (ISO) parametric maps. The mean age of the patients was 70.2 ± 14.8 with an average NIHSS of 13.0 (7.3-19.8). MR imaging was performed on average at 53.7 (27.8-93.3) hours from stroke symptom onset. The water exchange rate (kw) of the infarcted area and its contralateral territory were 89.7 min-1 (66.7-121.9) and 89.9 min-1 (65.9-106.0) respectively (p = 0.887). Multivariable linear regression analysis showed that b0, ODI, ISO and mechanical thrombectomy were significant predictors of kw. DP-pCASL and NODDI are promising non-contrast sequences for the routine assessment of BBBP.
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Affiliation(s)
- Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States.
| | - Isaiah Ailes
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Christian Raimondo
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Yazan Shamli Oghli
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Robert Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Mahdi Alizadeh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
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Virtanen P, Tomppo L, Georgiopoulos G, Brandstack N, Peltola E, Kokkonen T, Lappalainen K, Korvenoja A, Strbian D. Recanalization status and temporal evolution of early ischemic changes following stroke thrombectomy. Eur Stroke J 2024; 9:320-327. [PMID: 37991143 DOI: 10.1177/23969873231214207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023] Open
Abstract
INTRODUCTION Present-day computer tomography (CT) scanners have excellent spatial resolution and signal-to-noise ratio and are instrumental detecting early ischemic changes (EIC) in brain. We assessed the temporal changes of EIC based on the recanalization status after thrombectomy. PATIENTS AND METHODS The cohort comprises consecutive patients with acute ischemic stroke in anterior circulation treated with thrombectomy in tertiary referral hospital. All baseline and follow-up scans were screened for any ischemic changes and further classified using Alberta Stroke Program Early CT Score (ASPECTS). Generalized linear mixed models were used to analyze the impact of recanalization status using modified Thrombolysis in Cerebral Infarction (mTICI) on temporal evolution of ischemic changes. RESULTS We included 614 patients with ICA, M1, or M2 occlusions. Median ASPECTS score was 9 (IQR 7-10) at baseline and 7 (5-8) at approximately 24 h. mTICI 3 was achieved in 207 (33.8%), 2B 241 (39.3%), 2A in 77 (12.6%), and 0-1 in 88 (14.3%) patients. Compared to patients with mTICI 3, those with mTICI 0-1 and 2A had less favorable temporal changes of ASPECTS (p < 0.001). Effect of recanalization was noted in the cortical regions of ICA/M1 patients, but not in their deep structures or patients with M2 occlusions. All ischemic changes detected at baseline were also present at all follow-up images, regardless of the recanalization status. CONCLUSIONS Temporal evolution of the ischemic changes and ASPECTS are related to the success of the recanalization therapy in cortical regions of ICA/M1 patients, but not in their deep brain structures or M2 patients. In none of the patients did EIC revert in any brain region after successful recanalization.
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Affiliation(s)
- Pekka Virtanen
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Liisa Tomppo
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Georgios Georgiopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Nina Brandstack
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Erno Peltola
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Tatu Kokkonen
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Kimmo Lappalainen
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Antti Korvenoja
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Cortez GM, Benalia VHC, Sauvageau E, Aghaebrahim A, Pederson JM, Hanel RA. Diffusion-weighted imaging lesions after intracranial aneurysm treatment with Pipeline Flex and Pipeline Flex with Shield technology: a retrospective cohort analysis. J Neurointerv Surg 2024; 16:385-391. [PMID: 37197932 DOI: 10.1136/jnis-2023-020250] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/03/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND The Pipeline Flex embolization device with Shield technology (PED Shield) is the first flow diverter for brain aneurysm treatment approved in the United States using surface-modified technology. The effect of PED Shield on decreasing perioperative diffusion-weighted imaging positive (DWI+) hits, as a marker for in-human decrease thrombogenicity, is unclear. OBJECTIVE To determine if the number of periprocedural DWI+ lesions differs between patients with an aneurysm treated with PED Flex and PED Shield. METHODS This retrospective study compares the outcomes of consecutive patients with an aneurysm treated with PED Flex and PED Shield. The primary outcome of interest was the occurrence of DWI+ lesions. We also assessed potential predictors of DWI+ lesions and compared the outcomes between on-label and off-label treatment indications. RESULTS 89 patients were included, 48 (54%) treated with PED Flex and 41 (46%) with PED Shield. After matching, the incidence of DWI+ lesions was 61% and 62% for the PED Flex and PED Shield groups, respectively. Results were consistent across each model with no significant differences in DWI+ lesions between treatment groups, and effect sizes ranging from OR=1.08 (95% CI 0.41 to 2.89) after propensity score matching to OR=1.84 (95% CI 0.65 to 5.47) after multivariable regression. Multivariable models demonstrated reduced DWI+ lesions with balloon-assisted therapies and posterior circulation treatment, while a significant linear relationship was encountered with fluoroscopy time. CONCLUSION There was no significant difference in the incidence of perioperative DWI+ lesions between patients with an aneurysm treated with PED Flex and PED Shield. Larger cohorts are likely needed to demonstrate differences between the devices.
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Affiliation(s)
- Gustavo M Cortez
- Lyerly Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Victor H C Benalia
- Lyerly Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Amin Aghaebrahim
- Lyerly Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - John Michael Pederson
- Superior Medical Experts, Inc, St. Paul, Minnesota, USA
- Nested Knowledge, Inc, St. Paul, Minnesota, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
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Han C, Richerson WT, Garza M, Rodeghier M, Mishra M, Davis LT, Fusco M, Chitale R, Shiino S, Jordan LC, Donahue MJ. Cerebrovascular reactivity dispersion as a new biomarker of recent stroke symptomatology in moyamoya. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.02.27.24303346. [PMID: 38463978 PMCID: PMC10925366 DOI: 10.1101/2024.02.27.24303346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Background Moyamoya disease (MMD) is a non-atherosclerotic intracranial steno-occlusive condition placing patients at high risk for ischemic stroke. Direct and indirect surgical revascularization can improve blood flow in MMD; however, randomized trials demonstrating efficacy have not been performed and biomarkers of parenchymal hemodynamic impairment are needed to triage patients for interventions and evaluate post-surgical efficacy. We test the hypothesis that hypercapnia-induced maximum cerebrovascular reactivity (CVR MAX ) and the more novel indicator cerebrovascular reactivity (CVR) response time (CVR DELAY ), both assessed from time-regression analyses of non-invasive hypercapnic imaging, correlate with recent focal ischemic symptoms. Methods Hypercapnic reactivity medical resonance imaging (blood oxygenation level-dependent; echo time=35ms; spatial resolution=3.5×3.5×3.5mm) and catheter angiography assessments of cortical reserve capacity and vascular patency, respectively, in MMD participants (n=73) were performed in sequence. Time regression analyses were applied to quantify CVR MAX and CVR DELAY . Symptomatology information for each hemisphere (n=109) was categorized into symptomatic (ischemic symptoms within six months) or asymptomatic (no history of ischemic symptoms) and logistic regression analysis assessed the association of CVR metrics with ischemic symptoms after controlling for age and sex. Results Symptomatic hemispheres displayed lengthened CVR DELAY (p<0.001), which was more discriminatory between hemispheres than CVR MAX (p=0.037). CVR DELAY (p<0.001), but not CVR MAX (p=0.127), was found to be sensitively related to age in asymptomatic tissue (0.33-unit increase/year); age-dependent normative ranges are presented to enable quantitative assessment of patient-specific impairment. Furthermore, the area under the receiver operating characteristic curves shows that CVR DELAY predicts ischemic symptoms (p<0.001), whereas CVR MAX does not (p=0.056). Conclusion Findings support that CVR metrics are uniquely altered in hemispheres with recent ischemic symptoms, motivating the investigation of CVR as a surrogate of ischemic symptomatology and treatment efficacy.
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Hughes GC, Chen EP, Browndyke JN, Szeto WY, DiMaio JM, Brinkman WT, Gaca JG, Blumenthal JA, Karhausen JA, Bisanar T, James ML, Yanez D, Li YJ, Mathew JP. Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest Trial (GOT ICE): A Randomized Clinical Trial Comparing Outcomes After Aortic Arch Surgery. Circulation 2024; 149:658-668. [PMID: 38084590 PMCID: PMC10922813 DOI: 10.1161/circulationaha.123.067022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/10/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Deep hypothermia has been the standard for hypothermic circulatory arrest (HCA) during aortic arch surgery. However, centers worldwide have shifted toward lesser hypothermia with antegrade cerebral perfusion. This has been supported by retrospective data, but there has yet to be a multicenter, prospective randomized study comparing deep versus moderate hypothermia during HCA. METHODS This was a randomized single-blind trial (GOT ICE [Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest]) of patients undergoing arch surgery with HCA plus antegrade cerebral perfusion at 4 US referral aortic centers (August 2016-December 2021). Patients were randomized to 1 of 3 hypothermia groups: DP, deep (≤20.0 °C); LM, low-moderate (20.1-24.0 °C); and HM, high-moderate (24.1-28.0 °C). The primary outcome was composite global cognitive change score between baseline and 4 weeks postoperatively. Analysis followed the intention-to-treat principle to evaluate if: (1) LM noninferior to DP on global cognitive change score; (2) DP superior to HM. The secondary outcomes were domain-specific cognitive change scores, neuroimaging findings, quality of life, and adverse events. RESULTS A total of 308 patients consented; 282 met inclusion and were randomized. A total of 273 completed surgery, and 251 completed the 4-week follow-up (DP, 85 [34%]; LM, 80 [34%]; HM, 86 [34%]). Mean global cognitive change score from baseline to 4 weeks in the LM group was noninferior to the DP group; likewise, no significant difference was observed between DP and HM. Noninferiority of LM versus DP, and lack of difference between DP and HM, remained for domain-specific cognitive change scores, except structured verbal memory, with noninferiority of LM versus DP not established and structured verbal memory better preserved in DP versus HM (P = 0.036). There were no significant differences in structural or functional magnetic resonance imaging brain imaging between groups postoperatively. Regardless of temperature, patients who underwent HCA demonstrated significant reductions in cerebral gray matter volume, cortical thickness, and regional brain functional connectivity. Thirty-day in-hospital mortality, major morbidity, and quality of life were not different between groups. CONCLUSIONS This randomized multicenter study evaluating arch surgery HCA temperature strategies found low-moderate hypothermia noninferior to traditional deep hypothermia on global cognitive change 4 weeks after surgery, although in secondary analysis, structured verbal memory was better preserved in the deep group. The verbal memory differences in the low- and high-moderate groups and structural and functional connectivity reductions from baseline merit further investigation and suggest opportunities to further optimize brain perfusion during HCA. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02834065.
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Affiliation(s)
- G Chad Hughes
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - Edward P Chen
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - Jeffrey N Browndyke
- Department of Psychiatry & Behavioral Sciences, Division of Behavioral Medicine & Neurosciences (J.N.B., J.A.B.), Duke University Medical Center, Durham, NC
| | - Wilson Y Szeto
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia (W.Y.S.)
| | - J Michael DiMaio
- The Heart Hospital, Baylor Scott and White, Plano, TX (J.M.D., W.T.B.)
| | | | - Jeffrey G Gaca
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - James A Blumenthal
- Department of Psychiatry & Behavioral Sciences, Division of Behavioral Medicine & Neurosciences (J.N.B., J.A.B.), Duke University Medical Center, Durham, NC
| | - Jorn A Karhausen
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
| | - Tiffany Bisanar
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
| | - Michael L James
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
- Department of Neurology (M.L.J.), Duke University School of Medicine, Durham, NC
| | - David Yanez
- Department of Biostatistics and Bioinformatics (D.Y., Y.-J.L.), Duke University School of Medicine, Durham, NC
| | - Yi-Ju Li
- Department of Biostatistics and Bioinformatics (D.Y., Y.-J.L.), Duke University School of Medicine, Durham, NC
| | - Joseph P Mathew
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
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Ishii D, Maeda Y, Kuwabara M, Hosogai M, Kume S, Hara T, Kondo H, Horie N. Pulsatility index of superficial temporal artery was associated with cerebral infarction after direct bypass surgery for moyamoya disease. J Stroke Cerebrovasc Dis 2023; 32:107346. [PMID: 37708702 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/03/2023] [Accepted: 09/06/2023] [Indexed: 09/16/2023] Open
Abstract
OBJECTIVE Direct bypass surgery by superficial temporal artery (STA) - middle cerebral artery anastomosis is an established procedure for moyamoya disease (MMD). However, some patients may develop cerebral infarction (CI) due to the watershed shift phenomenon after the surgery. This study sought to investigate the correlation between the postoperative changes of STA flow as well as cerebral blood flow (CBF) and the incidence of CI after direct bypass surgery for MMD. METHODS We conducted a retrospective study of 62 hemispheres in 50 subjects who underwent direct bypass surgery for MMD. All subjects underwent pre- and post-operative MR imaging, ultrasound evaluation of STA, and single-photon emission computed tomography. The presence of CI was correlated with preoperative CBF, the delta difference of each value of the STA between before and after the surgery, and the postoperative increase ratio of CBF. RESULTS All bypass procedures were patent, and CI was observed in 4 cases (6.4%). There was no significant association between the incidence of CI and both pre- and post-operative CBF. However, there was a significant difference in delta pulsatility index (PI) of the STA between cases with or without CI (-0.38±0.22 and -0.87±0.63, respectively, p=0.03). Whereas, other factors did not show any significant differences between those with or without CI. CONCLUSIONS A relatively high postoperative PI of the STA was significantly associated with the incidence of CI after direct bypass surgery for MMD. A larger study is needed to confirm these findings.
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Affiliation(s)
- Daizo Ishii
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Yuyo Maeda
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masashi Kuwabara
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masahiro Hosogai
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shinji Kume
- Department of Clinical Laboratory, Hiroshima University Hospital, Hiroshima, Japan
| | - Takeshi Hara
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroshi Kondo
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Neurological Functional Independence After Endovascular Thrombectomy and Different Imaging Modalities for Large Infarct Core Assessment : A Systematic Review and Meta-analysis. Clin Neuroradiol 2023; 33:21-29. [PMID: 35920865 DOI: 10.1007/s00062-022-01202-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 07/10/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE To investigate the rate of neurological functional independence (NFI) at 90 days in patients with large infarct core (LIC), which was evaluated by different imaging modalities before endovascular thrombectomy (EVT). METHODS PubMed and EMBASE were searched for original studies on clinical functional outcomes at 90 days in LIC patients who received EVT treatment from inception to 28 September 2021. The pooled NFI rates were calculated using random effects model according to different imaging modalities and criteria. RESULTS We included 34 studies enrolling 2997 LIC patients. The NFI rates were 23% (95% confidence interval, CI 15-32%) and 24% (95% CI 10-38%) when LIC was defined as core volume ≥50 ml and ≥ 70 ml separately on computed tomography perfusion, 36% (95% CI 23-48%) and 21% (95% CI 17-25%) when LIC was defined as core volume ≥ 50 ml and ≥ 70 ml separately on magnetic resonance diffusion-weighted imaging (DWI), 28% (95% CI 24-32%) and 37% (95% CI 21-53%) when LIC was defined as DWI-ASPECTS ≤ 5 and ≤ 6 separately, 23% (95% CI 19-27%) and 32% (95% CI 18-46%) when LIC was defined as NCCT-ASPECTS ≤ 5 and ≤ 6 separately. CONCLUSION Similar NFI rates could be obtained after EVT in LIC patients if proper LIC criteria were select according to the imaging modality.
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How can imaging in acute ischemic stroke help us to understand tissue fate in the era of endovascular treatment and cerebroprotection? Neuroradiology 2022; 64:1697-1707. [PMID: 35854136 DOI: 10.1007/s00234-022-03001-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/21/2022] [Indexed: 10/17/2022]
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García AO, Brambati SM, Desautels A, Marcotte K. Timing stroke: A review on stroke pathophysiology and its influence over time on diffusion measures. J Neurol Sci 2022; 441:120377. [DOI: 10.1016/j.jns.2022.120377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 06/30/2022] [Accepted: 07/31/2022] [Indexed: 11/26/2022]
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Wu D, Zhou Y, Cho J, Shen N, Li S, Qin Y, Zhang G, Yan S, Xie Y, Zhang S, Zhu W, Wang Y. The Spatiotemporal Evolution of MRI-Derived Oxygen Extraction Fraction and Perfusion in Ischemic Stroke. Front Neurosci 2021; 15:716031. [PMID: 34483830 PMCID: PMC8415351 DOI: 10.3389/fnins.2021.716031] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/12/2021] [Indexed: 12/13/2022] Open
Abstract
Purpose This study aimed to assess the spatiotemporal evolution of oxygen extraction fraction (OEF) in ischemic stroke with a newly developed cluster analysis of time evolution (CAT) for a combined quantitative susceptibility mapping and quantitative blood oxygen level-dependent model (QSM + qBOLD, QQ). Method One hundred and fifteen patients in different ischemic stroke phases were retrospectively collected for measurement of OEF of the infarcted area defined on diffusion-weighted imaging (DWI). Clinical severity was assessed using the National Institutes of Health Stroke Scale (NIHSS). Of the 115 patients, 11 underwent two longitudinal MRI scans, namely, three-dimensional (3D) multi-echo gradient recalled echo (mGRE) and 3D pseudo-continuous arterial spin labeling (pCASL), to evaluate the reversal region (RR) of the initial diffusion lesion (IDL) that did not overlap with the final infarct (FI). The temporal evolution of OEF and the cerebral blood flow (CBF) in the IDL, the RR, and the FI were assessed. Results Compared to the contralateral mirror area, the OEF of the infarcted region was decreased regardless of stroke phases (p < 0.05) and showed a declining tendency from the acute to the chronic phase (p = 0.022). Five of the 11 patients with longitudinal scans showed reversal of the IDL. Relative oxygen extraction fraction (rOEF, compared to the contralateral mirror area) of the RR increased from the first to the second MRI (p = 0.044). CBF was about 1.5-fold higher in the IDL than in the contralateral mirror area in the first MRI. Two patients showed penumbra according to the enlarged FI volume. The rOEF of the penumbra fluctuated around 1.0 at earlier scan times and then decreased, while the CBF decreased continuously. Conclusion The spatiotemporal evolution of OEF and perfusion in ischemic lesions is heterogeneous, and the CAT-based QQ method is feasible to capture cerebral oxygen metabolic information.
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Affiliation(s)
- Di Wu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yiran Zhou
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Junghun Cho
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States.,Department of Biomedical Engineering, Cornell University, Ithaca, NY, United States
| | - Nanxi Shen
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shihui Li
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuanyuan Qin
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guiling Zhang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Su Yan
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yan Xie
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shun Zhang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wenzhen Zhu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yi Wang
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States.,Department of Biomedical Engineering, Cornell University, Ithaca, NY, United States
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Arca KN, VanderPluym JH, Halker Singh RB. Narrative review of neuroimaging in migraine with aura. Headache 2021; 61:1324-1333. [PMID: 34309848 DOI: 10.1111/head.14191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 04/21/2021] [Accepted: 05/27/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To improve the understanding of the role and utility of various neuroimaging modalities (clinical and research) for the evaluation of migraine aura (MA) and hemiplegic migraine during the ictal and interictal phases. BACKGROUND MA is defined by reversible neurologic symptoms and is considered a manifestation of a primary condition. As such, most patients with MA do not require imaging. However, if there are atypical features, change in symptom pattern, or it is a first-time presentation, neuroimaging may be used to evaluate for secondary conditions. Neuroimaging includes many modalities, and it is important to consider what information is being captured by these modalities (i.e., structural vs. functional). Imaging abnormalities may be noted both during (ictal) and between (interictal) MA attacks, and it is important for clinicians to be familiar with neuroimaging findings reported in migraine with aura (MWA) compared with other conditions. METHODS With the assistance of a medical librarian, we performed a review of the literature pertaining to MWA and neuroimaging in PubMed. Search terms included were magnetic resonance imaging, positron-emission tomography, single photon-emission computed tomography, functional magnetic resonance imaging, and migraine with aura. We hand-searched these references to inform our subsequent literature review. RESULTS Acute MA can be associated with several unique neuroimaging findings-reversible cortical diffusion restriction, cortical venous engorgement, and a "biphasic" transition from hypoperfusion to hyperperfusion. Imaging findings during MA tend to span more than one vascular territory. Between acute attacks, neuroimaging in people with MWA can resemble migraine without aura in terms of white matter abnormalities and "infarct-like lesions." Research imaging modalities such as volumetric analysis and functional imaging have demonstrated unique findings in migraine with aura. CONCLUSION Although migraine is a clinical diagnosis, understanding of neuroimaging findings in MWA can help clinicians interpret imaging findings and improve patient care.
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Affiliation(s)
- Karissa N Arca
- Department of Neurology, Mayo Clinic Arizona, Scottsdale, AZ, USA
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Magoufis G, Safouris A, Raphaeli G, Kargiotis O, Psychogios K, Krogias C, Palaiodimou L, Spiliopoulos S, Polizogopoulou E, Mantatzis M, Finitsis S, Karapanayiotides T, Ellul J, Bakola E, Brountzos E, Mitsias P, Giannopoulos S, Tsivgoulis G. Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach. Ther Adv Neurol Disord 2021; 14:17562864211021182. [PMID: 34122624 PMCID: PMC8175833 DOI: 10.1177/17562864211021182] [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: 02/20/2021] [Accepted: 05/10/2021] [Indexed: 02/05/2023] Open
Abstract
Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.
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Affiliation(s)
- Georgios Magoufis
- Interventional Neuroradiology Unit, Metropolitan Hospital, Piraeus, Greece
| | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Guy Raphaeli
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | | | - Klearchos Psychogios
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Lina Palaiodimou
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Eftihia Polizogopoulou
- Emergency Medicine Clinic, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Michael Mantatzis
- Department of Radiology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Stephanos Finitsis
- Department of Interventional Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, Aristotle University of Thessaloniki, School of Medicine, Faculty of Health Sciences, AHEPA University Hospital, Thessaloniki, Greece
| | - John Ellul
- Department of Neurology, University Hospital of Patras, School of Medicine, University of Patras, Patras, Greece
| | - Eleni Bakola
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Elias Brountzos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Panayiotis Mitsias
- Department of Neurology Medical School, University of Crete, Heraklion, Crete, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian, University of Athens, School of Medicine, “Attikon” University Hospital, Iras 39, Gerakas Attikis, Athens, 15344, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
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13
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Nagaraja N. Diffusion weighted imaging in acute ischemic stroke: A review of its interpretation pitfalls and advanced diffusion imaging application. J Neurol Sci 2021; 425:117435. [PMID: 33836457 DOI: 10.1016/j.jns.2021.117435] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 03/08/2021] [Accepted: 04/02/2021] [Indexed: 12/28/2022]
Abstract
Diffusion weighted imaging (DWI) is a widely used imaging technique to evaluate patients with stroke. It can detect brain ischemia within minutes of stroke onset. However, DWI has few potential pitfalls that should be recognized during interpretation. DWI lesion could be reversible in the early hours of stroke and the entire lesion may not represent ischemic core. False negative DWI could lead to diagnosis of DWI negative stroke or to a missed stroke diagnosis. Ischemic stroke mimics can occur on DWI with non-cerebrovascular neurological conditions. In this article, the history of DWI, its clinical applications, and potential pitfalls for use in acute ischemic stroke are reviewed. Advanced diffusion imaging techniques with reference to Diffusion Kurtosis Imaging and Diffusion Tensor Imaging that has been studied to evaluate ischemic core are discussed.
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Affiliation(s)
- Nandakumar Nagaraja
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.
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14
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Cerebral embolism accompanied by remarkable diffusion-weighted imaging reversal in a 10 month-old infant with congenital heart disease. eNeurologicalSci 2020; 20:100260. [PMID: 32885055 PMCID: PMC7452634 DOI: 10.1016/j.ensci.2020.100260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/30/2020] [Accepted: 07/29/2020] [Indexed: 12/03/2022] Open
Abstract
The case of infant ischemic stroke with remarkable DWI reversal. A mismatch between core volume and visually DWI lesion predicts DWI reversal. Chronic hypoxia and early recanalization may contribute to large DWI reversal. Mismatch between DWI-ASPECTS and core volume may occur in infant brain.
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15
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Lakomkin N, Pan J, Stein L, Malkani B, Dhamoon M, Mocco J. Diffusion MRI Reversibility in Ischemic Stroke Following Thrombolysis: A Meta-Analysis. J Neuroimaging 2020; 30:471-476. [PMID: 32436311 DOI: 10.1111/jon.12703] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/02/2020] [Accepted: 03/05/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Diffusion-weighted magnetic resonance imaging (DWI) detects early infarction in acute stroke. With the substantial progress in stroke therapies, the frequency of posttreatment DWI reversibility in modern stroke cohorts is currently unknown. The purpose of this study was to perform a systematic literature review examining the relationship between characteristics of patients with ischemic stroke and DWI reversibility following treatment with lytic therapy. METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, yielding a total of 422 unique articles. Studies that were nonclinical or did not report data pertaining to DWI reversibility in the context of an acute stroke series were excluded. Characteristics regarding presentation, diagnosis, intervention, and the timing of DWI reversibility were collected for each study. RESULTS After full-text review, 10 studies were identified as meeting inclusion criteria. The number of patients with DWI reversal ranged from .9% to 50%, whereas the extent of reversal ranged from 1.8% to 72.7%. Studies reporting on younger patients describe greater rates of reversibility following stroke treatment. CONCLUSIONS These data suggest that early DWI signal may not represent the definitive DWI burden in recanalized populations. However, substantial heterogeneity exists regarding the rate of DWI reversal following recanalization. Additional studies are needed to elucidate the relationship among time to treatment, early reversal rates, and clinical outcomes. Physicians should use caution when basing clinical decisions on DWI lesion volumes, as these likely change to some degree with recanalization.
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Affiliation(s)
- Nikita Lakomkin
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jonathan Pan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Laura Stein
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Brijesh Malkani
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mandip Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
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16
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Yue P, Dongmei W, Zhenzhou L, Yongming WU, Zhong JI. [Diffusion-weighted imaging hyperintensity is reversible in large middle cerebral artery infarction following thrombectomy:a case report]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2020; 40:459-462. [PMID: 32895146 DOI: 10.12122/j.issn.1673-4254.2020.04.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Diffusion-weighted imaging (DWI) is currently the most sensitive technique to diagnose early ischemic stroke. DWI signal hyperintensity is usually considered to suggest irreversible infarct core, but recent studies demonstrated that DWI hyperintensity signal could be reversible on small embolic lesions. Herein we present a case in a 63-year-old male patient, who was admitted to the emergency department with altered mental status and complaint of weakness in the left arm and leg 6.8 h prior to the admission. Emergency cranial magnetic resonance imaging (MRI) and angiography (MRA) revealed occlusion of his right middle cerebral artery (MCA) and large lesions on DWI. The patient underwent intra-artery thrombectomy after evaluation in spite of the large volume of the DWI lesions up to 91.5 mL at the baseline. His right MCA was recanalized at 8.5 h from symptom onset. One week after the procedure, the patient showed reduced DWI lesion volume to 11.58 mL. In this case we observed the reversibility of a large lesion of the anterior artery circulation presenting with hyperintensity on DWI, suggesting that the clinical implication of DWI hyperintensity should be interpreted with caution, and a large volume of baseline DWI hyperintensity may not be a contraindication to thrombectomy. This conclusion, however, awaits further validation by future large-scale randomized controlled trials.
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Affiliation(s)
- Pan Yue
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Wang Dongmei
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Lin Zhenzhou
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - W U Yongming
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - J I Zhong
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
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17
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Nagaraja N, Forder JR, Warach S, Merino JG. Reversible diffusion-weighted imaging lesions in acute ischemic stroke: A systematic review. Neurology 2020; 94:571-587. [PMID: 32132175 DOI: 10.1212/wnl.0000000000009173] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 01/27/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To systematically review the literature for reversible diffusion-weighted imaging (DWIR) lesions and to describe its prevalence, predictors, and clinical significance. METHODS Studies were included if the first DWI MRI was performed within 24 hours of stroke onset and follow-up DWI or fluid-attenuated inversion recovery (FLAIR)/T2 was performed within 7 or 90 days, respectively, to measure DWIR. We abstracted clinical, imaging, and outcomes data. RESULTS Twenty-three studies met the study criteria. The prevalence of DWIR was 26.5% in DWI-based studies and 6% in FLAIR/T2-based studies. DWIR was associated with recanalization or reperfusion of the ischemic tissue with or without the use of tissue plasminogen activator (t-PA) or endovascular therapy, earlier treatment with t-PA, shorter time to endovascular therapy after MRI, and absent or less severe perfusion deficit within the DWI lesion. DWIR was associated with early neurologic improvement in 5 of 6 studies (defined as improvement in the NIH Stroke Scale (NIHSS) score by 4 or 8 points from baseline or NIHSS score 0 to 2 at 24 hours after treatment or at discharge or median NIHSS score at 7 days) and long-term outcome in 6 of 7 studies (defined as NIHSS score ≤1, improvement in the NIHSS score ≥8 points, or modified Rankin Scale score up to ≤2 at 30 or 90 days) likely due to reperfusion. CONCLUSIONS DWIR is seen in up to a quarter of patients with acute ischemic stroke, and it is associated with good clinical outcome following reperfusion. Our findings highlight the pitfalls of DWI to define ischemic core in the early hours of stroke.
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Affiliation(s)
- Nandakumar Nagaraja
- From the Department of Neurology (N.N.), University of Florida College of Medicine, Gainesville; Department of Radiology and Biomedical Engineering (J.R.F.), University of Florida, Gainesville; Dell Medical School (S.W.), University of Texas at Austin; and Department of Neurology (J.G.M.), Georgetown University School of Medicine, Washington, DC.
| | - John R Forder
- From the Department of Neurology (N.N.), University of Florida College of Medicine, Gainesville; Department of Radiology and Biomedical Engineering (J.R.F.), University of Florida, Gainesville; Dell Medical School (S.W.), University of Texas at Austin; and Department of Neurology (J.G.M.), Georgetown University School of Medicine, Washington, DC
| | - Steven Warach
- From the Department of Neurology (N.N.), University of Florida College of Medicine, Gainesville; Department of Radiology and Biomedical Engineering (J.R.F.), University of Florida, Gainesville; Dell Medical School (S.W.), University of Texas at Austin; and Department of Neurology (J.G.M.), Georgetown University School of Medicine, Washington, DC
| | - Jośe G Merino
- From the Department of Neurology (N.N.), University of Florida College of Medicine, Gainesville; Department of Radiology and Biomedical Engineering (J.R.F.), University of Florida, Gainesville; Dell Medical School (S.W.), University of Texas at Austin; and Department of Neurology (J.G.M.), Georgetown University School of Medicine, Washington, DC
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18
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Kaesmacher J, Chaloulos-Iakovidis P, Panos L, Mordasini P, Michel P, Hajdu SD, Ribo M, Requena M, Maegerlein C, Friedrich B, Costalat V, Benali A, Pierot L, Gawlitza M, Schaafsma J, Mendes Pereira V, Gralla J, Fischer U. Mechanical Thrombectomy in Ischemic Stroke Patients With Alberta Stroke Program Early Computed Tomography Score 0-5. Stroke 2020; 50:880-888. [PMID: 30827193 PMCID: PMC6430594 DOI: 10.1161/strokeaha.118.023465] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— If anterior circulation large vessel occlusion acute ischemic stroke patients presenting with ASPECTS 0–5 (Alberta Stroke Program Early CT Score) should be treated with mechanical thrombectomy remains unclear. Purpose of this study was to report on the outcome of patients with ASPECTS 0–5 treated with mechanical thrombectomy and to provide data regarding the effect of successful reperfusion on clinical outcomes and safety measures in these patients. Methods— Multicenter, pooled analysis of 7 institutional prospective registries: Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the SOLITAIRE FR With the Intention for Thrombectomy (Clinical Trial Registration—URL: https://www.clinicaltrials.gov. Unique identifier: NCT03496064). Primary outcome was defined as modified Rankin Scale 0–3 at day 90 (favorable outcome). Secondary outcomes included rates of day 90 modified Rankin Scale 0–2 (functional independence), day 90 mortality and occurrence of symptomatic intracerebral hemorrhage. Multivariable logistic regression analyses were performed to assess the association of successful reperfusion with clinical outcomes. Outputs are displayed as adjusted Odds Ratios (aOR) and 95% CI. Results— Two hundred thirty-seven of 2046 patients included in this registry presented with anterior circulation large vessel occlusion and ASPECTS 0–5. In this subgroup, the overall rates of favorable outcome and mortality at day 90 were 40.1% and 40.9%. Achieving successful reperfusion was independently associated with favorable outcome (aOR, 5.534; 95% CI, 2.363–12.961), functional independence (aOR, 5.583; 95% CI, 1.964–15.873), reduced mortality (aOR, 0.180; 95% CI, 0.083–0.390), and lower rates of symptomatic intracerebral hemorrhage (aOR, 0.235; 95% CI, 0.062–0.887). The mortality-reducing effect remained in patients with ASPECTS 0–4 (aOR, 0.167; 95% CI, 0.056–0.499). Sensitivity analyses did not change the primary results. Conclusions— In patients presenting with ASPECTS 0–5, who were treated with mechanical thrombectomy, successful reperfusion was beneficial without increasing the risk of symptomatic intracerebral hemorrhage. Although the results do not allow for general treatment recommendations, formal testing of mechanical thrombectomy versus best medical treatment in these patients in a randomized controlled trial is warranted.
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Affiliation(s)
- Johannes Kaesmacher
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., P. Mordasini, J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland.,Department of Neurology (J.K., P.C.-I., L.P., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland.,University Institute of Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Panagiotis Chaloulos-Iakovidis
- Department of Neurology (J.K., P.C.-I., L.P., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Leonidas Panos
- Department of Neurology (J.K., P.C.-I., L.P., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Pasquale Mordasini
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., P. Mordasini, J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Patrik Michel
- Department of Neurology (P. Michel) and Department of Radiology (S.D.H.), CHUV Lausanne, Switzerland
| | - Steven D Hajdu
- Department of Neurology (P. Michel) and Department of Radiology (S.D.H.), CHUV Lausanne, Switzerland
| | - Marc Ribo
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain (M. Ribo, M. Requena)
| | - Manuel Requena
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain (M. Ribo, M. Requena)
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Germany (C.M., B.F.)
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Germany (C.M., B.F.)
| | - Vincent Costalat
- Department of Neuroradiology, CHU Montpellier, France (V.C., A.B.), Toronto Western Hospital, ON
| | - Amel Benali
- Department of Neuroradiology, CHU Montpellier, France (V.C., A.B.), Toronto Western Hospital, ON
| | - Laurent Pierot
- Department of Neuroradiology, CHU Reims, France (L.P., M.G.), Toronto Western Hospital, ON
| | - Matthias Gawlitza
- Department of Neuroradiology, CHU Reims, France (L.P., M.G.), Toronto Western Hospital, ON
| | | | | | - Jan Gralla
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., P. Mordasini, J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Urs Fischer
- Department of Neurology (J.K., P.C.-I., L.P., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
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19
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Lansky AJ, Messé SR, Brickman AM, Dwyer M, Bart van der Worp H, Lazar RM, Pietras CG, Abrams KJ, McFadden E, Petersen NH, Browndyke J, Prendergast B, Ng VG, Cutlip DE, Kapadia S, Krucoff MW, Linke A, Scala Moy C, Schofer J, van Es GA, Virmani R, Popma J, Parides MK, Kodali S, Bilello M, Zivadinov R, Akar J, Furie KL, Gress D, Voros S, Moses J, Greer D, Forrest JK, Holmes D, Kappetein AP, Mack M, Baumbach A. Proposed Standardized Neurological Endpoints for Cardiovascular Clinical Trials: An Academic Research Consortium Initiative. Eur Heart J 2019; 39:1687-1697. [PMID: 28171522 DOI: 10.1093/eurheartj/ehx037] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Surgical and catheter-based cardiovascular procedures and adjunctive pharmacology have an inherent risk of neurological complications. The current diversity of neurological endpoint definitions and ascertainment methods in clinical trials has led to uncertainties in the neurological risk attributable to cardiovascular procedures and inconsistent evaluation of therapies intended to prevent or mitigate neurological injury. Benefit-risk assessment of such procedures should be on the basis of an evaluation of well-defined neurological outcomes that are ascertained with consistent methods and capture the full spectrum of neurovascular injury and its clinical effect. The Neurologic Academic Research Consortium is an international collaboration intended to establish consensus on the definition, classification, and assessment of neurological endpoints applicable to clinical trials of a broad range of cardiovascular interventions. Systematic application of the proposed definitions and assessments will improve our ability to evaluate the risks of cardiovascular procedures and the safety and effectiveness of preventive therapies.
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Affiliation(s)
- Alexandra J Lansky
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Yale Cardiovascular Research Group, New Haven, Connecticut.,Department of Cardiology, St Bartholomew's Hospital, William Harvey Research Institute, and Queen Mary University of London, London, United Kingdom
| | - Steven R Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Adam M Brickman
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Michael Dwyer
- Buffalo Neuroimaging Analysis, University of Buffalo, Buffalo, New York
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ronald M Lazar
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Cody G Pietras
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Yale Cardiovascular Research Group, New Haven, Connecticut
| | - Kevin J Abrams
- Baptist Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, Florida
| | - Eugene McFadden
- Department of Cardiology, Cork University Hospital, Cork, Ireland
| | - Nils H Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Jeffrey Browndyke
- Division of Geriatric Behavioral Health, Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | | | - Vivian G Ng
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Yale Cardiovascular Research Group, New Haven, Connecticut
| | - Donald E Cutlip
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Mitchell W Krucoff
- Department of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Axel Linke
- Department of Internal Medicine/Cardiology, University of Leipzig, Leipzig, Germany
| | - Claudia Scala Moy
- Office of Clinical Research, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Joachim Schofer
- Medicare Center and Department for Percutaneous Interventions of Structural Heart Disease, Albertine Heart Center, Hamburg, Germany
| | | | | | - Jeffrey Popma
- Icahn School of Medicine at Mount Sinai Group, New York, New York
| | | | - Susheel Kodali
- Division of Cardiology, Department of Internal Medicine, Columbia University Medical Center, New York, New York
| | - Michel Bilello
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis, University of Buffalo, Buffalo, New York
| | - Joseph Akar
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Karen L Furie
- Department of Neurology, Rhode Island Hospital, Providence, Rhode Island
| | - Daryl Gress
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska
| | - Szilard Voros
- Global Institute for Research and Global Genomics Group, Richmond, Virginia
| | - Jeffrey Moses
- Division of Cardiology, Department of Internal Medicine, Columbia University Medical Center, New York, New York
| | - David Greer
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - John K Forrest
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - David Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Arie P Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands; and the
| | - Michael Mack
- Department of Cardiovascular Surgery, The Heart Hospital Baylor Plano Research Center, Plano Texas. Grants to support travel costs, meeting rooms, and lodging for academic attendees at the San Francisco and New York meetings were provided by Boston Scientific, Edwards Lifesciences, Medtronic Corporation, St. Jude Medical, NeuroSave Inc., and Keystone Heart Ltd
| | - Andreas Baumbach
- Department of Cardiology, St Bartholomew's Hospital, William Harvey Research Institute, and Queen Mary University of London, London, United Kingdom
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20
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Ng FC, Campbell BCV. Imaging After Thrombolysis and Thrombectomy: Rationale, Modalities and Management Implications. Curr Neurol Neurosci Rep 2019; 19:57. [PMID: 31278596 DOI: 10.1007/s11910-019-0970-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Urgent reperfusion treatment with intravenous thrombolysis or mechanical thrombectomy reduces disability after ischaemic stroke. Imaging plays an important role in identifying patients who benefit, particularly in extended time windows. However, the role of post-treatment neuroimaging is less well established. We review recent advances in neuroimaging after reperfusion treatment and provide a practical guide to the options and management implications. RECENT FINDINGS Post-treatment imaging is critical to identify patients with reperfusion-related haemorrhage and oedema requiring intervention. It also can guide the timing and intensity of antithrombotic medication. The degree of reperfusion on post-thrombectomy angiography and infarct volume and topography using CT or MRI carry important prognostic significance. Perfusion-weighted MRI and permeability analysis may help detect persistent perfusion abnormalities post-treatment and predict haemorrhagic complications. Post-treatment neuroimaging provides clinically relevant information to identify complications, assess prognosis and perform quality assurance after acute ischaemic stroke. Recent advances in neuroimaging represent a potential avenue to explore post-reperfusion pathophysiology and uncover therapeutic targets for secondary ischaemic and haemorrhagic injury.
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Affiliation(s)
- Felix C Ng
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Grattan Street, Parkville, VIC, 3050, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Grattan Street, Parkville, VIC, 3050, Australia.
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21
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Bilateral Cerebral Infarctions and Intracardiac Thrombus in a Young Duchenne Muscular Dystrophy Patient. J Stroke Cerebrovasc Dis 2018; 27:e150-e152. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.02.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 02/06/2018] [Accepted: 02/17/2018] [Indexed: 11/20/2022] Open
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22
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Iosif C, Lecomte JC, Pedrolo-Silveira E, Mendes G, Boncoeur Martel MP, Saleme S, Mounayer C. Evaluation of ischemic lesion prevalence after endovascular treatment of intracranial aneurysms, as documented by 3-T diffusion-weighted imaging: a 2-year, single-center cohort study. J Neurosurg 2018; 128:982-991. [DOI: 10.3171/2016.11.jns161020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEEven though published data exist concerning the prevalence of ischemic lesions detected by diffusion-weighted imaging (DWI) following endovascular treatment of intracranial aneurysms, a single-center cross-evaluation of the different endovascular techniques has been lacking. The authors sought to prospectively evaluate the prevalence and clinical significance of ischemic lesions occurring after endovascular treatment of intracranial aneurysms and to compare the safety and effectiveness of a broad spectrum of currently accepted endovascular techniques in a single-center setting.METHODSThis was a prospective cohort study involving consecutive patients treated for intracranial aneurysms exclusively by endovascular means, excluding treatments in the acute rupture phase, in a center featuring an endovascular-only treatment policy for intracranial aneurysms. All patients underwent MRI, including a 3-directional DWI sequence, before treatment, 24 hours postprocedure, and 6 months following endovascular embolization. Selective angiography was performed at 6 months’ follow-up.RESULTSFrom January 2012 through December 2013, 164 aneurysms were treated in 128 consecutive patients. Endovascular techniques included coiling (14.6%), balloon-assisted coiling (20.1%), stent-assisted coiling (3.7%), low-profile stent-assisted coiling, flow diversion (38.4%), and very complex treatments (6.1%) involving 2 stents in Y or T configurations. On postprocedure MRI, the rates of occurrence of new DWI-positive lesions were 64.3% for coiling, 54.5% for remodeling, 61.1% for stent-assisted coiling, 53.7% for flow-diverting stents, and 75% for very complex treatments (p = 0.4962). The 6-month procedure-related morbidity and mortality rates were 6.25% and 0%, respectively. At 6 months’ follow-up, 93% of the patients had modified Rankin Scale (mRS) scores of 0–2. Very complex treatments offered a higher complete occlusion rate (100%) than all other techniques (66.7%–88.9%). Age and length of procedure were independent factors for DWI lesion occurrence. The diameter of DWI lesions on 24-hour postprocedure MRI was positively correlated with mRS score at discharge. Among the DWI-positive lesions measuring less than 2 mm in diameter on the 24-hour MRI, 44.12% had regressed at 6 months.CONCLUSIONSProcedure-related DWI lesions are far more often encountered in silent forms than they are clinically evident. They do not seem to be significantly correlated with procedure-related complications, nor do they seem to impair clinical outcome, regardless of the endovascular technique. Small lesions (< 2 mm in diameter) may regress within 6 months. The use of the most adapted technique, in terms of aneurysm configuration, results in significant total occlusion rates, with acceptable safety.
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Affiliation(s)
- Christina Iosif
- Departments of 1Interventional Neuroradiology and
- 3University of Limoges, CNRS, XLIM, UMR 7252, Limoges, France
| | | | | | | | | | | | - Charbel Mounayer
- Departments of 1Interventional Neuroradiology and
- 3University of Limoges, CNRS, XLIM, UMR 7252, Limoges, France
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23
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Xu XH, Gao T, Zhang WJ, Tong LS, Gao F. Remote Diffusion-Weighted Imaging Lesions in Intracerebral Hemorrhage: Characteristics, Mechanisms, Outcomes, and Therapeutic Implications. Front Neurol 2017; 8:678. [PMID: 29326644 PMCID: PMC5736543 DOI: 10.3389/fneur.2017.00678] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 11/28/2017] [Indexed: 01/05/2023] Open
Abstract
Spontaneous intracerebral hemorrhage (ICH) is one of the most fatal form of stroke, with high mortality and disability rate. Small diffusion-weighed imaging lesions are not rare to see in regions remote from the hematoma after ICH and have been generally considered as related with poor outcome. In this review, we described the characteristics of remote ischemic lesions, discussed the possible mechanisms and clinical outcomes of these lesions, and evaluated the potential therapeutic implications.
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Affiliation(s)
- Xu-Hua Xu
- School of Medicine, Zhejiang University, Hangzhou, China.,Department of Neurology, The Fourth Affiliated Hospital, School of Medicine, Zhejiang University, Yiwu, China
| | - Ting Gao
- School of Medicine, Zhejiang University, Hangzhou, China
| | - Wen-Ji Zhang
- Department of Radiology, The Fourth Affiliated Hospital, School of Medicine, Zhejiang University, Yiwu, China
| | - Lu-Sha Tong
- Department of Neurology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Feng Gao
- School of Medicine, Zhejiang University, Hangzhou, China.,Department of Neurology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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24
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Abbott AL, Silvestrini M, Topakian R, Golledge J, Brunser AM, de Borst GJ, Harbaugh RE, Doubal FN, Rundek T, Thapar A, Davies AH, Kam A, Wardlaw JM. Optimizing the Definitions of Stroke, Transient Ischemic Attack, and Infarction for Research and Application in Clinical Practice. Front Neurol 2017; 8:537. [PMID: 29104559 PMCID: PMC5654955 DOI: 10.3389/fneur.2017.00537] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 09/25/2017] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND PURPOSE Until now, stroke and transient ischemic attack (TIA) have been clinically based terms which describe the presence and duration of characteristic neurological deficits attributable to intrinsic disorders of particular arteries supplying the brain, retina, or (sometimes) the spinal cord. Further, infarction has been pathologically defined as death of neural tissue due to reduced blood supply. Recently, it has been proposed we shift to definitions of stroke and TIA determined by neuroimaging results alone and that neuroimaging findings be equated with infarction. METHODS We examined the scientific validity and clinical implications of these proposals using the existing published literature and our own experience in research and clinical practice. RESULTS We found that the proposals to change to imaging-dominant definitions, as published, are ambiguous and inconsistent. Therefore, they cannot provide the standardization required in research or its application in clinical practice. Further, we found that the proposals are scientifically incorrect because neuroimaging findings do not always correlate with the clinical status or the presence of infarction. In addition, we found that attempts to use the proposals are disrupting research, are otherwise clinically unhelpful and do not solve the problems they were proposed to solve. CONCLUSION We advise that the proposals must not be accepted. In particular, we explain why the clinical focus of the definitions of stroke and TIA should be retained with continued sub-classification of these syndromes depending neuroimaging results (with or without other information) and that infarction should remain a pathological term. We outline ways the established clinically based definitions of stroke and TIA, and use of them, may be improved to encourage better patient outcomes in the modern era.
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Affiliation(s)
- Anne L. Abbott
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- The Neurology Department, The Alfred Hospital, Melbourne, VIC, Australia
| | | | - Raffi Topakian
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, QLD, Australia
| | - Alejandro M. Brunser
- Cerebrovascular Program, Neurology Service, Department of Medicine, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana – Universidad del Desarrollo, Santiago, Chile
| | - Gert J. de Borst
- Department of Vascular Surgery, University Medical Centre of Utrecht, Utrecht, Netherlands
| | - Robert E. Harbaugh
- Department of Neurosurgery, Penn State University, State College, PA, United States
| | - Fergus N. Doubal
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Department of Medicine, Elderly Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, Miami, FL, United States
| | - Ankur Thapar
- Imperial College Healthcare NHS Trust, London, United Kingdom
- Imperial College, London, United Kingdom
| | - Alun H. Davies
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College School of Medicine, Charing Cross Hospital, London, United Kingdom
| | - Anthony Kam
- Department of Radiology, Alfred Health, Melbourne, VIC, Australia
| | - Joanna M. Wardlaw
- Division of Neuroimaging Sciences, Centre for Clinical Brain Sciences, UK Dementia Research Institute at the University of Edinburgh, Edinburgh, United Kingdom
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25
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Cho SM, Deshpande A, Pasupuleti V, Hernandez AV, Uchino K. Radiographic and symptomatic brain ischemia in CEA and CAS: A systematic review and meta-analysis. Neurology 2017; 89:1977-1984. [PMID: 29021357 DOI: 10.1212/wnl.0000000000004626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 08/21/2017] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE In a systematic review, we compared ratio of new periprocedural radiographic brain ischemia (RBI) to the number of strokes and TIAs among patients undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS). METHODS We searched 5 databases for entries related to brain ischemia in CEA or CAS from inception through September 2015. We included articles with CEA or CAS and systematic performance of preprocedural and postprocedural brain MRI and reporting of RBI and stroke incidence. We calculated a symptomatic risk ratio of number of strokes and TIAs to RBI. Random effects models were used. RESULTS Fifty-nine studies (5,431 participants) met the inclusion criteria. There were 22 cohorts in CEA, 34 in CAS with distal protection, 8 in CAS with proximal protection, 9 in CAS without protection, and 9 in CAS with unspecified devices. Overall, 30.7% (95% confidence interval [CI] 26.6%-34.7%) had RBI, while 3.2% (95% CI 2.6%-3.8%) had clinical strokes or TIAs, with a stroke and TIA to RBI weighted ratio of 0.18 (95% CI 0.15-0.22). CEA had lower incidence of RBI compared to CAS (13.0% vs 37.4%) and also lower number of strokes and TIAs (1.8% vs 4.1%). The stroke and TIA to RBI ratio did not differ across 5 different types of carotid interventions (p = 0.58). CONCLUSIONS One in 5 persons with periprocedural radiographic brain ischemia during CEA and CAS had strokes and TIAs. The stable ratio of stroke and TIA to radiographic ischemia suggests that MRI ischemia could serve as a surrogate measure of periprocedural risk.
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Affiliation(s)
- Sung-Min Cho
- From the Cerebrovascular Center, Neurological Institute (S.-M.C., K.U.), and Medicine Institute (A.D.), Cleveland Clinic, Cleveland, OH; Case Western Reserve University (V.P.), Cleveland, OH; School of Medicine (A.V.H.), Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; and University of Connecticut/Hartford Hospital Evidence-Based Practice Center (A.V.H.)
| | - Abhishek Deshpande
- From the Cerebrovascular Center, Neurological Institute (S.-M.C., K.U.), and Medicine Institute (A.D.), Cleveland Clinic, Cleveland, OH; Case Western Reserve University (V.P.), Cleveland, OH; School of Medicine (A.V.H.), Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; and University of Connecticut/Hartford Hospital Evidence-Based Practice Center (A.V.H.)
| | - Vinay Pasupuleti
- From the Cerebrovascular Center, Neurological Institute (S.-M.C., K.U.), and Medicine Institute (A.D.), Cleveland Clinic, Cleveland, OH; Case Western Reserve University (V.P.), Cleveland, OH; School of Medicine (A.V.H.), Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; and University of Connecticut/Hartford Hospital Evidence-Based Practice Center (A.V.H.)
| | - Adrian V Hernandez
- From the Cerebrovascular Center, Neurological Institute (S.-M.C., K.U.), and Medicine Institute (A.D.), Cleveland Clinic, Cleveland, OH; Case Western Reserve University (V.P.), Cleveland, OH; School of Medicine (A.V.H.), Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; and University of Connecticut/Hartford Hospital Evidence-Based Practice Center (A.V.H.)
| | - Ken Uchino
- From the Cerebrovascular Center, Neurological Institute (S.-M.C., K.U.), and Medicine Institute (A.D.), Cleveland Clinic, Cleveland, OH; Case Western Reserve University (V.P.), Cleveland, OH; School of Medicine (A.V.H.), Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; and University of Connecticut/Hartford Hospital Evidence-Based Practice Center (A.V.H.).
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26
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Lansky AJ, Messé SR, Brickman AM, Dwyer M, van der Worp HB, Lazar RM, Pietras CG, Abrams KJ, McFadden E, Petersen NH, Browndyke J, Prendergast B, Ng VG, Cutlip DE, Kapadia S, Krucoff MW, Linke A, Moy CS, Schofer J, van Es GA, Virmani R, Popma J, Parides MK, Kodali S, Bilello M, Zivadinov R, Akar J, Furie KL, Gress D, Voros S, Moses J, Greer D, Forrest JK, Holmes D, Kappetein AP, Mack M, Baumbach A. Proposed Standardized Neurological Endpoints for Cardiovascular Clinical Trials: An Academic Research Consortium Initiative. J Am Coll Cardiol 2017; 69:679-691. [PMID: 28183511 DOI: 10.1016/j.jacc.2016.11.045] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 10/20/2016] [Accepted: 11/17/2016] [Indexed: 11/16/2022]
Abstract
Surgical and catheter-based cardiovascular procedures and adjunctive pharmacology have an inherent risk of neurological complications. The current diversity of neurological endpoint definitions and ascertainment methods in clinical trials has led to uncertainties in the neurological risk attributable to cardiovascular procedures and inconsistent evaluation of therapies intended to prevent or mitigate neurological injury. Benefit-risk assessment of such procedures should be on the basis of an evaluation of well-defined neurological outcomes that are ascertained with consistent methods and capture the full spectrum of neurovascular injury and its clinical effect. The Neurologic Academic Research Consortium is an international collaboration intended to establish consensus on the definition, classification, and assessment of neurological endpoints applicable to clinical trials of a broad range of cardiovascular interventions. Systematic application of the proposed definitions and assessments will improve our ability to evaluate the risks of cardiovascular procedures and the safety and effectiveness of preventive therapies.
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Affiliation(s)
- Alexandra J Lansky
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Yale Cardiovascular Research Group, New Haven, Connecticut; Department of Cardiology, St Bartholomew's Hospital, William Harvey Research Institute, and Queen Mary University of London, London, United Kingdom.
| | - Steven R Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Adam M Brickman
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Michael Dwyer
- Buffalo Neuroimaging Analysis, University of Buffalo, Buffalo, New York
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ronald M Lazar
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Cody G Pietras
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Yale Cardiovascular Research Group, New Haven, Connecticut
| | - Kevin J Abrams
- Baptist Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, Florida
| | - Eugene McFadden
- Department of Cardiology, Cork University Hospital, Cork, Ireland
| | - Nils H Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Jeffrey Browndyke
- Division of Geriatric Behavioral Health, Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | | | - Vivian G Ng
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Yale Cardiovascular Research Group, New Haven, Connecticut
| | - Donald E Cutlip
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Mitchell W Krucoff
- Department of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Axel Linke
- Department of Internal Medicine/Cardiology, University of Leipzig, Leipzig, Germany
| | - Claudia Scala Moy
- Office of Clinical Research, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Joachim Schofer
- Medicare Center and Department for Percutaneous Interventions of Structural Heart Disease, Albertine Heart Center, Hamburg, Germany
| | | | | | - Jeffrey Popma
- Icahn School of Medicine at Mount Sinai Group, New York, New York
| | | | - Susheel Kodali
- Division of Cardiology, Department of Internal Medicine, Columbia University Medical Center, New York, New York
| | - Michel Bilello
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis, University of Buffalo, Buffalo, New York
| | - Joseph Akar
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Karen L Furie
- Department of Neurology, Rhode Island Hospital, Providence, Rhode Island
| | - Daryl Gress
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska
| | - Szilard Voros
- Global Institute for Research and Global Genomics Group, Richmond, Virginia
| | - Jeffrey Moses
- Division of Cardiology, Department of Internal Medicine, Columbia University Medical Center, New York, New York
| | - David Greer
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - John K Forrest
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - David Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Arie P Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Michael Mack
- Department of Cardiovascular Surgery, The Heart Hospital Baylor Plano Research Center, Plano Texas
| | - Andreas Baumbach
- Department of Cardiology, St Bartholomew's Hospital, William Harvey Research Institute, and Queen Mary University of London, London, United Kingdom
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27
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Ono H, Nishijima Y, Ohta S, Sakamoto M, Kinone K, Horikosi T, Tamaki M, Takeshita H, Futatuki T, Ohishi W, Ishiguro T, Okamoto S, Ishii S, Takanami H. Hydrogen Gas Inhalation Treatment in Acute Cerebral Infarction: A Randomized Controlled Clinical Study on Safety and Neuroprotection. J Stroke Cerebrovasc Dis 2017; 26:2587-2594. [PMID: 28669654 DOI: 10.1016/j.jstrokecerebrovasdis.2017.06.012] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 05/29/2017] [Accepted: 06/04/2017] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Molecular hydrogen (H2) acts as a therapeutic antioxidant. Inhalation of H2 gas (1-4%) was effective for the improvement of cerebral infarction in multiple animal experiments. Thus, for actual applications, a randomized controlled clinical study is desired to evaluate the effects of inhalation of H2 gas. Here, we evaluate the H2 treatment on acute cerebral infarction. METHODS Through this randomized controlled clinical study, we assessed the safety and effectiveness of H2 treatment in patients with cerebral infarction in an acute stage with mild- to moderate-severity National Institute of Health Stroke Scale (NIHSS) scores (NIHSS = 2-6). We enrolled 50 patients (25 each in the H2 group and the control group) with a therapeutic time window of 6 to 24 hours. The H2 group inhaled 3% H2 gas (1 hour twice a day), and the control group received conventional intravenous medications for the initial 7 days. The evaluations included daily vital signs, NIHSS scores, physical therapy indices, weekly blood chemistry, and brain magnetic resonance imaging (MRI) scans over the 2-week study period. RESULTS The H2 group showed no significant adverse effects with improvements in oxygen saturation. The following significant effects were found: the relative signal intensity of MRI, which indicated the severity of the infarction site, NIHSS scores for clinically quantifying stroke severity, and physical therapy evaluation, as judged by the Barthel Index. CONCLUSIONS H2 treatment was safe and effective in patients with acute cerebral infarction. These results suggested a potential for widespread and general application of H2 gas.
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Affiliation(s)
- Hirohisa Ono
- Department of Neurosurgery, Nishijima Hospital, Numazu-city, Shizuoka-ken, Japan.
| | - Yoji Nishijima
- Department of Neurosurgery, Nishijima Hospital, Numazu-city, Shizuoka-ken, Japan
| | - Shigeo Ohta
- Department of Biochemistry and Cell Biology, Graduate School of Medicine, Nippon Medical School, Kawasaki-city, Kanagawa-ken, Japan; Department of Neurology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Masaki Sakamoto
- Department of Neurosurgery, Nishijima Hospital, Numazu-city, Shizuoka-ken, Japan
| | - Kazunori Kinone
- Department of Neurosurgery, Nishijima Hospital, Numazu-city, Shizuoka-ken, Japan
| | - Tohru Horikosi
- Department of Neurosurgery, Nishijima Hospital, Numazu-city, Shizuoka-ken, Japan
| | - Mituyuki Tamaki
- Department of Neurology, Nishijima Hospital, Numazu-city, Shizuoka-ken, Japan
| | - Hirosi Takeshita
- Department of Neurosurgery, Nishijima Hospital, Numazu-city, Shizuoka-ken, Japan
| | - Tomoko Futatuki
- Department of Neurosurgery, Nishijima Hospital, Numazu-city, Shizuoka-ken, Japan
| | - Wataru Ohishi
- Department of Neurosurgery, Nishijima Hospital, Numazu-city, Shizuoka-ken, Japan
| | - Taichi Ishiguro
- Department of Neurosurgery, Nishijima Hospital, Numazu-city, Shizuoka-ken, Japan
| | - Saori Okamoto
- Department of Neurosurgery, Nishijima Hospital, Numazu-city, Shizuoka-ken, Japan
| | - Shou Ishii
- Department of Neurosurgery, Nishijima Hospital, Numazu-city, Shizuoka-ken, Japan
| | - Hiroko Takanami
- Department of Laboratory, Nishijima Hospital, Numazu-city, Shizuoka-ken, Japan
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28
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Yi KS, Choi CH, Lee SR, Lee HJ, Lee Y, Jeong KJ, Hwang J, Chang KT, Cha SH. Sustained diffusion reversal with in-bore reperfusion in monkey stroke models: Confirmed by prospective magnetic resonance imaging. J Cereb Blood Flow Metab 2017; 37:2002-2012. [PMID: 27401804 PMCID: PMC5464696 DOI: 10.1177/0271678x16659302] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although early diffusion lesion reversal after recanalization treatment of acute ischaemic stroke has been observed in clinical settings, the reversibility of lesions observed by diffusion-weighted imaging remains controversial. Here, we present consistent observations of sustained diffusion lesion reversal after transient middle cerebral artery occlusion in a monkey stroke model. Seven rhesus macaques were subjected to endovascular transient middle cerebral artery occlusion with in-bore reperfusion confirmed by repeated prospective diffusion-weighted imaging. Early diffusion lesion reversal was defined as lesion reversal at 3 h after reperfusion. Sustained diffusion lesion reversal was defined as the difference between the ADC-derived pre-reperfusion maximal ischemic lesion volume (ADCD-P Match) and the lesion on 4-week follow-up FLAIR magnetic resonance imaging. Diffusion lesions were spatiotemporally assessed using a 3-D voxel-based quantitative technique. The ADCD-P Match was 9.7 ± 6.0% (mean ± SD) and the final infarct was 1.2-6.0% of the volume of the ipsilateral hemisphere. Early diffusion lesion reversal and sustained diffusion lesion reversal were observed in all seven animals, and the calculated percentages compared with their ADCD-P Match ranged from 8.3 to 51.9% (mean ± SD, 26.9 ± 15.3%) and 41.7-77.8% (mean ± SD, 65.4 ± 12.2%), respectively. Substantial sustained diffusion lesion reversal and early reversal were observed in all animals in this monkey model of transient focal cerebral ischaemia.
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Affiliation(s)
- Kyung Sik Yi
- 1 Department of Radiology, Chungbuk National University Hospital, Chungbuk, Republic of Korea
| | - Chi-Hoon Choi
- 1 Department of Radiology, Chungbuk National University Hospital, Chungbuk, Republic of Korea
| | - Sang-Rae Lee
- 2 National Primate Research Center, Korea Research Institute of Bioscience and Biotechnology, Chungbuk, Republic of Korea
| | - Hong Jun Lee
- 3 Medical Research Institute, Chung-Ang University, Seoul, Korea
| | - Youngjeon Lee
- 2 National Primate Research Center, Korea Research Institute of Bioscience and Biotechnology, Chungbuk, Republic of Korea
| | - Kang-Jin Jeong
- 2 National Primate Research Center, Korea Research Institute of Bioscience and Biotechnology, Chungbuk, Republic of Korea
| | - Jinwoo Hwang
- 4 Clinical Science, Philips Healthcare, Seoul, Republic of Korea
| | - Kyu-Tae Chang
- 2 National Primate Research Center, Korea Research Institute of Bioscience and Biotechnology, Chungbuk, Republic of Korea
| | - Sang-Hoon Cha
- 1 Department of Radiology, Chungbuk National University Hospital, Chungbuk, Republic of Korea.,5 College of Medicine, Chungbuk National University, Chungbuk, Republic of Korea
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29
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Yamamoto T, Ohshima T, Sato M, Goto S, Ishikawa K, Nishizawa T, Shimato S, Kato K. A Case of Acute Isolated Posterior Cerebral Artery Occlusion Successfully Treated with Endovascular Clot Aspiration. NMC Case Rep J 2017; 4:55-58. [PMID: 28664028 PMCID: PMC5453301 DOI: 10.2176/nmccrj.cr.2016-0214] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 10/24/2016] [Indexed: 11/20/2022] Open
Abstract
Posterior cerebral artery (PCA) strokes produce various symptoms. Therefore, the diagnosis is often delayed and patients arrive late for thrombolytic therapy. We report a case of acute isolated PCA occlusion that was successfully treated with endovascular clot aspiration. A 63-year-old man presented with right complete homonymous hemianopia. Diffusion-weighted image (DWI) showed a high-intensity area (HIA) in the occipital lobe, and magnetic resonance angiography (MRA) showed PCA occlusion. Emergency endovascular clot aspiration was performed immediately after the diagnosis. Blood flow in PCA completely recovered 210 min after symptom onset. DWI after surgery showed partial disappearance of HIA, and the patient recovered from the symptom of right complete homonymous hemianopia. Endovascular recanalization is useful for acute PCA occlusion. This is the first reported case of acute isolated PCA occlusion successfully treated with endovascular clot aspiration. Prompt reperfusion results in a good clinical course in patients with PCA stroke. In this case, endovascular clot aspiration resulted in prompt recanalization in a patient with acute isolated PCA occlusion.
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Affiliation(s)
- Taiki Yamamoto
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Tomotaka Ohshima
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Masaki Sato
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Shunsaku Goto
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Kojiro Ishikawa
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Toshihisa Nishizawa
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Shinji Shimato
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
| | - Kyozo Kato
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Aichi, Japan
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Effects of Obstructive Carotid Artery Disease on Ocular Circulation and the Safety of Carotid Artery Stenting. Heart Lung Circ 2017; 26:1069-1078. [PMID: 28162948 DOI: 10.1016/j.hlc.2016.11.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 10/19/2016] [Accepted: 11/24/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND The aims of this study were to examine the ophthalmic artery flow changes in patients with obstructive carotid artery disease, evaluate the orbital blood flow changes after carotid artery stenting and assess the safety of carotid stenting procedure by using transorbital colour and spectral Doppler sonography. METHODS Thirty-one consecutive patients scheduled for carotid stenting with severe internal carotid artery stenosis (>60%; the study group) and 30 control subjects were included. Ophthalmic artery (OA) Doppler sonography was performed in the control group and study group before and after stenting. Peak systolic velocity (PSV), end-diastolic velocity (EDV), pulsatility index (PI), and resistive index (RI) and systolic/diastolic ratio (S/D) in the ophthalmic artery were recorded. Statistical comparisons were made between controls and study group before stenting and before and after stenting in the study group. RESULTS Comparison between control and study group before stenting revealed a statistically significant decrease in OA PSV (51.5±14.5 vs. 39.7±19cm/sec, p= 0.008) and EDV (15.2±4.5 vs. 11.3±5.7cm/sec, p=0.004) in the study group. Differences in PI (1.3±0.14 vs. 1.36±0.4, p=0.47), RI (0.7±0.04 vs. 0.75±0.21, p=0.19), and S/D (3.5±0.6 vs. 3.6±1, p= 0.5) ratio were not statistically significant between groups. Peak systolic velocity (39.7±18.9 vs. 51.3±22.2cm/sec, p <0.001), RI (0.75±0.21 vs. 0.81±0.13, p=0.16) and S/D ratio (3.6±1 vs. 4.6±1.5, p= 0.001) were found to be significantly increased in the study group after stenting compared to baseline. There were no statistically significant differences in EDV and RI EDV(11.3±5.7 vs. 11.7±5.7cm/sec, p=0.66), PI (1.36±0.4 vs. 1.6±0.6, p =0.047) after stenting. CONCLUSIONS Ophthalmic artery flow parameters were significantly lower in patients with severe carotid artery stenosis compared to control, indicating compromised ocular blood flow in severe carotid stenosis. Flow indicators significantly improved after stent implantation suggesting the importance of revascularisation in restoring ocular blood flow and safety of carotid stenting.
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van der Kleij LA, De Vis JB, Olivot JM, Calviere L, Cognard C, Zuithoff NPA, Rinkel GJE, Hendrikse J, Vergouwen MDI. Magnetic Resonance Imaging and Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. Stroke 2017; 48:239-245. [DOI: 10.1161/strokeaha.116.011707] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 04/30/2016] [Accepted: 11/15/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Lisa A van der Kleij
- From the Department of Radiology (L.A.v.d.K., J.B.D.V., J.H.), Julius Center for Health Sciences and Primary Care (N.P.A.Z.), and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (G.J.E.R., M.D.I.V.), University Medical Center Utrecht, The Netherlands; and Department of Neurology (J.M.O., L.C.) and Department of Radiology (C.C.), University of Toulouse, France
| | - Jill B De Vis
- From the Department of Radiology (L.A.v.d.K., J.B.D.V., J.H.), Julius Center for Health Sciences and Primary Care (N.P.A.Z.), and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (G.J.E.R., M.D.I.V.), University Medical Center Utrecht, The Netherlands; and Department of Neurology (J.M.O., L.C.) and Department of Radiology (C.C.), University of Toulouse, France
| | - Jean-Marc Olivot
- From the Department of Radiology (L.A.v.d.K., J.B.D.V., J.H.), Julius Center for Health Sciences and Primary Care (N.P.A.Z.), and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (G.J.E.R., M.D.I.V.), University Medical Center Utrecht, The Netherlands; and Department of Neurology (J.M.O., L.C.) and Department of Radiology (C.C.), University of Toulouse, France
| | - Lionel Calviere
- From the Department of Radiology (L.A.v.d.K., J.B.D.V., J.H.), Julius Center for Health Sciences and Primary Care (N.P.A.Z.), and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (G.J.E.R., M.D.I.V.), University Medical Center Utrecht, The Netherlands; and Department of Neurology (J.M.O., L.C.) and Department of Radiology (C.C.), University of Toulouse, France
| | - Christophe Cognard
- From the Department of Radiology (L.A.v.d.K., J.B.D.V., J.H.), Julius Center for Health Sciences and Primary Care (N.P.A.Z.), and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (G.J.E.R., M.D.I.V.), University Medical Center Utrecht, The Netherlands; and Department of Neurology (J.M.O., L.C.) and Department of Radiology (C.C.), University of Toulouse, France
| | - Nicolaas P A Zuithoff
- From the Department of Radiology (L.A.v.d.K., J.B.D.V., J.H.), Julius Center for Health Sciences and Primary Care (N.P.A.Z.), and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (G.J.E.R., M.D.I.V.), University Medical Center Utrecht, The Netherlands; and Department of Neurology (J.M.O., L.C.) and Department of Radiology (C.C.), University of Toulouse, France
| | - Gabriel J E Rinkel
- From the Department of Radiology (L.A.v.d.K., J.B.D.V., J.H.), Julius Center for Health Sciences and Primary Care (N.P.A.Z.), and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (G.J.E.R., M.D.I.V.), University Medical Center Utrecht, The Netherlands; and Department of Neurology (J.M.O., L.C.) and Department of Radiology (C.C.), University of Toulouse, France
| | - Jeroen Hendrikse
- From the Department of Radiology (L.A.v.d.K., J.B.D.V., J.H.), Julius Center for Health Sciences and Primary Care (N.P.A.Z.), and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (G.J.E.R., M.D.I.V.), University Medical Center Utrecht, The Netherlands; and Department of Neurology (J.M.O., L.C.) and Department of Radiology (C.C.), University of Toulouse, France
| | - Mervyn D I Vergouwen
- From the Department of Radiology (L.A.v.d.K., J.B.D.V., J.H.), Julius Center for Health Sciences and Primary Care (N.P.A.Z.), and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (G.J.E.R., M.D.I.V.), University Medical Center Utrecht, The Netherlands; and Department of Neurology (J.M.O., L.C.) and Department of Radiology (C.C.), University of Toulouse, France.
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Magnetic resonance imaging detection of multiple ischemic injury produced in an adult rat model of minor stroke followed by mild transient cerebral ischemia. MAGNETIC RESONANCE MATERIALS IN PHYSICS BIOLOGY AND MEDICINE 2016; 30:175-188. [PMID: 27815649 PMCID: PMC5364243 DOI: 10.1007/s10334-016-0597-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 10/13/2016] [Accepted: 10/14/2016] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To determine whether cumulative brain damage produced adjacent to a minor stroke that is followed by a mild transient ischemia is detectable with MRI and histology, and whether acute or chronic recovery between insults influences this damage. MATERIALS AND METHODS A minor photothrombotic (PT) stroke was followed acutely (1-2 days) or chronically (7 days) by a mild transient middle cerebral artery occlusion (tMCAO). MRI was performed after each insult, followed by final histology. RESULTS The initial PT produced small hyperintense T2 and DW infarct lesions and peri-lesion regions of scattered necrosis and modestly increased T2. Following tMCAO, in a slice and a region adjacent to the PT, a region of T2 augmentation was observed when recovery between insults was acute but not chronic. Within the PT slice, a modest region of exacerbated T2 change proximate to the PT was also observed in the chronic group. Corresponding histological changes within regions of augmented T2 included increased vacuolation and cell death. CONCLUSION Within regions adjacent to an experimental minor stroke, a recurrence of a mild transient cerebral ischemia augmented T2 above increases produced by tMCAO alone, reflecting increased damage in this region. Exacerbation appeared broader with acute versus chronic recovery between insults.
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33
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Guillon B, Bourcier R, Toulgoat F, de Gaalon S, Gaultier-Lintia A, Sévin M. Gestione dell’infarto cerebrale acuto. Neurologia 2016. [DOI: 10.1016/s1634-7072(16)80382-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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34
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Pagnesi M, Martino EA, Chiarito M, Mangieri A, Jabbour RJ, Van Mieghem NM, Kodali SK, Godino C, Landoni G, Colombo A, Latib A. Silent cerebral injury after transcatheter aortic valve implantation and the preventive role of embolic protection devices: A systematic review and meta-analysis. Int J Cardiol 2016; 221:97-106. [DOI: 10.1016/j.ijcard.2016.06.143] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 06/19/2016] [Accepted: 06/24/2016] [Indexed: 12/29/2022]
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Tamura G, Ihara S, Morota N. Reversible diffusion weighted imaging hyperintensities during the acute phase of ischemic stroke in pediatric moyamoya disease: a case report. Childs Nerv Syst 2016; 32:1531-5. [PMID: 26971501 DOI: 10.1007/s00381-016-3052-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 03/04/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Moyamoya disease is one of the primary causes of pediatric ischemic stroke, especially in East Asia. Areas of high signal intensity on diffusion weighted imaging (DWI) with decreased apparent diffusion coefficient (ADC) values usually point to irreversible ischemic damage. Reversibility of these DWI hyperintensities during the acute phase of ischemic stroke in pediatric moyamoya disease has not previously been reported. CASE REPORT A 3-year-old girl was admitted to our emergency department due to sudden onset speech impairment and right hemiplegia. Computed tomography (CT) revealed a multilobal low-density area in the left cerebral hemisphere. The area was hyperintense on DWI with decreased ADC values. Magnetic resonance (MR) angiography revealed stenosis of the bilateral internal carotid artery bifurcations and their branches. Acute cerebral infarction due to moyamoya disease was diagnosed. MR images taken 4 days later showed resolution of most of the DWI hyperintensity areas. The initial decline in the ADC of the reversible DWI hyperintensities was less severe compared to the irreversible lesion. Within several days after onset, the patient became ambulatory although the follow-up MR fluid attenuated inversion recovery (FLAIR) images taken 2 weeks after onset revealed thinning of the corresponding cortical gyri. CONCLUSION These findings indicate that a wide area of DWI hyperintensity during the acute phase of ischemic stroke can be reversed by appropriate treatment in pediatric moyamoya disease. To the best of our knowledge, this is the first report of reversible DWI hyperintensities over a wide cortical area during the acute phase of ischemic stroke in pediatric moyamoya disease.
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Affiliation(s)
- Goichiro Tamura
- Division of Neurosurgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan.
| | - Satoshi Ihara
- Division of Neurosurgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Nobuhito Morota
- Division of Neurosurgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
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36
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Kaseka ML, Moharir M, deVeber G, MacGregor D, Askalan R, Dlamini N. Prognostication Value of Descending Corticospinal Tract DWI Signal in Neonatal Cerebral Sinovenous Thrombosis. Pediatr Neurol 2016; 59:90-4. [PMID: 27025187 DOI: 10.1016/j.pediatrneurol.2016.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 02/04/2016] [Indexed: 01/26/2023]
Abstract
BACKGROUND Descending corticospinal tract diffusion-weighted magnetic resonance imaging (MRI) signal is predictive of poor motor outcome in neonatal and childhood arterial ischemic stroke. However, descending corticospinal tract diffusion-weighted MRI signal has not been documented in the setting of cerebral sinovenous thrombosis, and its role is not understood. OBJECTIVE We describe a neonate with cerebral sinovenous thrombosis, extensive diffusion restriction, and bilateral descending corticospinal tract diffusion-weighted MRI signal on MRI of the brain. We discuss the underlying mechanisms and implications of these findings in venous ischemia. CONCLUSION The prognostic value of descending corticospinal tract diffusion-weighted MRI signal differs when observed in cerebral sinovenous thrombosis from when observed in arterial ischemic stroke. Consequently, caution should be exercised in using descending corticospinal tract diffusion-weighted MRI signal to predict outcome in children with cerebral sinovenous thrombosis.
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Affiliation(s)
- Matsanga Leyila Kaseka
- Neurologie pédiatrique, CHU Sainte-Justine, Université de Montréal, Montreal, Ontario, Canada
| | - Mahendranath Moharir
- Stroke Program, Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gabrielle deVeber
- Stroke Program, Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Daune MacGregor
- Stroke Program, Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rand Askalan
- Stroke Program, Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nomazulu Dlamini
- Stroke Program, Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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37
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Cora EA, White PM, Wardlaw JM. Stroke imaging in the age of thrombolysis. IMAGING 2016. [DOI: 10.1259/img.20120004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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38
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Nakamura K, Naito S, Sasaki T, Minami K, Take Y, Goto E, Shimizu S, Yamaguchi Y, Suzuki N, Yano T, Senga M, Kumagai K, Kaseno K, Funabashi N, Oshima S. Silent Cerebral Ischemic Lesions After Catheter Ablation of Atrial Fibrillation in Patients on 5 Types of Periprocedural Oral Anticoagulation – Predictors of Diffusion-Weighted Imaging-Positive Lesions and Follow-up Magnetic Resonance Imaging –. Circ J 2016; 80:870-7. [DOI: 10.1253/circj.cj-15-1368] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Kentaro Minami
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Yutaka Take
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Eri Goto
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Satoru Shimizu
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | | | - Naoko Suzuki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Toshiaki Yano
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Michiharu Senga
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Koji Kumagai
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Kenichi Kaseno
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui
| | - Nobusada Funabashi
- Department of Cardiovascular Science and Medicine, Chiba University Graduate School of Medicine
| | - Shigeru Oshima
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
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Ostwaldt AC, Usnich T, Nolte CH, Villringer K, Fiebach JB. Case report of a young stroke patient showing interim normalization of the MRI diffusion-weighted imaging lesion. BMC Med Imaging 2015; 15:33. [PMID: 26303115 PMCID: PMC4548688 DOI: 10.1186/s12880-015-0077-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 08/14/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In acute ischemic stroke, diffusion weighted imaging (DWI) shows hyperintensities and is considered to indicate irreversibly damaged tissue. We present the case of a young stroke patient with unusual variability in the development of signal intensities within the same vessel territory. CASE PRESENTATION A 35-year-old patient presented with symptoms of global aphasia and hypesthesia of the left hand. MRI demonstrated a scattered lesion in the MCA territory. After rtPA therapy the patient received further MRI examination, three times on day 1, and once on day 2, 3, 5 and 43. The posterior part of the lesion showed the usual pattern with increasing DWI hyperintensity and decreased ADC, as well as delayed FLAIR positivity. However, the anterior part of the lesion, which was clearly visible in the first examination completely normalized on the first day and only reappeared on day 2. This was accompanied by a normalization of the ADC as well as an even further delayed FLAIR positivity. CONCLUSION We showed that interim normalization of DWI and ADC in the acute phase can not only be found in rodent models of stroke, but also in humans. We propose that DWI lesion development might be more variable during the first 24 h after stroke than previously assumed.
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Affiliation(s)
- Ann-Christin Ostwaldt
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany.
| | - Tatiana Usnich
- Department of Neurology, Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany.
| | - Christian H Nolte
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany. .,Department of Neurology, Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany.
| | - Kersten Villringer
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany.
| | - Jochen B Fiebach
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany.
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Na DG, Sohn CH, Kim EY. Imaging-based management of acute ischemic stroke patients: current neuroradiological perspectives. Korean J Radiol 2015; 16:372-90. [PMID: 25741200 PMCID: PMC4347274 DOI: 10.3348/kjr.2015.16.2.372] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 12/02/2014] [Indexed: 01/05/2023] Open
Abstract
Advances in imaging-based management of acute ischemic stroke now provide crucial information such as infarct core, ischemic penumbra/degree of collaterals, vessel occlusion, and thrombus that helps in the selection of the best candidates for reperfusion therapy. It also predicts thrombolytic efficacy and benefit or potential hazards from therapy. Thus, radiologists should be familiar with various imaging studies for patients with acute ischemic stroke and the applicability to clinical trials. This helps radiologists to obtain optimal rapid imaging as well as its accurate interpretation. This review is focused on imaging studies for acute ischemic stroke, including their roles in recent clinical trials and some guidelines to optimal interpretation.
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Affiliation(s)
- Dong Gyu Na
- Department of Neuroradiology, Head & Neck Radiology, Thyroid Radiology Human Medical Imaging & Intervention Center, Seoul 137-902, Korea
| | - Chul-Ho Sohn
- Department of Radiology, Seoul National University Hospital, Seoul 110-744, Korea
| | - Eung Yeop Kim
- Department of Radiology, Gachon University Gil Medical Center, Incheon 405-760, Korea
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Abstract
Background and Purpose—
Here, we assessed how sustained is reversal of the acute diffusion lesion (RAD) observed 24 hours after intravenous thrombolysis, and the relationships between RAD fate and early neurological improvement.
Methods—
We analyzed 155 consecutive patients thrombolyzed intravenously 152 minutes (median) after stroke onset and who underwent 3 MR sessions: 1 before and 2 after treatment (median times from onset, 25.6 and 54.3 hours, respectively). Using voxel-based analysis of diffusion-weighted imaging (DWI)
1
, DWI
2
, and DWI
3
lesions on coregistered image data sets, we assessed the outcome of RAD voxels (hyperintense on DWI
1
but not on DWI
2
) as transient or sustained on DWI
3
, and their relationships with early neurological improvement, defined as ΔNational Institutes of Health Stroke Scale ≥8 or National Institutes of Health Stroke Scale ≤1 at 24 hours.
T
max
and apparent diffusion coefficient values were compared between sustained and transient RAD voxels.
Results—
The median (interquartile range) baseline National Institutes of Health Stroke Scale and DWI
1
lesion volume were 11 (7–18) mL and 15.6 (6.0–50.9) mL, respectively. The median (interquartile range) RAD volume on DWI
2
was 2.8 (1.1–6.6) mL, of which 70% was sustained on DWI
3
. Sixteen (10.3%) patients had sustained RAD ≥10 mL. As compared with transient RAD voxels, sustained RAD voxels had nonsignificantly higher baseline apparent diffusion coefficient values (median [interquartile range], 793 [717–887] versus 777 [705–869]×10
−6
mm
2
·s
−1
, respectively;
P
=0.08) and significantly better perfusion (
T
max
, mean±SD, 6.3±3.2 versus 7.8±4.0 s;
P
<0.001). At variance with transient RAD, the volume of sustained RAD was associated with early neurological improvement in multivariate analysis (odds ratio, 1.08; 95% confidence interval, [1.01–1.17], per 1-mL increase;
P
=0.03).
Conclusions—
After thrombolysis, over two-thirds of the DWI lesion reversal captured on 24-hour follow-up MR is sustained. Sustained DWI lesion reversal volume is a strong imaging correlate of early neurological improvement.
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Erdélyi-Bótor S, Aradi M, Kamson DO, Kovács N, Perlaki G, Orsi G, Nagy SA, Schwarcz A, Dóczi T, Komoly S, Deli G, Trauninger A, Pfund Z. Changes of migraine-related white matter hyperintensities after 3 years: a longitudinal MRI study. Headache 2014; 55:55-70. [PMID: 25319529 DOI: 10.1111/head.12459] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE/BACKGROUND The aim of this longitudinal study was to investigate changes of migraine-related brain white matter hyperintensities 3 years after an initial study. Baseline quantitative magnetic resonance imaging (MRI) studies of migraine patients with hemispheric white matter hyperintensities performed in 2009 demonstrated signs of tissue damage within the hyperintensities. The hyperintensities appeared most frequently in the deep white matter of the frontal lobe with a similar average hyperintensity size in all hemispheric lobes. Since in this patient group the repeated migraine attacks were the only known risk factors for the development of white matter hyperintensities, the remeasurements of migraineurs after a 3-year long follow-up may show changes in the status of these structural abnormalities as the effects of the repeated headaches. METHODS The same patient group was reinvestigated in 2012 using the same MRI scanner and acquisition protocol. MR measurements were performed on a 3.0-Tesla clinical MRI scanner. Beyond the routine T1-, T2-weighted, and fluid-attenuated inversion recovery imaging, diffusion and perfusion-weighted imaging, proton magnetic resonance spectroscopy, and T1 and T2 relaxation time measurements were also performed. Findings of the baseline and follow-up studies were compared with each other. RESULTS The follow-up proton magnetic resonance spectroscopy studies of white matter hyperintensities showed significantly decreased N-acetyl-aspartate (median values 8.133 vs 7.153 mmol/L, P=.009) and creatine/phosphocreatine (median values 4.970 vs 4.641 mmol/L, P=.015) concentrations compared to the baseline, indicating a more severe axonal loss and glial hypocellularity with decreased intracellular energy production. The diffusion values, the T1 and T2 relaxation times, and the cerebral blood flow and volume measurements presented only mild changes between the studies. The number (median values 21 vs 25, P<.001) and volume (median values 0.896 vs 1.140 mL, P<.001) of hyperintensities were significantly higher in the follow-up study. No changes were found in the hemispheric and lobar distribution of hyperintensities. An increase in the hyperintensity size of preexisting lesions was much more common than a decrease (median values 14 vs 5, P=.004). A higher number of newly developed hyperintensities were detected than disappeared ones (130 vs 22), and most of them were small (<.034 mL). Small white matter hyperintensities in patients with a low migraine attack frequency had a higher chance to disappear than large white matter hyperintensities or white matter hyperintensities in patients with a high attack frequency (coefficient: -0.517, P=.034). CONCLUSIONS This longitudinal MRI study found clinically silent brain white matter hyperintensities to be predominantly progressive in nature. The absence of a control group precludes definitive conclusions about the nature of these changes or if their degree is beyond normal aging.
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Tsai YH, Lee MH, Weng HH, Chang SW, Yang JT, Huang YC. Fate of diffusion restricted lesions in acute intracerebral hemorrhage. PLoS One 2014; 9:e105970. [PMID: 25166754 PMCID: PMC4148355 DOI: 10.1371/journal.pone.0105970] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 07/29/2014] [Indexed: 11/18/2022] Open
Abstract
Background Diffusion-restricted lesions on diffusion-weighted imaging (DWI) are detected in patients with intracerebral hemorrhage (ICH). In this study, we aimed to determine the fate of DWI lesions in ICH patients and whether the presence of DWI lesions is associated with functional outcome in patients with ICH. Methods This prospective study enrolled 153 patients with acute ICH. Baseline MRI scans were performed within 2 weeks after ICH to detect DWI lesions and imaging markers for small vessel disease (SVD). Follow-up MRI scans were performed at 3 months after ICH to assess the fate of the DWI lesions. We analyzed the associations between the characteristics of DWI lesions with clinical features and functional outcome. Results Seventeen of the 153 patients (11.1%) had a total of 25 DWI lesions. Factors associated with DWI lesions were high initial systolic and mean arterial blood pressure (MAP) at the emergency room, additional lowering of MAP within 24 hours, and the presence of white matter hyperintensity and cerebral microbleeds. Thirteen of the 25 DWI lesions (52%) were not visible on follow-up T2-weighted or fluid-attenuated inversion recovery images and were associated with high apparent diffusion coefficient value and a sharper decease in MAP. The regression of DWI lesions was associated with good functional outcome. Conclusions More than half of the DWI lesions in the ICH patients did not transition to visible, long-term infarction. Only if the DWI lesion finally transitioned to final infarction was a poor functional outcome predicted. A DWI lesion may be regarded as an ischemic change of SVD and does not always indicate certain cerebral infarction or permanent tissue injury.
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Affiliation(s)
- Yuan-Hsiung Tsai
- Department of Diagnostic Radiology, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Hsueh Lee
- Department of Neurosurgery, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Hsu-Huei Weng
- Department of Diagnostic Radiology, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Sheng-Wei Chang
- Department of Diagnostic Radiology, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Jen-Tsung Yang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Yen-Chu Huang
- Department of Neurology, Chang Gung Memorial Hospital at Chiayi, Chang-Gung University College of Medicine, Taoyuan, Taiwan
- * E-mail:
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Matthews PM, Geraghty OC. Understanding the pharmacology of stroke and multiple sclerosis through imaging. Curr Opin Pharmacol 2014; 14:34-41. [PMID: 24565010 DOI: 10.1016/j.coph.2013.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 10/27/2013] [Accepted: 10/30/2013] [Indexed: 01/09/2023]
Abstract
Stroke and multiple sclerosis (MS) illustrate how clinical imaging can facilitate early phase drug development and most effective medicine use in the clinic. Imaging has enhanced understanding of the dynamics of evolution of disease pathophysiology, better defining treatment targets. Imaging measures can enable stratification of patients for clinical trials and for most cost-effective use in the clinic. In MS, imaging has allowed smaller Phase II clinical trials and contributed to medicine differentiation. It also has led to consideration of suppression of inflammation and neurodegeneration as meaningfully distinct pharmacodynamic concepts. Similar imaging measures can be used in preclinical and clinical studies. Testing translational pharmacological hypotheses using clinical imaging more explicitly could improve the success of the next generation of stroke therapeutics.
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Affiliation(s)
- Paul M Matthews
- Division of Brain Sciences, Department of Medicine, Imperial College London, UK; Neurosciences Therapeutic Area Unit, GlaxoSmithKline Research and Development, Brentford, UK.
| | - Olivia C Geraghty
- Division of Brain Sciences, Department of Medicine, Imperial College London, UK
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