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Lakhani DA, Balar AB, Salim H, Koneru M, Wen S, Ozkara B, Lu H, Wang R, Hoseinyazdi M, Xu R, Nabi M, Mazumdar I, Cho A, Chen K, Sepehri S, Hyson N, Urrutia V, Luna L, Hillis AE, Heit JJ, Albers GW, Rai AT, Dmytriw AA, Faizy TD, Wintermark M, Nael K, Yedavalli VS. CT Perfusion Derived rCBV < 42% Lesion Volume Is Independently Associated with Followup FLAIR Infarct Volume in Anterior Circulation Large Vessel Occlusion. Diagnostics (Basel) 2024; 14:845. [PMID: 38667490 PMCID: PMC11049259 DOI: 10.3390/diagnostics14080845] [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: 04/03/2024] [Revised: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
Pretreatment CT Perfusion (CTP) parameter rCBV < 42% lesion volume has recently been shown to predict 90-day mRS. In this study, we aim to assess the relationship between rCBV < 42% and a radiographic follow-up infarct volume delineated on FLAIR images. In this retrospective evaluation of our prospectively collected database, we included acute stroke patients triaged by multimodal CT imaging, including CT angiography and perfusion imaging, with confirmed anterior circulation large vessel occlusion between 9 January 2017 and 10 January 2023. Follow-up FLAIR imaging was used to determine the final infarct volume. Student t, Mann-Whitney-U, and Chi-Square tests were used to assess differences. Spearman's rank correlation and linear regression analysis were used to assess associations between rCBV < 42% and follow-up infarct volume on FLAIR. In total, 158 patients (median age: 68 years, 52.5% female) met our inclusion criteria. rCBV < 42% (ρ = 0.56, p < 0.001) significantly correlated with follow-up-FLAIR infarct volume. On multivariable linear regression analysis, rCBV < 42% lesion volume (beta = 0.60, p < 0.001), ASPECTS (beta = -0.214, p < 0.01), mTICI (beta = -0.277, p < 0.001), and diabetes (beta = 0.16, p < 0.05) were independently associated with follow-up infarct volume. The rCBV < 42% lesion volume is independently associated with FLAIR follow-up infarct volume.
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Affiliation(s)
- Dhairya A. Lakhani
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Aneri B. Balar
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Hamza Salim
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Manisha Koneru
- Cooper Medical School, Rowan University, Camden, NJ 08103, USA
| | - Sijin Wen
- Department of Biostatistics, West Virginia University, Morgantown, WV 26506, USA;
| | - Burak Ozkara
- Department of Neurology, Johns Hopkins University, Baltimore, MD 21218, USA (A.E.H.)
| | - Hanzhang Lu
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Richard Wang
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Meisam Hoseinyazdi
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Risheng Xu
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Mehreen Nabi
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Ishan Mazumdar
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Andrew Cho
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Kevin Chen
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Sadra Sepehri
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Nathan Hyson
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Victor Urrutia
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Licia Luna
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
| | - Argye E. Hillis
- Department of Neurology, Johns Hopkins University, Baltimore, MD 21218, USA (A.E.H.)
| | - Jeremy J. Heit
- Department of Neurology, Stanford University, Stanford, CA 94305, USA; (J.J.H.); (G.W.A.)
| | - Greg W. Albers
- Department of Neurology, Stanford University, Stanford, CA 94305, USA; (J.J.H.); (G.W.A.)
| | - Ansaar T. Rai
- Department of Neuroradiology, West Virginia University, Morgantown, WV 26506, USA;
| | - Adam A. Dmytriw
- Department of Radiology, Harvard Medical School, Boston, MA 02115, USA;
| | - Tobias D. Faizy
- Department of Radiology, Neuroendovascular Division, University Medical Center Münster, 48149 Münster, Germany;
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson Medical Center, Houston, TX 77030, USA;
| | - Kambiz Nael
- Division of Neuroradiology, Department of Radiology, University of California San Francisco (UCSF), San Francisco, CA 94143, USA;
| | - Vivek S. Yedavalli
- Department of Radiology and Radiological Sciences, Johns Hopkins University, 600 N. Wolfe St., Phipps B100, Baltimore, MD 21287, USA; (A.B.B.); (H.S.); (H.L.); (R.W.); (M.H.); (R.X.); (M.N.); (I.M.); (A.C.); (K.C.); (S.S.); (N.H.); (V.U.); (L.L.); (V.S.Y.)
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Koneru M, Hoseinyazdi M, Wang R, Ozkara BB, Hyson NZ, Marsh EB, Llinas RH, Urrutia VC, Leigh R, Gonzalez LF, Xu R, Caplan JM, Huang J, Lu H, Luna L, Wintermark M, Dmytriw AA, Guenego A, Albers GW, Heit JJ, Nael K, Hillis AE, Yedavalli VS. Pretreatment parameters associated with hemorrhagic transformation among successfully recanalized medium vessel occlusions. J Neurol 2024; 271:1901-1909. [PMID: 38099953 DOI: 10.1007/s00415-023-12149-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 11/26/2023] [Accepted: 12/03/2023] [Indexed: 03/28/2024]
Abstract
Although pretreatment radiographic biomarkers are well established for hemorrhagic transformation (HT) following successful mechanical thrombectomy (MT) in large vessel occlusion (LVO) strokes, they are yet to be explored for medium vessel occlusion (MeVO) acute ischemic strokes. We aim to investigate pretreatment imaging biomarkers representative of collateral status, namely the hypoperfusion intensity ratio (HIR) and cerebral blood volume (CBV) index, and their association with HT in successfully recanalized MeVOs. A prospectively collected registry of acute ischemic stroke patients with MeVOs successfully recanalized with MT between 2019 and 2023 was retrospectively reviewed. A multivariate logistic regression for HT of any subtype was derived by combining significant univariate predictors into a forward stepwise regression with minimization of Akaike information criterion. Of 60 MeVO patients successfully recanalized with MT, HT occurred in 28.3% of patients. Independent factors for HT included: diabetes mellitus history (p = 0.0005), CBV index (p = 0.0071), and proximal versus distal occlusion location (p = 0.0062). A multivariate model with these factors had strong diagnostic performance for predicting HT (area under curve [AUC] 0.93, p < 0.001). Lower CBV indexes, distal occlusion location, and diabetes history are significantly associated with HT in MeVOs successfully recanalized with MT. Of note, HIR was not found to be significantly associated with HT.
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Affiliation(s)
- Manisha Koneru
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Meisam Hoseinyazdi
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Richard Wang
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | | | - Nathan Z Hyson
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | | | - Rafael H Llinas
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Victor C Urrutia
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Richard Leigh
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | | | - Risheng Xu
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Justin M Caplan
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Judy Huang
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Hanzhang Lu
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Licia Luna
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | | | | | - Adrien Guenego
- Universite Libre De Bruxelles Hospital Erasme, Anderlecht, Belgium
| | | | - Jeremy J Heit
- Stanford University School of Medicine, Stanford, CA, USA
| | - Kambiz Nael
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Argye E Hillis
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Vivek S Yedavalli
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA.
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Lakhani DA, Balar AB, Koneru M, Wen S, Ozkara BB, Wang R, Hoseinyazdi M, Nabi M, Mazumdar I, Cho A, Chen K, Sepehri S, Hyson N, Xu R, Urrutia V, Luna L, Hillis AE, Heit JJ, Albers GW, Rai AT, Yedavalli VS. CT perfusion based rCBF <38% volume is independently and negatively associated with digital subtraction angiography collateral score in anterior circulation large vessel occlusions. Neuroradiol J 2024:19714009241242639. [PMID: 38528780 DOI: 10.1177/19714009241242639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Collateral status (CS) is an important biomarker of functional outcomes in patients with acute ischemic stroke secondary to large vessel occlusion (AIS-LVO). Pretreatment CT perfusion (CTP) parameters serve as reliable surrogates of collateral status (CS). In this study, we aim to assess the relationship between the relative cerebral blood flow less than 38% (rCBF <38%), with the reference standard American Society of Interventional and Therapeutic Neuroradiology (ASITN) collateral score (CS) on DSA. METHODS In this prospectively collected, retrospectively reviewed analysis, inclusion criteria were as follows: (a) CT angiography (CTA) confirmed anterior circulation large vessel occlusion from 9/1/2017 to 10/01/2023; (b) diagnostic CT perfusion; and (c) underwent mechanical thrombectomy with documented ASITN CS. The ratios of the CTP-derived CBF values were calculated by dividing the values of the ischemic lesion by the corresponding values of the contralateral normal region (which were defined as rCBF). Spearman's rank correlation and logistic regression analysis were performed to determine the relationship of rCBF <38% lesion volume with DSA ASITN CS. p ≤ .05 was considered significant. RESULTS In total, 223 patients [mean age: 67.77 ± 15.76 years, 56.1% (n = 125) female] met our inclusion criteria. Significant negative correlation was noted between rCBF <38% volume and DSA CS (ρ = -0.37, p < .001). On multivariate logistic regression analysis, rCBF <38% volume was found to be independently associated with worse ASITN CS (unadjusted OR: 3.03, 95% CI: 1.60-5.69, p < .001, and adjusted OR: 2.73, 95% CI: 1.34-5.50, p < .01). CONCLUSION Greater volume of tissue with rCBF <38% is independently associated with better DSA CS. rCBF <38% is a useful adjunct tool in collateralization-based prognostication. Future studies are needed to expand our understanding of the role of rCBF <38% within the decision-making in patients with AIS-LVO.
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Affiliation(s)
- Dhairya A Lakhani
- Department of Radiology and Radiological Sciences, Johns Hopkins University, USA
| | - Aneri B Balar
- Department of Radiology and Radiological Sciences, Johns Hopkins University, USA
| | - Manisha Koneru
- Department of Radiology and Radiological Sciences, Johns Hopkins University, USA
| | - Sijin Wen
- Department of Biostatistics, West Virginia University, USA
| | - Burak Berksu Ozkara
- Department of Radiology and Radiological Sciences, Johns Hopkins University, USA
| | - Richard Wang
- Department of Radiology and Radiological Sciences, Johns Hopkins University, USA
| | - Meisam Hoseinyazdi
- Department of Radiology and Radiological Sciences, Johns Hopkins University, USA
| | - Mehreen Nabi
- Department of Radiology and Radiological Sciences, Johns Hopkins University, USA
| | - Ishan Mazumdar
- Department of Radiology and Radiological Sciences, Johns Hopkins University, USA
| | - Andrew Cho
- Department of Radiology and Radiological Sciences, Johns Hopkins University, USA
| | - Kevin Chen
- Department of Radiology and Radiological Sciences, Johns Hopkins University, USA
| | - Sadra Sepehri
- Department of Radiology and Radiological Sciences, Johns Hopkins University, USA
| | - Nathan Hyson
- Department of Radiology and Radiological Sciences, Johns Hopkins University, USA
| | - Risheng Xu
- Department of Radiology and Radiological Sciences, Johns Hopkins University, USA
| | - Victor Urrutia
- Department of Radiology and Radiological Sciences, Johns Hopkins University, USA
| | - Licia Luna
- Department of Radiology and Radiological Sciences, Johns Hopkins University, USA
| | | | | | | | - Ansaar T Rai
- Department of Neuroradiology, West Virginia University, USA
| | - Vivek S Yedavalli
- Department of Radiology and Radiological Sciences, Johns Hopkins University, USA
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Franx BAA, Lebrun F, Chin Joe Kie L, Deffieux T, Vivien D, Bonnard T, Dijkhuizen RM. Dynamics of cerebral blood volume during and after middle cerebral artery occlusion in rats - Comparison between ultrafast ultrasound and dynamic susceptibility contrast-enhanced MRI measurements. J Cereb Blood Flow Metab 2024; 44:333-344. [PMID: 38126356 PMCID: PMC10870967 DOI: 10.1177/0271678x231220698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 11/06/2023] [Accepted: 11/19/2023] [Indexed: 12/23/2023]
Abstract
Tomographic perfusion imaging techniques are integral to translational stroke research paradigms that advance our understanding of the disease. Functional ultrasound (fUS) is an emerging technique that informs on cerebral blood volume (CBV) through ultrasensitive Doppler and flow velocity (CBFv) through ultrafast localization microscopy. It is not known how experimental results compare with a classical CBV-probing technique such as dynamic susceptibility contrast-enhanced perfusion MRI (DSC-MRI). To that end, we assessed hemodynamics based on uUS (n = 6) or DSC-MRI (n = 7) before, during and up to three hours after 90-minute filament-induced middle cerebral artery occlusion (MCAO) in rats. Recanalization was followed by a brief hyperperfusion response, after which CBV and CBFv temporarily normalized but progressively declined after one hour in the lesion territory. DSC-MRI data corroborated the incomplete restoration of CBV after recanalization, which may have been caused by the free-breathing anesthetic regimen. During occlusion, MCAO-induced hypoperfusion was more discrepant between either technique, likely attributable to artefactual signal mechanisms related to slow flow, and processing algorithms employed for either technique. In vivo uUS- and DSC-MRI-derived measures of CBV enable serial whole-brain assessment of post-stroke hemodynamics, but readouts from both techniques need to be interpreted cautiously in situations of very low blood flow.
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Affiliation(s)
- Bart AA Franx
- Translational Neuroimaging Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Florent Lebrun
- Normandie University, UNICAEN, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Institute Blood and Brain @ Caen-Normandie (BB@C), Caen, France
- ETAP-Lab, STROK@LLIANCE, 13 Rue du bois de la champelle, 54500, Vandoeuvre-les-Nancy, France
| | - Lois Chin Joe Kie
- Translational Neuroimaging Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Thomas Deffieux
- Institute of Physics for Medicine Paris, INSERM U1273, ESPCI Paris, CNRS UMR 8063, PSL Université Recherche, Paris, France
| | - Denis Vivien
- Normandie University, UNICAEN, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Institute Blood and Brain @ Caen-Normandie (BB@C), Caen, France
- CHU Caen, Department of Clinical Research, CHU Caen, Côte de Nacre, France
| | - Thomas Bonnard
- Normandie University, UNICAEN, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Institute Blood and Brain @ Caen-Normandie (BB@C), Caen, France
| | - Rick M Dijkhuizen
- Translational Neuroimaging Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
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Xu Y, Yang J, Gao X, Sun J, Shang Q, Han Q, Wu Y, Li J, Xu T, Huang Y, Pan Y, Parson MW, Lin L. Quantitative assessment of collateral time on perfusion computed tomography in acute ischemic stroke patients. Front Neurol 2023; 14:1230697. [PMID: 37693754 PMCID: PMC10491895 DOI: 10.3389/fneur.2023.1230697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/27/2023] [Indexed: 09/12/2023] Open
Abstract
Background and aim Good collateral circulation is recognized to maintain perfusion and contribute to favorable clinical outcomes in acute ischemic stroke. This study aimed to derive and validate an optimal collateral time measurement on perfusion computed tomography imaging for patients with acute ischemic stroke. Methods This study included 106 acute ischemic stroke patients with complete large vessel occlusions. In deriving cohort of 23 patients, the parasagittal region of the ischemic hemisphere was divided into six pial arterial zones according to pial branches of the middle cerebral artery. Within the 85 arterial zones with collateral vessels, the receiver operating characteristic analysis was performed to derive the optimal collateral time threshold for fast collateral flow on perfusion computed tomography. The reference for fast collateral flow was the peak contrast delay on the collateral vessels within each ischemic arterial zone compared to its contralateral normal arterial zone on dynamic computed tomography angiography. The optimal perfusion collateral time threshold was then tested in predicting poor clinical outcomes (modified Rankin score of 5-6) and final infarct volume in the validation cohort of 83 patients. Results For the derivation cohort of 85 arterial zones, the optimal collateral time threshold for fast collateral flow on perfusion computed tomography was a delay time of 4.04 s [area under the curve = 0.78 (0.67, 0.89), sensitivity = 73%, and specificity = 77%]. Therefore, the delay time of 4 s was used to define the perfusion collateral time. In the validation cohort, the perfusion collateral time showed a slightly higher predicting power than dynamic computed tomography angiography collateral time in poor clinical outcomes (area under the curve = 0.72 vs. 0.67; P < 0.001). Compared to dynamic computed tomography angiography collateral time, the perfusion collateral time also had better performance in predicting final infarct volume (R-squared values = 0.55 vs. 0.23; P < 0.001). Conclusion Our results indicate that perfusion computed tomography can accurately quantify the collateral time after acute ischemic stroke.
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Affiliation(s)
- Yao Xu
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Jianhong Yang
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Xiang Gao
- Department of Neurosurgery, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Jie Sun
- Department of Neurosurgery, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Qing Shang
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Qing Han
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Yuefei Wu
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Jichuan Li
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Tianqi Xu
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Yi Huang
- Department of Neurosurgery, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
- Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, Ningbo, China
| | - Yuning Pan
- Department of Radiology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Mark W. Parson
- Sydney Brain Center, University of New South Wales, Sydney, NSW, Australia
- Department of Neurology, Liverpool Hospital, Sydney, NSW, Australia
| | - Longting Lin
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
- Sydney Brain Center, University of New South Wales, Sydney, NSW, Australia
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Value of CT Perfusion for Collateral Status Assessment in Patients with Acute Ischemic Stroke. Diagnostics (Basel) 2022; 12:diagnostics12123014. [PMID: 36553021 PMCID: PMC9777468 DOI: 10.3390/diagnostics12123014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/24/2022] [Accepted: 11/27/2022] [Indexed: 12/04/2022] Open
Abstract
Good collateral status in acute ischemic stroke patients is an important indicator for good outcomes. Perfusion imaging potentially allows for the simultaneous assessment of local perfusion and collateral status. We combined multiple CTP parameters to evaluate a CTP-based collateral score. We included 85 patients with a baseline CTP and single-phase CTA images from the MR CLEAN Registry. We evaluated patients' CTP parameters, including relative CBVs and tissue volumes with several time-to-maximum ranges, to be candidates for a CTP-based collateral score. The score candidate with the strongest association with CTA-based collateral score and a 90-day mRS was included for further analyses. We assessed the association of the CTP-based collateral score with the functional outcome (mRS 0-2) by analyzing three regression models: baseline prognostic factors (model 1), model 1 including the CTA-based collateral score (model 2), and model 1 including the CTP-based collateral score (model 3). The model performance was evaluated using C-statistic. Among the CTP-based collateral score candidates, relative CBVs with a time-to-maximum of 6-10 s showed a significant association with CTA-based collateral scores (p = 0.02) and mRS (p = 0.05) and was therefore selected for further analysis. Model 3 most accurately predicted favorable outcomes (C-statistic = 0.86, 95% CI: 0.77-0.94) although differences between regression models were not statistically significant. We introduced a CTP-based collateral score, which is significantly associated with functional outcome and may serve as an alternative collateral measure in settings where MR imaging is not feasible.
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Katyal A, Bhaskar SMM. Value of pre-intervention computed tomography perfusion imaging in the assessment of tissue outcome and long-term clinical prognosis in patients with anterior circulation acute ischemic stroke receiving reperfusion therapy: a systematic review. Acta Radiol 2022; 63:1243-1254. [PMID: 34342497 DOI: 10.1177/02841851211035892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Computed tomography perfusion (CTP) imaging has emerged as an important adjunct to the current armamentarium of acute ischemic stroke (AIS) workflow. However, its adoption in routine clinical practice is far from optimal. PURPOSE To investigate the putative association of CTP imaging biomarkers in the assessment of prognosis in acute ischemic stroke. MATERIAL AND METHODS We performed a systematic review of the literature using MEDLINE, EMBASE, and Cochrane Central Register of Clinical Trials focusing on CTP biomarkers, tissue-based and clinical-based patient outcomes. We included randomized controlled trials, prospective cohort studies, and case-controlled studies published from January 2005 to 28 August 2020. Two independent reviewers conducted the study appraisal, data extraction, and quality assessment of the studies. RESULTS A total of 60 full-text studies were included in the final systematic review analysis. Increasing infarct core volume is associated with reduced odds of achieving functional independence (modified Rankin score 0-2) at 90 days and is correlated with the final infarct volume when reperfusion is achieved. CONCLUSION CTP has value in assessing tissue perfusion status in the hyperacute stroke setting and the long-term clinical prognosis of patients with AIS receiving reperfusion therapy. However, the prognostic use of CTP requires optimization and further validation.
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Affiliation(s)
- Anubhav Katyal
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, NSW, Australia.,University of New South Wales (UNSW), South West Sydney Clinical School, Sydney, NSW, Australia
| | - Sonu Menachem Maimonides Bhaskar
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, NSW, Australia.,Liverpool Hospital & South West Sydney Local Health District (SWSLHD), Department of Neurology & Neurophysiology, Sydney, NSW, Australia.,NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW, Australia.,Thrombolysis and Endovascular WorkFLOw Network (TEFLON), Sydney, NSW, Australia
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8
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Ma YC, Chen AQ, Guo F, Yu J, Xu M, Shan DD, Zhang SH. The value of whole-brain CT perfusion imaging combined with dynamic CT angiography in the evaluation of pial collateral circulation with middle cerebral artery occlusion. Technol Health Care 2022; 30:967-979. [PMID: 35275581 DOI: 10.3233/thc-213118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Middle cerebral artery (MCA) occlusion is extremely common, especially unilateral artery, which can result in a significant incidence of cerebral infarction. OBJECTIVE To assess the value of whole-brain computed tomography perfusion (CTP) imaging combined with dynamic CT angiography (dCTA) in the evaluation of pial collateral circulation in patients with MCA occlusion. METHODS Whole-brain CTP and dCTA images were acquired in 58 patients with unilateral MCA occlusion. All patients were divided into three groups according to the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) collateral score (by CTA). The CTP parameters were analysed, including relative cerebral blood flow (rCBF), relative cerebral blood volume (rCBV), relative mean transit time (rMTT), and relative time to peak (rTTP). Patients were followed up with the modified Rankin scale (mRS). All cases in this study were confirmed by DSA. RESULTS The CTP parameters of the MCA blood supply area on the affected side of patients with different degrees of stenosis were significantly different from those on the unaffected side. There are significant differences in the CTP parameters and openings of the Willis circle in patients with different degrees of stenosis. Significant differences were found in the number of patients with good prognosis. CONCLUSIONS Whole-brain CT perfusion combined with dynamic CTA can structurally and functionally evaluate the establishment of pial collateral circulation and its effect on cerebral hemodynamic changes.
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Affiliation(s)
- Yi-Chuan Ma
- Department of Radiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Ai-Qi Chen
- Department of Radiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Fei Guo
- Department of Radiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Juan Yu
- Department of Radiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Min Xu
- Department of Radiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Dan-Dan Shan
- Department of Radiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Shun-Hua Zhang
- School of Medical Imaging, Bengbu Medical College, Bengbu, Anhui, China
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9
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Hung SH, Kramer S, Werden E, Campbell BCV, Brodtmann A. Pre-stroke Physical Activity and Cerebral Collateral Circulation in Ischemic Stroke: A Potential Therapeutic Relationship? Front Neurol 2022; 13:804187. [PMID: 35242097 PMCID: PMC8886237 DOI: 10.3389/fneur.2022.804187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/12/2022] [Indexed: 11/13/2022] Open
Abstract
Favorable cerebral collateral circulation contributes to hindering penumbral tissue from progressing to infarction and is associated with positive clinical outcomes after stroke. Given its clinical importance, improving cerebral collateral circulation is considered a therapeutic target to reduce burden after stroke. We provide a hypothesis-generating discussion on the potential association between pre-stroke physical activity and cerebral collateral circulation in ischemic stroke. The recruitment of cerebral collaterals in acute ischemic stroke may depend on anatomical variations, capacity of collateral vessels to vasodilate, and individual risk factors. Physical activity is associated with improved cerebral endothelial and vascular function related to vasodilation and angiogenic adaptations, and risk reduction in individual risk factors. More research is needed to understand association between cerebral collateral circulation and physical activity. A presentation of different methodological considerations for measuring cerebral collateral circulation and pre-stroke physical activity in the context of acute ischemic stroke is included. Opportunities for future research into cerebral collateral circulation, physical activity, and stroke recovery is presented.
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Affiliation(s)
- Stanley Hughwa Hung
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Sharon Kramer
- Centre for Quality and Patient Safety Research, Alfred Health Partnership, Melbourne, VIC, Australia.,Faculty of Health, School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia
| | - Emilio Werden
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia.,Melbourne Dementia Research Centre, The Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
| | - Bruce C V Campbell
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia.,Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Amy Brodtmann
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia.,Melbourne Dementia Research Centre, The Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
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10
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Katyal A, Bhaskar SMM. Value of pre-intervention CT perfusion imaging in acute ischemic stroke prognosis. DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY (ANKARA, TURKEY) 2021; 27:774-785. [PMID: 34792033 DOI: 10.5152/dir.2021.20805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Noninvasive imaging plays an important role in acute stroke towards diagnosis and ongoing management of patients. Systemic thrombolysis and endovascular thrombectomy (EVT) are proven treatments currently used in standards of care in acute stroke settings. The role of computed tomography angiography (CTA) in selecting patients with large vessel occlusion for EVT is well established. However, the value of CT perfusion (CTP) imaging in predicting outcomes after stroke remains ambiguous. This article critically evaluates the value of multimodal CT imaging in early diagnosis and prognosis of acute ischemic stroke with a focus on the role of CTP in delineating tissue characteristics, patient selection, and outcomes after reperfusion therapy. Insights on various technical and clinical considerations relevant to CTP applications in acute ischemic stroke, recommendations for existing workflow, and future areas of research are discussed.
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Affiliation(s)
- Anubhav Katyal
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, Australia; University of New South Wales (UNSW), South Western Sydney Clinical School, NSW, Australia
| | - Sonu Menachem Maimonides Bhaskar
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, Australia; Department of Neurology - Neurophysiology, Liverpool Hospital - South West Sydney Local Health District (SWSLHD), Sydney, Australia;University of New South Wales (UNSW), South Western Sydney Clinical School, NSW, Australia; Ingham Institute for Applied Medical Research, Stroke - Neurology Research Group, Sydney, Australia; NSW Brain Clot Bank, NSW Health Statewide Biobank and NSW Health Pathology, Sydney, NSW, Australia;Thrombolysis and Endovascular WorkFLOw Network (TEFLON), Sydney, Australia
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11
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Nael K, Sakai Y, Larson J, Goldstein J, Deutsch J, Awad AJ, Pawha P, Aggarwal A, Fifi J, Deleacy R, Yaniv G, Wintermark M, Liebeskind DS, Shoirah H, Mocco J. CT Perfusion collateral index in assessment of collaterals in acute ischemic stroke with delayed presentation: Comparison to single phase CTA. J Neuroradiol 2021; 49:198-204. [PMID: 34800563 DOI: 10.1016/j.neurad.2021.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 11/04/2021] [Accepted: 11/09/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND & PURPOSE Perfusion collateral index (PCI) has been recently defined as a promising measure of collateral status. We sought to compare collateral status assessed via CT-PCI in comparison to single-phase CTA and their relationship to outcome measures including final infarction volume, final recanalization status and functional outcome in ELVO patients. METHODS ELVO patients with anterior circulation large vessel occlusion who had baseline CTA and CT perfusion and underwent endovascular treatment were included. Collateral status was assessed on CTA. PCI from CT perfusion was calculated in each patient and an optimal threshold to separate good vs insufficient collaterals was identified using DSA as reference. The collateral status determined by CTA and PCI were assessed against 3 measured outcomes: 1) final infarction volume; 2) final recanalization status defined by TICI scores; 3) functional outcome measured by 90-day mRS. RESULTS A total of 53 patients met inclusion criteria. Excellent recanalization defined by TICI ≥2C was achieved in 36 (68%) patients and 23 patients (43%) had good functional outcome (mRS ≤2). While having good collaterals on both CTA and CTP-PCI was associated with significantly (p<0.05) smaller final infarction volume, only good collaterals status determined by CTP-PCI was associated with achieving excellent recanalization (p = 0.001) and good functional outcome (p = 0.003). CONCLUSION CTP-based PCI outperforms CTA collateral scores in determination of excellent recanalization and good functional outcome and may be a promising imaging marker of collateral status in patients with delayed presentation of AIS.
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Affiliation(s)
- Kambiz Nael
- Department of Radiological Sciences, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA 90095, USA; Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.
| | - Yu Sakai
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Jonathan Larson
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Jared Goldstein
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Jacob Deutsch
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Ahmed J Awad
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Puneet Pawha
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Amit Aggarwal
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Johanna Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Reade Deleacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Gal Yaniv
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Max Wintermark
- Department of Radiology, Stanford University, Paolo Alto, CA, 10029, USA
| | - David S Liebeskind
- Department of Neurology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Hazem Shoirah
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
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12
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Xiao J, Liang H, Wang Y, Wang S, Wang Y, Bi Y. Risk Factors of Hypoperfusion on MRI of Ischemic Stroke Patients Within 7 Days of Onset. Front Neurol 2021; 12:668360. [PMID: 34025571 PMCID: PMC8137898 DOI: 10.3389/fneur.2021.668360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/13/2021] [Indexed: 11/16/2022] Open
Abstract
Objective: Hypoperfusion is an important factor determining the prognosis of ischemic stroke patients. The present study aimed to investigate possible predictors of hypoperfusion on MRI of ischemic stroke patients within 7 days of stroke onset. Methods: Ischemic stroke patients, admitted to the comprehensive Stroke Center of Shanghai Fourth People's Hospital affiliated to Tongji University within 7 days of onset between January 2016 and June 2017, were recruited to the present study. Magnetic resonance imaging (MRI), including both diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI), was performed within 7 days of the symptom onset. Time to maximum of the residue function (Tmax) maps were automatically evaluated using the RAPID software. The volume of hypoperfusion was measured outside the infarct area based on ADC < 620 × 10−6 mm2/s. The 90 d mRS score was assessed through either clinic visits or telephone calls. Multivariate step-wise analysis was used to assess the correlation between MR findings and clinical variables, including the demographic information, cardio-metabolic characteristics, and functional outcomes. Results: Among 635 patients admitted due to acute ischemic stroke within 7 days of onset, 241 met the inclusion criteria. Hypoperfusion volume of 38 ml was the best cut-off value for predicting poor prognosis of patients with cerebral infarction (90 d-mRS score ≥ 2). The incidences of MR perfusion Tmax > 4–6 s maps with a volume of 0–38 mL or >38 mL were 51.9% (125/241) and 48.1% (116/241), respectively. Prior stroke and vascular stenosis (≥70%) were associated with MR hypoperfusion. Multivariate step-wise analysis showed that prior stroke and vascular stenosis (≥70%) were risk factors of Tmax > 4–6 s maps, and the odds ratios (OR) were 3.418 (adjusted OR 95% CI: 1.537–7.600), and 2.265 (adjusted OR, 95% CI: 1.199–4.278), respectively. Conclusion: Our results suggest that prior stroke and vascular stenosis (≥70%) are strong predictors of hypoperfusion in patients with acute ischemic stroke within 7 days of stroke onset.
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Affiliation(s)
- Jingjing Xiao
- Department of Neurology, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Huazheng Liang
- Department of Neurology, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China.,Department of Neurology, Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Yue Wang
- Department of Neurology, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Shaoshi Wang
- Department of Neurology, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Yi Wang
- Department of Neurology, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China.,College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Yong Bi
- Department of Neurology, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
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13
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Raychev R, Liebeskind DS, Yoo AJ, Rasmussen M, Arnaudov D, Brown S, Saver J, Simonsen CZ. Physiologic predictors of collateral circulation and infarct growth during anesthesia - Detailed analyses of the GOLIATH trial. J Cereb Blood Flow Metab 2020; 40:1203-1212. [PMID: 31366300 PMCID: PMC7238375 DOI: 10.1177/0271678x19865219] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Collateral circulation plays a pivotal role in acute ischemic stroke due to large vessel occlusion (LVO) and may be affected by multiple variables during sedation for endovascular therapy (EVT). We conducted detailed analyses of the GOLIATH trial to identify predictors of collateral circulation grade and infarct growth. We also modified the ASITN collateral grading scale and sought to determine its impact on clinical outcome and infarct growth. Multivariable analysis was used to identify predictors of collaterals and infarct growth. Ordinal analysis demonstrated nominal, but non-significant association between modified ASITN scale and infarct growth. Among all analyzed baseline clinical and procedural variables, the most significant predictors of infarct growth at 24 h were phenylephrine dose (estimate 6.78; p = 0.014) and baseline infarct volume (estimate 0.93; p = 0.03). The most significant predictors of worse collateral grade were mean arterial pressure (MAP) <70 mmHg (OR 0.35; p = 0.048) and baseline infarct volume (OR 0.96; p = 0.003). Hypotension during sedation for EVT for LVO negatively impacts collateral circulation, while higher pressor dose is a strong predictor of infarct growth. Avoidance of anesthesia-induced hypotension and consequent need for pressor therapy may prevent collateral failure and minimize infarct growth.
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Affiliation(s)
- Radoslav Raychev
- Department of Neurology and Comprehensive Stroke Center, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - David S Liebeskind
- Department of Neurology and Comprehensive Stroke Center, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Albert J Yoo
- Division of Neurointervention, Texas Stroke Institute, Texas, TX, USA
| | - Mads Rasmussen
- Department of Anesthesiology and Critical Care Medicine, Section of Neuroanesthesiology, Aarhus University Hospital, Aarhus, Denmark
| | - Dimiter Arnaudov
- Department of Anesthesiology, Keck Hospital of USC, Glendale, CA, USA
| | - Scott Brown
- BRIGHT Research Partners, Minneapolis, MN, USA
| | - Jeffrey Saver
- Department of Neurology and Comprehensive Stroke Center, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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14
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Trillo S, Ramos MC, Aguirre C, Caniego JL, Bárcena E, Bashir S, Zapata-Wainberg G, Alcántara-Miranda P, Díaz-Pérez C, Barbosa A, Manzanares R, Ximénez-Carrillo Á, Garrido J, Nombela F, Vivancos J. Assessment of Collateral Circulation Using Perfusion CT in Middle Cerebral Artery Thrombectomy-Treated Patients. J Stroke Cerebrovasc Dis 2020; 29:104805. [PMID: 32334917 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/27/2020] [Accepted: 03/04/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The prognostic value of leptomeningeal collateral circulation in thrombectomy-treated patients remains unclear. We evaluated the construct validity of assessing leptomeningeal collateral circulation using a new regional perfusion CT source image-based approach, the Perfusion Acquisition for THrombectomy Scale (PATHS). We also compared the prognostic value of PATHS with a further 6 scales based on various techniques: CT-angiography, perfusion CT, and digital subtraction angiography. Additionally, we studied the relationship between the scores for the different scales. PATIENTS AND METHODS We performed a retrospective study of consecutive patients with stroke and M1/terminal carotid occlusion treated with thrombectomy in our center. Leptomeningeal collateral circulation was prospectively evaluated using 7 scales: Tan and Miteff (CT Angiography); Calleja, Cao, American Society of Intervention and Therapeutic Neuroradiology/Society of Interventional Radiology, and PATHS (perfusion); and Christoforidis (Digital Subtraction Angiography). Correlations were studied using the Spearman method. RESULTS The study population comprised 108 patients. All scales predicted the modified Rankin Scale at 3 months (P ≤ .02) and all but 1 (Christoforidis) correlated with 24-hour brain infarct volume (P ≤ .02). These correlations were higher with PATHS (rho = -0.47, P < .001 for 3-month modified Rankin Scale; rho = -0.35, P < .001 for follow-up infarct volume). The multivariate analysis showed PATHS to be an independent predictor of modified Rankin Scale at 3 months less than equal to 2. A crosscorrelation analysis revealed a better correlation between scales that used the same techniques. CONCLUSIONS PATHS can be used to assess leptomeningeal collateral circulation. PATHS had better prognostic value than other scales; therefore, it might be considered for assessment of leptomeningeal collateral circulation in candidates for thrombectomy. The moderate correlation between scales suggests that scores are not interchangeable.
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Affiliation(s)
- Santiago Trillo
- Stroke Unit, Neurology Department, La Princesa University Hospital, La Princesa Institute for Health Research, Madrid, Spain.
| | - María Carmen Ramos
- Stroke Unit, Neurology Department, La Princesa University Hospital, La Princesa Institute for Health Research, Madrid, Spain
| | - Clara Aguirre
- Stroke Unit, Neurology Department, La Princesa University Hospital, La Princesa Institute for Health Research, Madrid, Spain
| | - José Luis Caniego
- Neurointerventional Radiology, Radiology Department, La Princesa University Hospital, La Princesa Institute for Health Research, Madrid, Spain
| | - Eduardo Bárcena
- Neurointerventional Radiology, Radiology Department, La Princesa University Hospital, La Princesa Institute for Health Research, Madrid, Spain
| | - Saima Bashir
- Stroke Unit, Neurology Department, La Princesa University Hospital, La Princesa Institute for Health Research, Madrid, Spain
| | - Gustavo Zapata-Wainberg
- Stroke Unit, Neurology Department, La Princesa University Hospital, La Princesa Institute for Health Research, Madrid, Spain
| | - Pilar Alcántara-Miranda
- Stroke Unit, Neurology Department, La Princesa University Hospital, La Princesa Institute for Health Research, Madrid, Spain
| | - Carolina Díaz-Pérez
- Stroke Unit, Neurology Department, La Princesa University Hospital, La Princesa Institute for Health Research, Madrid, Spain
| | - Antonio Barbosa
- Diagnostic Neuroradiology, Radiology Department, La Princesa University Hospital, La Princesa Institute for Health Research, Madrid, Spain
| | - Rafael Manzanares
- Diagnostic Neuroradiology, Radiology Department, La Princesa University Hospital, La Princesa Institute for Health Research, Madrid, Spain
| | - Álvaro Ximénez-Carrillo
- Stroke Unit, Neurology Department, La Princesa University Hospital, La Princesa Institute for Health Research, Madrid, Spain
| | - Jesús Garrido
- Methodological Support Unit, La Princesa University Hospital, La Princesa Institute for Health Research, Madrid, Spain
| | - Florentino Nombela
- Stroke Unit, Neurology Department, La Princesa University Hospital, La Princesa Institute for Health Research, Madrid, Spain
| | - José Vivancos
- Stroke Unit, Neurology Department, La Princesa University Hospital, La Princesa Institute for Health Research, Madrid, Spain
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15
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Nagel S, Joly O, Pfaff J, Papanagiotou P, Fassbender K, Reith W, Möhlenbruch MA, Herweh C, Grunwald IQ. e-ASPECTS derived acute ischemic volumes on non-contrast-enhanced computed tomography images. Int J Stroke 2019; 15:995-1001. [PMID: 31570065 PMCID: PMC7739116 DOI: 10.1177/1747493019879661] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background and purpose Validation of automatically derived acute ischemic volumes (AAIV) from e-ASPECTS on non-contrast computed tomography (NCCT). Materials and methods Data from three studies were reanalyzed with e-ASPECTS Version 7. AAIV was calculated in milliliters (ml) in all scored ASPECTS regions of the hemisphere detected by e-ASPECTS. The National Institute of Health Stroke Scale (NIHSS) determined stroke severity at baseline and clinical outcome was measured with the modified Rankin Scale (mRS) between 45 and 120 days. Spearman ranked correlation coefficients (R) of AAIV and e-ASPECTS scores with NIHSS and mRS as well as Pearson correlation of AAIV with diffusion-weighted imaging and CT perfusion-estimated ischemic “core” volumes were calculated. Multivariate regression analysis (odds ratio, OR with 95% confidence intervals, CI) and Bland–Altman plots were performed. Results We included 388 patients. Mean AAIV was 11.6 ± 18.9 ml and e-ASPECTS was 9 (8–10: median and interquartile range). AAIV, respectively e-ASPECTS correlated with NIHSS at baseline (R = 0.35, p < 0.001; R = −0.36, p < 0.001) and follow-up mRS (R = 0.29, p < 0.001; R = −0.3, p < 0.001). In subsets of patients, AAIV correlated strongly with diffusion-weighted imaging (n = 37, R = 0.68, p < 0.001) and computed tomography perfusion-derived ischemic “core” (n = 41, R = 0.76, p < 0.001) lesion volume and Bland–Altman plots showed a bias close to zero (−2.65 ml for diffusion-weighted imaging and 0.45 ml forcomputed tomography perfusion “core”). Within the whole cohort, the AAIV (OR 0.98 per ml, 95% CI 0.96–0.99) and e-ASPECTS scores (OR 1.3, 95%CI 1.07–1.57) were independent predictors of good outcome Conclusion AAIV on NCCT correlated moderately with clinical severity but strongly with diffusion-weighted imaging lesion and computed tomography perfusion ischemic “core” volumes and predicted clinical outcome.
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Affiliation(s)
- Simon Nagel
- Department of Neurology, University Hospital Heidelberg, Germany
| | | | - Johannes Pfaff
- Department of Neuroradiology, University Hospital Heidelberg, Germany
| | | | - Klaus Fassbender
- Department of Neurology, University of the Saarland, Homburg, Germany
| | - Wolfgang Reith
- Department of Neuroradiology, University of the Saarland, Homburg, Germany
| | | | - Christian Herweh
- Department of Neuroradiology, University Hospital Heidelberg, Germany
| | - Iris Q Grunwald
- Brainomix Ltd, Oxford, UK.,Neuroscience Department, Anglia Ruskin University, Essex, UK
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16
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Weiss D, Kraus B, Rubbert C, Kaschner M, Jander S, Gliem M, Lee JI, Haensch CA, Turowski B, Caspers J. Systematic evaluation of computed tomography angiography collateral scores for estimation of long-term outcome after mechanical thrombectomy in acute ischaemic stroke. Neuroradiol J 2019; 32:277-286. [PMID: 31104586 DOI: 10.1177/1971400919847182] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE This study compares computed tomography angiography-based collateral scoring systems in regard to their inter-rater reliability and potential to predict functional outcome after endovascular thrombectomy, and relates them to parenchymal perfusion as measured by computed tomography perfusion. METHODS Eighty-four patients undergoing endovascular thrombectomy in anterior circulation ischaemic stroke were enrolled. Modified Tan Score, Miteff Score, Maas Score and Opercular Index Score ratio were assessed in pre-interventional computed tomography angiographies independently by two readers. Collateral scores were tested for inter-rater reliability by weighted-kappa, for correlations with three-months modified Rankin Scale, and their potential to differentiate between patients with favourable (modified Rankin Scale ≤2) and poor outcome (modified Rankin Scale ≥3). Correlations with relative cerebral blood volume and relative cerebral blood flow were tested in patients with available computed tomography perfusion. RESULTS Very good inter-rater reliability was found for Modified Tan, Miteff and Opercular Index Score ratio, and substantial reliability for Maas. There were no significant correlations between collateral scores and three-months modified Rankin Scale, but significant group differences between patients with favourable and poor outcome for Maas, Miteff and Opercular Index Score ratio. Miteff and Maas were significant predictors of favourable outcome in binary logistic regression analysis. Miteff best differentiated between both outcome groups in receiver-operating characteristics, and Maas reached highest sensitivity for favourable outcome prediction of 96%. All collateral scores significantly correlated with mean relative cerebral blood volume and relative cerebral blood flow. CONCLUSIONS Computed tomography angiography scores are valuable in estimating functional outcome after mechanical thrombectomy and reliable across readers. The more complex scores, Maas and Miteff, show the best performances in predicting favourable outcome.
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Affiliation(s)
- Daniel Weiss
- 1 Medical Faculty, Department of Diagnostic and Interventional Radiology, University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany
| | - Bastian Kraus
- 1 Medical Faculty, Department of Diagnostic and Interventional Radiology, University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany
| | - Christian Rubbert
- 1 Medical Faculty, Department of Diagnostic and Interventional Radiology, University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany
| | - Marius Kaschner
- 1 Medical Faculty, Department of Diagnostic and Interventional Radiology, University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany
| | - Sebastian Jander
- 2 Medical Faculty, Department of Neurology, University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany
| | - Michael Gliem
- 2 Medical Faculty, Department of Neurology, University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany
| | - John-Ih Lee
- 2 Medical Faculty, Department of Neurology, University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany
| | - Carl-Albrecht Haensch
- 3 Department of Neurology, Krankenhaus St Franziskus, Viersener Str. 450, 41063 Mönchengladbach, Germany
| | - Bernd Turowski
- 1 Medical Faculty, Department of Diagnostic and Interventional Radiology, University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany
| | - Julian Caspers
- 1 Medical Faculty, Department of Diagnostic and Interventional Radiology, University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany
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17
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Yang L, Luo S. Clinical application of susceptibility-weighted imaging in the evaluation of leptomeningeal collateralization. Medicine (Baltimore) 2018; 97:e13345. [PMID: 30572437 PMCID: PMC6320133 DOI: 10.1097/md.0000000000013345] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The feasibility of using susceptibility-weighted imaging (SWI) in a clinical setting was assessed for quantifying leptomeningeal collateralization.Eighteen patients with stroke and acute infarction underwent diffusion-weighted imaging, SWI, perfusion-weighted imaging, and magnetic resonance angiography within 3 days after symptom onset. Lesions were evaluated by the Alberta Stroke Program Early CT score (ASPECTS), based on mean transit time, SWI, and cerebral blood volume (CBV).For evaluating ischemic penumbra and leptomeningeal collateralization, the SWI-ASPECTS significantly correlated, respectively, with mean transit time and CBV-ASPECTS (Spearman test, r = 0.793 and 0.682; P < .001, both).The SWI may be useful to quantify leptomeningeal collateralization in patients with acute cerebral infarction.
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Affiliation(s)
| | - Song Luo
- Department of Neurology, The first affiliated hospital of Bengbu Medical College, Bengbu, China
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18
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Arenillas JF, Cortijo E, García-Bermejo P, Levy EI, Jahan R, Liebeskind D, Goyal M, Saver JL, Albers GW. Relative cerebral blood volume is associated with collateral status and infarct growth in stroke patients in SWIFT PRIME. J Cereb Blood Flow Metab 2018; 38:1839-1847. [PMID: 29135347 PMCID: PMC6168913 DOI: 10.1177/0271678x17740293] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
UNLABELLED We aimed to evaluate how predefined candidate cerebral perfusion parameters correlate with collateral circulation status and to assess their capacity to predict infarct growth in patients with acute ischemic stroke (AIS) eligible for endovascular therapy. Patients enrolled in the SWIFT PRIME trial with baseline computed tomography perfusion (CTP) scans were included. RAPID software was used to calculate mean relative cerebral blood volume (rCBV) in hypoperfused regions, and hypoperfusion index ratio (HIR). Blind assessments of collaterals were performed using CT angiography in the whole sample and cerebral angiogram in the endovascular group. Reperfusion was assessed on 27-h CTP; infarct volume was assessed on 27-h magnetic resonance imaging/CT scans. Logistic and rank linear regression models were conducted. We included 158 patients. High rCBV ( p = 0.03) and low HIR ( p = 0.03) were associated with good collaterals. A positive association was found between rCBV and better collateral grades on cerebral angiography ( p = 0.01). Baseline and 27-h follow-up CTP were available for 115 patients, of whom 74 (64%) achieved successful reperfusion. Lower rCBV predicted a higher infarct growth in successfully reperfused patients ( p = 0.038) and in the endovascular treatment group ( p = 0.049). Finally, rCBV and HIR may serve as markers of collateral circulation in AIS patients prior to endovascular therapy. CLINICAL TRIAL REGISTRATION Unique identifier: NCT0165746.
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Affiliation(s)
- Juan F Arenillas
- 1 Stroke Program, Department of Neurology, Hospital Clínico Universitario, Valladolid, Spain.,2 Neurovascular Research i3 Laboratory, Institute for Molecular Biology and Genetics (IBGM), University of Valladolid, Valladolid, Spain
| | - Elisa Cortijo
- 1 Stroke Program, Department of Neurology, Hospital Clínico Universitario, Valladolid, Spain.,2 Neurovascular Research i3 Laboratory, Institute for Molecular Biology and Genetics (IBGM), University of Valladolid, Valladolid, Spain
| | - Pablo García-Bermejo
- 1 Stroke Program, Department of Neurology, Hospital Clínico Universitario, Valladolid, Spain
| | - Elad I Levy
- 3 Department of Neurosurgery, State University of New York at Buffalo, Buffalo, New York, USA
| | - Reza Jahan
- 4 Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles, Los Angeles, CA, USA
| | - David Liebeskind
- 4 Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles, Los Angeles, CA, USA
| | - Mayank Goyal
- 5 Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Jeffrey L Saver
- 4 Division of Interventional Neuroradiology (R.J.) and Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine (J.L.S.), University of California Los Angeles, Los Angeles, CA, USA
| | - Gregory W Albers
- 6 Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
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19
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Rabinstein AA, Albers GW, Brinjikji W, Koch S. Factors that may contribute to poor outcome despite good reperfusion after acute endovascular stroke therapy. Int J Stroke 2018; 14:23-31. [DOI: 10.1177/1747493018799979] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Endovascular therapy with mechanical thrombectomy is a formidable treatment for severe acute ischemic stroke caused by occlusion of a proximal intracranial artery. Its strong beneficial effect is explained by the high rates of very good and excellent reperfusion achieved with current endovascular techniques. However, there is a sizable proportion of patients who do not experience clinical improvement despite successful recanalization of the occluded artery and reperfusion of the ischemic territory. Factors such as baseline reserve, collateral flow, anesthesia and systemic factors have been identified as potential culprits for lack of improvement in the setting of timely and successful revascularization. Older age, baseline disability and perhaps radiological markers of chronic brain injury can affect the prognosis of patients treated with endovascular therapy. Collateral flow is a major determinant of outcome after endovascular therapy and it is manifested by the size of the core in relation to the volume of the salvageable tissue. Parenchymal and vascular imaging can help assess the quality of collateral flow, but the optimal radiological strategy for daily practice (i.e. the optimal combination of rapid availability and diagnostic precision) has not been established. A sizable body of observational evidence indicates that acute hypertension, hyperglycemia and fever are associated with worse outcomes after a stroke even after optimal reperfusion with endovascular therapy. Lastly, current randomized controlled trials in anesthesia for stroke demonstrate similar rates of good functional outcome between general anesthesia and conscious sedation suggesting equipoise exists.
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Affiliation(s)
| | | | | | - Sebastian Koch
- Department of Neurology, University of Miami, Coral Gables, FL, USA
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20
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Yoshie T, Ueda T, Takada T, Nogoshi S, Miyashita F, Takaishi S, Fukano T, Tokuura D, Hasegawa Y. Effects of Pretreatment Cerebral Blood Volume and Time to Recanalization on Clinical Outcomes in Endovascular Thrombectomy for Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2018. [PMID: 29525081 DOI: 10.1016/j.jstrokecerebrovasdis.2018.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Faster time to recanalization leads to better clinical outcomes in patients treated with endovascular thrombectomy. Whether the association between time to recanalization and clinical outcomes depends on cerebral blood volume (CBV) obtained from pretreatment computed tomography (CT) perfusion (CTP) imaging was investigated. METHODS In consecutive patients with acute ischemic stroke who achieved recanalization by endovascular thrombectomy for intracranial internal carotid artery or M1 occlusion, the effects on clinical outcome of time to recanalization and the relative CBV value (rCBV) assessed by pretreatment CTP were evaluated. The patient population was divided into 2 groups according to rCBV: normal rCBV group (rCBV ≥ .9) and low rCBV group (rCBV < .9). In each group, time to recanalization was compared between the good and the poor clinical outcome groups. RESULTS Sixty-four patients were eligible for this study. Twenty-six patients (40.6%) achieved good clinical outcomes. In the normal rCBV group, no association was found between clinical outcome and time to recanalization. In the low rCBV group, time to recanalization from CTP (101 minutes versus 136 minutes, P = .040) was significantly shorter in the good clinical outcome group. On binary logistic regression modeling, CTP to recanalization time (odds ratio 1.035 [1.004-1.067], P = .025) was an independent predictor of good clinical outcome only in the low rCBV group. CONCLUSIONS The association between time to recanalization and clinical outcomes depends on rCBV obtained from pretreatment CTP. Time to recanalization is more important for good clinical outcomes in patients with low rCBV than in patients with normal rCBV.
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Affiliation(s)
- Tomohide Yoshie
- Department of Strokology, Stroke Center, St. Marianna University, Toyoko Hospital, Kawasaki, Japan.
| | - Toshihiro Ueda
- Department of Strokology, Stroke Center, St. Marianna University, Toyoko Hospital, Kawasaki, Japan
| | - Tatsuro Takada
- Department of Strokology, Stroke Center, St. Marianna University, Toyoko Hospital, Kawasaki, Japan
| | - Shinji Nogoshi
- Department of Strokology, Stroke Center, St. Marianna University, Toyoko Hospital, Kawasaki, Japan
| | - Fumio Miyashita
- Department of Strokology, Stroke Center, St. Marianna University, Toyoko Hospital, Kawasaki, Japan
| | - Satoshi Takaishi
- Department of Strokology, Stroke Center, St. Marianna University, Toyoko Hospital, Kawasaki, Japan
| | - Takayuki Fukano
- Department of Strokology, Stroke Center, St. Marianna University, Toyoko Hospital, Kawasaki, Japan
| | - Daiki Tokuura
- Department of Strokology, Stroke Center, St. Marianna University, Toyoko Hospital, Kawasaki, Japan
| | - Yasuhiro Hasegawa
- Department of Internal Medicine, Division of Neurology, St. Marianna University School of Medicine, Kawasaki, Japan
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21
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Ginsberg MD. The cerebral collateral circulation: Relevance to pathophysiology and treatment of stroke. Neuropharmacology 2017; 134:280-292. [PMID: 28801174 DOI: 10.1016/j.neuropharm.2017.08.003] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 07/28/2017] [Accepted: 08/06/2017] [Indexed: 12/29/2022]
Abstract
The brain's collateral circulation consists of arterial anastomotic channels capable of providing nutrient perfusion to brain regions whose normal sources of flow have become compromised, as occurs in acute ischemic stroke. Modern CT-based neuroimaging is capable of providing detailed information as to collateral extent and sufficiency and is complemented by magnetic resonance-based methods. In the present era of standard-of-care IV thrombolysis for acute ischemic stroke, and following the recent therapeutic successes of randomized clinical trials of acute endovascular intervention, the sufficiency of the collateral circulation has been convincingly established as a key factor influencing the likelihood of successful reperfusion and favorable clinical outcome. This article reviews the features of the brain's collateral circulation; methods for its evaluation in the acute clinical setting; the relevance of collateral circulation to prognosis in acute ischemic stroke; the specific insights into the collateral circulation learned from recent trials of endovascular intervention; and the major influence of genetic factors. Finally, we emphasize the need to develop therapeutic approaches to augment collateral perfusion as an adjunctive strategy to be employed along with, or prior to, thrombolysis and endovascular interventions, and we highlight the possible potential of inhaled nitric oxide, albumin, and other approaches. This article is part of the Special Issue entitled 'Cerebral Ischemia'.
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Affiliation(s)
- Myron D Ginsberg
- Department of Neurology, University of Miami Miller School of Medicine, Clinical Research Center, Room 1331, 1120 NW 14th Street, Miami, FL 33136, USA.
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22
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Khalil AA, Ostwaldt AC, Nierhaus T, Ganeshan R, Audebert HJ, Villringer K, Villringer A, Fiebach JB. Relationship Between Changes in the Temporal Dynamics of the Blood-Oxygen-Level-Dependent Signal and Hypoperfusion in Acute Ischemic Stroke. Stroke 2017; 48:925-931. [DOI: 10.1161/strokeaha.116.015566] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 12/24/2016] [Accepted: 12/24/2017] [Indexed: 01/22/2023]
Abstract
Background and Purpose—
Changes in the blood-oxygen-level-dependent (BOLD) signal provide a noninvasive measure of blood flow, but a detailed comparison with established perfusion parameters in acute stroke is lacking. We investigated the relationship between BOLD signal temporal delay and dynamic susceptibility contrast magnetic resonance imaging (DSC-MRI) in stroke patients.
Methods—
In 30 patients with acute (<24 hours) ischemic stroke, we performed Pearson correlation and multiple linear regression between DSC-MRI parameters (time to maximum [Tmax], mean transit time, cerebral blood flow, and cerebral blood volume) and BOLD-based parameters (BOLD delay and coefficient of BOLD variation). Prediction of severe hypoperfusion (Tmax >6 seconds) was assessed using receiver–operator characteristic (ROC) analysis.
Results—
Correlation was highest between Tmax and BOLD delay (venous sinus reference; time shift range 7; median
r
=0.60; interquartile range=0.49–0.71). Coefficient of BOLD variation correlated with cerebral blood volume (median
r
= 0.37; interquartile range=0.24–0.51). Mean
R
2
for predicting BOLD delay by DSC-MRI was 0.54 (SD=0.2) and for predicting coefficient of BOLD variation was 0.37 (SD=0.17). BOLD delay (whole-brain reference, time shift range 3) had an area under the curve of 0.76 for predicting severe hypoperfusion (sensitivity=69.2%; specificity=80%), whereas BOLD delay (venous sinus reference, time shift range 3) had an area under the curve of 0.76 (sensitivity=67.3%; specificity=83.5%).
Conclusions—
BOLD delay is related to macrovascular delay and microvascular hypoperfusion, can identify severely hypoperfused tissue in acute stroke, and is a promising alternative to gadolinium contrast agent–based perfusion assessment in acute stroke.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00715533 and NCT02077582.
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Affiliation(s)
- Ahmed A. Khalil
- From the Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany (A.A.K., A.-C.O., R.G., H.J.A., K.V., J.B.F.); Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany (A.A.K., T.N., A.V.); Mind, Brain, Body Institute, Berlin School of Mind and Brain, Humboldt-University, Berlin, Germany (A.A.K., A.V.); and Center for Cognitive Neuroscience Berlin (CCNB), Department of Education and Psychology, Freie Universität Berlin, Germany (T
| | - Ann-Christin Ostwaldt
- From the Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany (A.A.K., A.-C.O., R.G., H.J.A., K.V., J.B.F.); Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany (A.A.K., T.N., A.V.); Mind, Brain, Body Institute, Berlin School of Mind and Brain, Humboldt-University, Berlin, Germany (A.A.K., A.V.); and Center for Cognitive Neuroscience Berlin (CCNB), Department of Education and Psychology, Freie Universität Berlin, Germany (T
| | - Till Nierhaus
- From the Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany (A.A.K., A.-C.O., R.G., H.J.A., K.V., J.B.F.); Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany (A.A.K., T.N., A.V.); Mind, Brain, Body Institute, Berlin School of Mind and Brain, Humboldt-University, Berlin, Germany (A.A.K., A.V.); and Center for Cognitive Neuroscience Berlin (CCNB), Department of Education and Psychology, Freie Universität Berlin, Germany (T
| | - Ramanan Ganeshan
- From the Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany (A.A.K., A.-C.O., R.G., H.J.A., K.V., J.B.F.); Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany (A.A.K., T.N., A.V.); Mind, Brain, Body Institute, Berlin School of Mind and Brain, Humboldt-University, Berlin, Germany (A.A.K., A.V.); and Center for Cognitive Neuroscience Berlin (CCNB), Department of Education and Psychology, Freie Universität Berlin, Germany (T
| | - Heinrich J. Audebert
- From the Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany (A.A.K., A.-C.O., R.G., H.J.A., K.V., J.B.F.); Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany (A.A.K., T.N., A.V.); Mind, Brain, Body Institute, Berlin School of Mind and Brain, Humboldt-University, Berlin, Germany (A.A.K., A.V.); and Center for Cognitive Neuroscience Berlin (CCNB), Department of Education and Psychology, Freie Universität Berlin, Germany (T
| | - Kersten Villringer
- From the Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany (A.A.K., A.-C.O., R.G., H.J.A., K.V., J.B.F.); Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany (A.A.K., T.N., A.V.); Mind, Brain, Body Institute, Berlin School of Mind and Brain, Humboldt-University, Berlin, Germany (A.A.K., A.V.); and Center for Cognitive Neuroscience Berlin (CCNB), Department of Education and Psychology, Freie Universität Berlin, Germany (T
| | - Arno Villringer
- From the Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany (A.A.K., A.-C.O., R.G., H.J.A., K.V., J.B.F.); Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany (A.A.K., T.N., A.V.); Mind, Brain, Body Institute, Berlin School of Mind and Brain, Humboldt-University, Berlin, Germany (A.A.K., A.V.); and Center for Cognitive Neuroscience Berlin (CCNB), Department of Education and Psychology, Freie Universität Berlin, Germany (T
| | - Jochen B. Fiebach
- From the Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany (A.A.K., A.-C.O., R.G., H.J.A., K.V., J.B.F.); Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany (A.A.K., T.N., A.V.); Mind, Brain, Body Institute, Berlin School of Mind and Brain, Humboldt-University, Berlin, Germany (A.A.K., A.V.); and Center for Cognitive Neuroscience Berlin (CCNB), Department of Education and Psychology, Freie Universität Berlin, Germany (T
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23
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Kao YCJ, Oyarzabal EA, Zhang H, Faber JE, Shih YYI. Role of Genetic Variation in Collateral Circulation in the Evolution of Acute Stroke: A Multimodal Magnetic Resonance Imaging Study. Stroke 2017; 48:754-761. [PMID: 28188261 DOI: 10.1161/strokeaha.116.015878] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 12/05/2016] [Accepted: 12/08/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE No studies have determined the effect of differences in pial collateral extent (number and diameter), independent of differences in environmental factors and unknown genetic factors, on severity of stroke. We examined ischemic tissue evolution during acute stroke, as measured by magnetic resonance imaging and histology, by comparing 2 congenic mouse strains with otherwise identical genetic backgrounds but with different alleles of the Determinant of collateral extent-1 (Dce1) genetic locus. We also optimized magnetic resonance perfusion and diffusion-deficit thresholds by using histological measures of ischemic tissue. METHODS Perfusion, diffusion, and T2-weighted magnetic resonance imaging were performed on collateral-poor (congenic-Bc) and collateral-rich (congenic-B6) mice at 1, 5, and 24 hours after permanent middle cerebral artery occlusion. Magnetic resonance imaging-derived penumbra and ischemic core volumes were confirmed by histology in a subset of mice at 5 and 24 hours after permanent middle cerebral artery occlusion. RESULTS Although perfusion-deficit volumes were similar between strains 1 hour after permanent middle cerebral artery occlusion, diffusion-deficit volumes were 32% smaller in collateral-rich mice. At 5 hours, collateral-rich mice had markedly restored perfusion patterns showing reduced perfusion-deficit volumes, smaller infarct volumes, and smaller perfusion-diffusion mismatch volumes compared with the collateral-poor mice (P<0.05). At 24 hours, collateral-rich mice had 45% smaller T2-weighted lesion volumes (P<0.005) than collateral-poor mice, with no difference in perfusion-diffusion mismatch volumes because of penumbral death occurring 5 to 24 hours after permanent middle cerebral artery occlusion in collateral-poor mice. CONCLUSIONS Variation in collateral extent significantly alters infarct volume expansion, transiently affects perfusion and diffusion magnetic resonance imaging signatures, and impacts salvage of ischemic penumbra after stroke onset.
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Affiliation(s)
- Yu-Chieh Jill Kao
- From the Department of Neurology (Y.-C.J.K., E.A.O.), Biomedical Research Imaging Center (Y.-C.J.K., E.A.O., Y.-Y.I.S.), Neurobiology Curriculum (E.A.O., J.E.F.), Department of Cell Biology and Physiology (H.Z., J.E.F.), McAllister Heart Institute (H.Z., J.E.F., Y.-Y.I.S.), and Department of Biomedical Engineering (Y.-Y.I.S.), University of North Carolina, Chapel Hill; and Translational Imaging Research Center (Y.-C.J.K.) and Department of Radiology, School of Medicine (Y.-C.J.K.), College of Medicine, Taipei Medical University, Taiwan
| | - Esteban A Oyarzabal
- From the Department of Neurology (Y.-C.J.K., E.A.O.), Biomedical Research Imaging Center (Y.-C.J.K., E.A.O., Y.-Y.I.S.), Neurobiology Curriculum (E.A.O., J.E.F.), Department of Cell Biology and Physiology (H.Z., J.E.F.), McAllister Heart Institute (H.Z., J.E.F., Y.-Y.I.S.), and Department of Biomedical Engineering (Y.-Y.I.S.), University of North Carolina, Chapel Hill; and Translational Imaging Research Center (Y.-C.J.K.) and Department of Radiology, School of Medicine (Y.-C.J.K.), College of Medicine, Taipei Medical University, Taiwan
| | - Hua Zhang
- From the Department of Neurology (Y.-C.J.K., E.A.O.), Biomedical Research Imaging Center (Y.-C.J.K., E.A.O., Y.-Y.I.S.), Neurobiology Curriculum (E.A.O., J.E.F.), Department of Cell Biology and Physiology (H.Z., J.E.F.), McAllister Heart Institute (H.Z., J.E.F., Y.-Y.I.S.), and Department of Biomedical Engineering (Y.-Y.I.S.), University of North Carolina, Chapel Hill; and Translational Imaging Research Center (Y.-C.J.K.) and Department of Radiology, School of Medicine (Y.-C.J.K.), College of Medicine, Taipei Medical University, Taiwan
| | - James E Faber
- From the Department of Neurology (Y.-C.J.K., E.A.O.), Biomedical Research Imaging Center (Y.-C.J.K., E.A.O., Y.-Y.I.S.), Neurobiology Curriculum (E.A.O., J.E.F.), Department of Cell Biology and Physiology (H.Z., J.E.F.), McAllister Heart Institute (H.Z., J.E.F., Y.-Y.I.S.), and Department of Biomedical Engineering (Y.-Y.I.S.), University of North Carolina, Chapel Hill; and Translational Imaging Research Center (Y.-C.J.K.) and Department of Radiology, School of Medicine (Y.-C.J.K.), College of Medicine, Taipei Medical University, Taiwan
| | - Yen-Yu Ian Shih
- From the Department of Neurology (Y.-C.J.K., E.A.O.), Biomedical Research Imaging Center (Y.-C.J.K., E.A.O., Y.-Y.I.S.), Neurobiology Curriculum (E.A.O., J.E.F.), Department of Cell Biology and Physiology (H.Z., J.E.F.), McAllister Heart Institute (H.Z., J.E.F., Y.-Y.I.S.), and Department of Biomedical Engineering (Y.-Y.I.S.), University of North Carolina, Chapel Hill; and Translational Imaging Research Center (Y.-C.J.K.) and Department of Radiology, School of Medicine (Y.-C.J.K.), College of Medicine, Taipei Medical University, Taiwan.
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24
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Munuera J, Blasco G, Hernández-Pérez M, Daunis-I-Estadella P, Dávalos A, Liebeskind DS, Wintermark M, Demchuk A, Menon BK, Thomalla G, Nael K, Pedraza S, Puig J. Venous imaging-based biomarkers in acute ischaemic stroke. J Neurol Neurosurg Psychiatry 2017; 88:62-69. [PMID: 27807197 DOI: 10.1136/jnnp-2016-314814] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/06/2016] [Accepted: 10/10/2016] [Indexed: 11/04/2022]
Abstract
Vascular neuroimaging plays a decisive role in selecting the best therapy in patients with acute ischaemic stroke. However, compared with the arterial system, the role of veins has not been thoroughly studied. In this review, we present the major venous imaging-based biomarkers in ischaemic stroke. First, the presence of hypodense veins in the monophasic CT angiography ipsilateral to the arterial occlusion. Second, the asymmetry of venous drainage in the pathological cerebral hemisphere on CT and MRI dynamic angiography. Finally, the presence of hypodense veins on T2* -based MRI. From the physiological point of view, the venous imaging-based biomarkers would detect the alteration of brain perfusion (flow), as well as the optimisation of extraction oxygen mechanisms (misery perfusion). Several studies have correlated the venous imaging-based biomarkers with grade of collateral circulation, the ischaemic penumbra and clinical functional outcome. Although venous imaging-based biomarkers still have to be validated, growing evidence highlights a potential complementary role in the acute stroke clinical decision-making process.
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Affiliation(s)
- Josep Munuera
- Diagnostic Imaging Institute (IDI), Germans Trias i Pujol University Hospital, Badalona, Spain
| | - Gerard Blasco
- Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR), Girona, Spain.,Girona Biomedical Research Institute (IDIBGI)-Medical Imaging, Girona, Spain
| | | | - Pepus Daunis-I-Estadella
- Department of Computer Science, Applied Mathematics and Statistics, University of Girona, Girona, Spain
| | - Antoni Dávalos
- Stroke Unit, Germans Trias i Pujol University Hospital, Badalona, Spain
| | - David S Liebeskind
- Neurovascular Imaging Research Core and UCLA Stroke Center, Los Angeles, California, USA
| | - Max Wintermark
- Department of Radiology, Neuroradiology Division, Stanford University, Stanford, California, USA
| | - Andrew Demchuk
- Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Bijoy K Menon
- Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Götz Thomalla
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Kambiz Nael
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Salvador Pedraza
- Girona Biomedical Research Institute (IDIBGI)-Medical Imaging, Girona, Spain.,Institute of Diagnostic Imaging (IDI)-Dr. Josep Trueta University Hospital, Girona, Spain
| | - Josep Puig
- Institute of Diagnostic Imaging (IDI)-Research Unit (IDIR), Girona, Spain.,Girona Biomedical Research Institute (IDIBGI)-Medical Imaging, Girona, Spain
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25
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Ginsberg MD. Expanding the concept of neuroprotection for acute ischemic stroke: The pivotal roles of reperfusion and the collateral circulation. Prog Neurobiol 2016; 145-146:46-77. [PMID: 27637159 DOI: 10.1016/j.pneurobio.2016.09.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/22/2016] [Accepted: 09/10/2016] [Indexed: 12/27/2022]
Abstract
This review surveys the efforts taken to achieve clinically efficacious protection of the ischemic brain and underscores the necessity of expanding our purview to include the essential role of cerebral perfusion and the collateral circulation. We consider the development of quantitative strategies to measure cerebral perfusion at the regional and local levels and the application of these methods to elucidate flow-related thresholds of ischemic viability and to characterize the ischemic penumbra. We stress that the modern concept of neuroprotection must consider perfusion, the necessary substrate upon which ischemic brain survival depends. We survey the major mechanistic approaches to neuroprotection and review clinical neuroprotection trials, focusing on those phase 3 multicenter clinical trials for acute ischemic stroke that have been completed or terminated. We review the evolution of thrombolytic therapies; consider the lessons learned from the initial, negative multicenter trials of endovascular therapy; and emphasize the highly successful positive trials that have finally established a clinical role for endovascular clot removal. As these studies point to the brain's collateral circulation as key to successful reperfusion, we next review the anatomy and pathophysiology of collateral perfusion as it relates to ischemic infarction, as well as the molecular and genetic influences on collateral development. We discuss the current MR and CT-based diagnostic methods for assessing the collateral circulation and the prognostic significance of collaterals in ischemic stroke, and we consider past and possible future therapeutic directions.
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Affiliation(s)
- Myron D Ginsberg
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, United States.
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26
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Liu X, Pu Y, Pan Y, Zhang Y, Dou X, Tan Y, Liu L, Wang Y. Multi-mode CT in the evaluation of leptomeningeal collateral flow and the related factors: comparing with digital subtraction angiography. Neurol Res 2016; 38:504-9. [DOI: 10.1080/01616412.2016.1187828] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Kawano H, Bivard A, Lin L, Spratt NJ, Miteff F, Parsons MW, Levi CR. Relationship Between Collateral Status, Contrast Transit, and Contrast Density in Acute Ischemic Stroke. Stroke 2016; 47:742-9. [PMID: 26839354 DOI: 10.1161/strokeaha.115.011320] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 12/14/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Collateral circulation is recognized to influence the life expectancy of the ischemic penumbra in acute ischemic stroke. The best method to quantify collateral status on acute imaging is uncertain. We aimed to determine the relationship between visual collateral status, quantitative collateral assessments, baseline computed tomographic perfusion measures, and tissue outcomes on follow-up imaging. METHODS Sixty-six consecutive patients with acute ischemic stroke clinically eligible for recanalization therapy and with M1 or M2 middle cerebral artery occlusion were evaluated. We compared the visual collateral scoring with measures of contrast peak time delay and contrast peak density. We also compared these measures for their ability to predict perfusion lesion and infarct core volumes, final infarct, and infarct growth. RESULTS Shorter contrast peak time delay (P=0.041) and higher contrast peak density (P=0.002) were associated with good collateral status. Shorter contrast peak time delay correlated with higher contrast peak density (β=-4.413; P=0.037). In logistic regression analysis after adjustment for age, sex, onset-computed tomographic time, and occlusion site, higher contrast peak density was independently associated with good collateral status (P=0.009). Multiple regression analysis showed that higher contrast peak density was an independent predictor of smaller perfusion lesion volume (P=0.029), smaller ischemic core volume (P=0.044), smaller follow-up infarct volume (P=0.005), and smaller infarct growth volume (P=0.010). CONCLUSIONS Visual collateral status, contrast peak density, and contrast peak time delay were inter-related, and good collateral status was strongly associated with contrast peak density. Contrast peak density in collateral vessel may be an important factor in tissue fate in acute ischemic stroke.
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Affiliation(s)
- Hiroyuki Kawano
- From the Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, and the University of Newcastle, Newcastle, New South Wales, Australia
| | - Andrew Bivard
- From the Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, and the University of Newcastle, Newcastle, New South Wales, Australia
| | - Longting Lin
- From the Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, and the University of Newcastle, Newcastle, New South Wales, Australia
| | - Neil J Spratt
- From the Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, and the University of Newcastle, Newcastle, New South Wales, Australia
| | - Ferdinand Miteff
- From the Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, and the University of Newcastle, Newcastle, New South Wales, Australia
| | - Mark W Parsons
- From the Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, and the University of Newcastle, Newcastle, New South Wales, Australia
| | - Christopher R Levi
- From the Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, and the University of Newcastle, Newcastle, New South Wales, Australia.
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28
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Consoli A, Andersson T, Holmberg A, Verganti L, Saletti A, Vallone S, Zini A, Cerase A, Romano D, Bracco S, Lorenzano S, Fainardi E, Mangiafico S. CT perfusion and angiographic assessment of pial collateral reperfusion in acute ischemic stroke: the CAPRI study. J Neurointerv Surg 2016; 8:1211-1216. [PMID: 26801947 DOI: 10.1136/neurintsurg-2015-012155] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 12/23/2015] [Accepted: 12/29/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the correlation between a novel angiographic score for collaterals and CT perfusion (CTP) parameters in patients undergoing endovascular treatment for acute ischemic stroke (AIS). METHODS 103 patients (mean age 66.7±12.7; 48.5% men) with AIS in the anterior circulation territory, imaged with non-contrast CT, CT angiography, and CTP, admitted within 8 h from symptom onset and treated with any endovascular approach, were retrospectively included in the study. Clinical, neuroradiological data, and all time intervals were collected. Careggi Collateral Score (CCS) was used for angiographic assessment of collaterals and the Alberta Stroke Program Early CT Score (ASPECTS) for semiquantitative analysis of CTP maps. Two centralized core laboratories separately reviewed angiographic data, whereas CT findings were evaluated by an expert neuroradiologist. Univariate and multivariate analysis were performed considering CCS both as an ordinal and a dichotomous variable. RESULTS 37/103 patients (35.9%) received intravenous tissue plasminogen activator. Median (IQR) ASPECTS was 9 (6-10) for admission CT, 9 (5-10) for cerebral blood volume (CBV) maps, 3 (2-3) for mean transit time maps, 3 (2-4), for cerebral blood flow maps, and 5 (3-7) for CTP mismatch. Univariate analysis showed a significant correlation between CCS and ASPECTS for all CTP parameters. Multivariate analysis confirmed an independent association only between CCS and CBV (p=0.020 when CCS was considered as a dichotomous variable, p=0.026 with ordinal CCS). CONCLUSIONS A correlation between angiographic assessment of the collateral circulation and CTP seems to be present, suggesting that CCS may provide an indirect evaluation of the infarct core volume to consider for patient selection in AIS.
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Affiliation(s)
- Arturo Consoli
- Interventional Neuroradiology Unit, Careggi University Hospital, Florence, Italy
| | - Tommy Andersson
- Departments of Radiology and Neurology, AZ Groeninge, Kortrijk, Belgium.,Department of Neuroradiology, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ake Holmberg
- Department of Neuroradiology, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Luca Verganti
- Department of Neuroradiology, Nuovo Ospedale Civile 'S Agostino-Estense', Modena, Italy
| | - Andrea Saletti
- Neuroradiology Unit, Azienda Ospedaliero-Universitaria of Ferrara, Cona, Ferrara, Italy
| | - Stefano Vallone
- Department of Neuroradiology, Nuovo Ospedale Civile 'S Agostino-Estense', Modena, Italy
| | - Andrea Zini
- Stroke Unit, Department of Neuroscience, Nuovo Ospedale Civile 'S Agostino-Estense', Modena, Italy
| | - Alfonso Cerase
- Unit of Neuroimaging and Neurointervention, Policlinico 'Santa Maria alle Scotte,', Siena, Italy
| | - Daniele Romano
- Unit of Neuroimaging and Neurointervention, Policlinico 'Santa Maria alle Scotte,', Siena, Italy
| | - Sandra Bracco
- Unit of Neuroimaging and Neurointervention, Policlinico 'Santa Maria alle Scotte,', Siena, Italy
| | - Svetlana Lorenzano
- Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Enrico Fainardi
- Neuroradiology Unit, Azienda Ospedaliero-Universitaria of Ferrara, Cona, Ferrara, Italy
| | - Salvatore Mangiafico
- Interventional Neuroradiology Unit, Careggi University Hospital, Florence, Italy
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29
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CT perfusion cerebral blood volume does not always predict infarct core in acute ischemic stroke. Neurol Sci 2015; 36:1777-83. [PMID: 25981225 DOI: 10.1007/s10072-015-2244-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 05/08/2015] [Indexed: 10/23/2022]
Abstract
We investigated the practical clinical utility of the CT perfusion (CTP) cerebral blood volume (CBV) parameter for differentiating salvageable from non-salvageable tissue in acute ischemic stroke (AIS). Fifty-five patients with AIS were imaged within 6 h from onset using CTP. Admission CBV defect (CBVD) volume was outlined using previously established gray and white matter CBV thresholds for infarct core. Admission cerebral blood flow (CBF) hypoperfusion and CBF/CBV mismatch were visually evaluated. Truncation of the ischemic time-density curve (ITDC) and hypervolemia status at admission, recanalization at 24-h CT angiography, hemorrhagic transformation (HT) at 24 h and/or 7-day non-contrast CT (NCCT), final infarct volume as indicated by 3-month NCCT defect (NCCTD) and 3-month modified Rankin Score were determined. Patients with recanalization and no truncation had the highest correlation (R = 0.81) and regression slope (0.80) between CBVD and NCCTD. Regression slopes were close to zero for patients with admission hypervolemia with/without recanalization. Hypervolemia underestimated (p = 0.02), while recanalization and ITDC truncation overestimated (p = 0.03) the NCCTD. Among patients with confirmed recanalization at 24 h, 38 % patients had an admission CBF/CBV mismatch within normal appearing areas on respective NCCT. 83 % of these patients developed infarction in admission hypervolemic CBF/CBV mismatch tissue. A reduction in CBV is a valuable predictor of infarct core when the acquisition of ITDC data is complete and hypervolemia is absent within the tissue destined to infarct. Raised or normal CBV is not always indicative of salvageable tissue, contrary to the current definition of penumbra.
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30
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Sohn SW, Park HS, Cha JK, Kim DH, Kang MJ, Choi JH, Nah HW, Huh JT. Relative CBV ratio on perfusion-weighted MRI indicates the probability of early recanalization after IV t-PA administration for acute ischemic stroke. J Neurointerv Surg 2015; 8:235-9. [PMID: 25583534 DOI: 10.1136/neurintsurg-2014-011501] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Accepted: 12/19/2014] [Indexed: 11/03/2022]
Abstract
BACKGROUND We hypothesized that the relative cerebral blood volume (rCBV) ratio on perfusion-weighted imaging (PWI) using MRI might serve as a predictor of early recanalization (ER) after intravenous tissue plasminogen activator (IV t-PA) administration for acute ischemic stroke. METHODS Patients with acute middle cerebral artery (MCA) ischemic stroke (IS) were enrolled in the study. They were evaluated by MRI, including PWI and diffusion-weighted imaging, before administration of IV t-PA and underwent digital subtraction angiography (DSA) of the brain within 2 h after t-PA administration. We compared the rCBV ratio on PWI between patients with and without ER on DSA and investigated the proportion of patients with an excellent outcome at 90 days after t-PA administration (modified Rankin Scale score 0-1) among those with and without ER. RESULTS 85 patients with acute MCA IS were included; 16 patients (18.8%) experienced ER on DSA after IV t-PA administration. Patients with ER more frequently had an excellent outcome at 90 days than those without ER. The rCBV ratio on PWI was higher in the ER group (1.01±0.21, p<0.01) than in the non-ER group (0.82±0.18). After adjusting for the presence of atrial fibrillation and the serum glucose level, the rCBV ratio on PWI (OR 1.07; 95% CI 1.02 to 1.12; p<0.01) was a significant independent indicator of ER. CONCLUSIONS The results of this study suggest that the rCBV ratio on PWI might serve as a useful indicator of ER after IV t-PA administration.
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Affiliation(s)
- Sang-Wook Sohn
- Busan-Ulsan Regional Cardio-Cerebral Vascular Center, Dong-A University Hospital, Busan, Korea
| | - Hyun-Seok Park
- Busan-Ulsan Regional Cardio-Cerebral Vascular Center, Dong-A University Hospital, Busan, Korea
| | - Jae-Kwan Cha
- Busan-Ulsan Regional Cardio-Cerebral Vascular Center, Dong-A University Hospital, Busan, Korea
| | - Dae-Hyun Kim
- Busan-Ulsan Regional Cardio-Cerebral Vascular Center, Dong-A University Hospital, Busan, Korea
| | - Myung-Jin Kang
- Busan-Ulsan Regional Cardio-Cerebral Vascular Center, Dong-A University Hospital, Busan, Korea
| | - Jae-Hyung Choi
- Busan-Ulsan Regional Cardio-Cerebral Vascular Center, Dong-A University Hospital, Busan, Korea
| | - Hyun-Wook Nah
- Busan-Ulsan Regional Cardio-Cerebral Vascular Center, Dong-A University Hospital, Busan, Korea
| | - Jae-Taeck Huh
- Busan-Ulsan Regional Cardio-Cerebral Vascular Center, Dong-A University Hospital, Busan, Korea
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31
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Kaesemann P, Thomalla G, Cheng B, Treszl A, Fiehler J, Forkert ND. Impact of Severe Extracranial ICA Stenosis on MRI Perfusion and Diffusion Parameters in Acute Ischemic Stroke. Front Neurol 2014; 5:254. [PMID: 25538674 PMCID: PMC4257016 DOI: 10.3389/fneur.2014.00254] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 11/16/2014] [Indexed: 12/21/2022] Open
Abstract
Purpose: The aim of this study was to investigate the impact of a coexisting internal carotid artery (ICA) stenosis on lesion volumes as well as diffusion and perfusion parameters in acute ischemic stroke resulting from middle cerebral artery (MCA) occlusion. Material and methods: Magnetic resonance imaging data of 32 patients with MCA occlusion with or without additional ICA stenosis imaged within 4.5 h of symptom onset were analyzed. Both groups consisted of 16 patients. Acute diffusion lesions were semi-automatically segmented in apparent diffusion coefficient (ADC) MRI datasets. Perfusion maps of cerebral blood volume (CBV), cerebral blood flow, mean transit time and Tmax were calculated using perfusion-weighted MRI datasets. Tissue-at-risk (TAR) volumes were generated by subtracting the ADC lesion from the hypoperfusion lesion defined by Tmax >6 s. Median ADC and perfusion parameter values were extracted separately for the diffusion lesion and TAR and used for statistical analysis. Results: No significant differences were found between the groups regarding the diffusion lesion and TAR volumes. Statistical analysis of diffusion and perfusion parameters revealed CBV as the only parameter with a significant difference (p = 0.009) contributing a small effect (η2 = 0.11) to the group comparison with higher CBV values for the patient group with a coexisting ICA stenosis, while no significant effects were found for the other diffusion and perfusion parameters analyzed. Conclusion: The results of this study suggest that a coexisting ICA stenosis does not have a strong effect on tissue status or perfusion parameters in acute stroke patients except for a moderate elevation of CBV. This may reflect improved collateral circulation or ischemic preconditioning in patients with a pre-existing proximal stenosis balancing impaired perfusion from the stenosis.
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Affiliation(s)
- Philipp Kaesemann
- Department of Computational Neuroscience, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Bastian Cheng
- Department of Neurology, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Andras Treszl
- Department of Medical Biometrics and Epidemiology, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Nils Daniel Forkert
- Department of Computational Neuroscience, University Medical Center Hamburg-Eppendorf , Hamburg , Germany ; Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
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32
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Beretta S, Cuccione E, Versace A, Carone D, Riva M, Padovano G, Dell'Era V, Cai R, Monza L, Presotto L, Rousseau D, Chauveau F, Paternò G, Pappadà GB, Giussani C, Sganzerla EP, Ferrarese C. Cerebral collateral flow defines topography and evolution of molecular penumbra in experimental ischemic stroke. Neurobiol Dis 2014; 74:305-13. [PMID: 25484287 DOI: 10.1016/j.nbd.2014.11.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Revised: 11/18/2014] [Accepted: 11/26/2014] [Indexed: 01/12/2023] Open
Abstract
Intracranial collaterals are dynamically recruited after arterial occlusion and are emerging as a strong determinant of tissue outcome in both human and experimental ischemic stroke. The relationship between collateral flow and ischemic penumbra remains largely unexplored in pre-clinical studies. The aim of the present study was to investigate the pattern of collateral flow with regard to penumbral tissue after transient middle cerebral artery (MCA) occlusion in rats. MCA was transiently occluded (90min) by intraluminal filament in adult male Wistar rats (n=25). Intracranial collateral flow was studied in terms of perfusion deficit and biosignal fluctuation analyses using multi-site laser Doppler monitoring. Molecular penumbra was defined by topographical mapping and quantitative signal analysis of Heat Shock Protein 70kDa (HSP70) immunohistochemistry. Functional deficit and infarct volume were assessed 24h after ischemia induction. The results show that functional performance of intracranial collaterals during MCA occlusion inversely correlated with HSP70 immunoreactive areas in both the cortex and the striatum, as well as with infarct size and functional deficit. Intracranial collateral flow was associated with reduced areas of both molecular penumbra and ischemic core and increased areas of intact tissue in rats subjected to MCA occlusion followed by reperfusion. Our findings prompt the development of collateral therapeutics to provide tissue-saving strategies in the hyper-acute phase of ischemic stroke prior to recanalization therapy.
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Affiliation(s)
- Simone Beretta
- Laboratory of Experimental Stroke Research, Department of Surgery and Translational Medicine, University of Milano Bicocca, Monza, Italy; Milan Center for Neuroscience (NeuroMi), Milano, Italy.
| | - Elisa Cuccione
- Laboratory of Experimental Stroke Research, Department of Surgery and Translational Medicine, University of Milano Bicocca, Monza, Italy; PhD Programme in Neuroscience, University of Milano Bicocca, Monza, Italy
| | - Alessandro Versace
- Laboratory of Experimental Stroke Research, Department of Surgery and Translational Medicine, University of Milano Bicocca, Monza, Italy
| | - Davide Carone
- Laboratory of Experimental Stroke Research, Department of Surgery and Translational Medicine, University of Milano Bicocca, Monza, Italy
| | - Matteo Riva
- Laboratory of Experimental Stroke Research, Department of Surgery and Translational Medicine, University of Milano Bicocca, Monza, Italy
| | - Giada Padovano
- Laboratory of Experimental Stroke Research, Department of Surgery and Translational Medicine, University of Milano Bicocca, Monza, Italy
| | - Valentina Dell'Era
- Laboratory of Experimental Stroke Research, Department of Surgery and Translational Medicine, University of Milano Bicocca, Monza, Italy
| | - Ruiyao Cai
- Laboratory of Experimental Stroke Research, Department of Surgery and Translational Medicine, University of Milano Bicocca, Monza, Italy
| | - Laura Monza
- Laboratory of Experimental Stroke Research, Department of Surgery and Translational Medicine, University of Milano Bicocca, Monza, Italy
| | - Luca Presotto
- Department of Nuclear Medicine, San Raffaele Scientific Institute, Milan, Italy; Institute of Bioimaging and Molecular Physiology, National Research Council, Milan, Italy
| | - David Rousseau
- Université de Lyon, CREATIS, CNRS UMR5220, Inserm U1044, INSA-Lyon, Université Lyon 1, France
| | - Fabien Chauveau
- Université de Lyon, CREATIS, CNRS UMR5220, Inserm U1044, INSA-Lyon, Université Lyon 1, France
| | - Giovanni Paternò
- Laboratory of Experimental Stroke Research, Department of Surgery and Translational Medicine, University of Milano Bicocca, Monza, Italy
| | - Giovanni B Pappadà
- Laboratory of Experimental Stroke Research, Department of Surgery and Translational Medicine, University of Milano Bicocca, Monza, Italy
| | - Carlo Giussani
- Laboratory of Experimental Stroke Research, Department of Surgery and Translational Medicine, University of Milano Bicocca, Monza, Italy
| | - Erik P Sganzerla
- Laboratory of Experimental Stroke Research, Department of Surgery and Translational Medicine, University of Milano Bicocca, Monza, Italy
| | - Carlo Ferrarese
- Laboratory of Experimental Stroke Research, Department of Surgery and Translational Medicine, University of Milano Bicocca, Monza, Italy; Milan Center for Neuroscience (NeuroMi), Milano, Italy
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