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Li X, Lu Z, Li S, Zhu L, Jiang T, Sun H, Pan Y, Zhou J, Deng Q. Effect of MR-guided perfusion imaging mismatch profiles within 6 h on endovascular thrombectomy outcomes. Neurol Sci 2024:10.1007/s10072-024-07751-x. [PMID: 39242369 DOI: 10.1007/s10072-024-07751-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 08/26/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND The treatment of acute ischemic stroke (AIS) aims to achieve early vascular recanalization and reperfusion of the penumbra. However, the effect of early penumbral imaging within 6 h on clinical outcomes remains unclear. The objective of this study was to determine the effect of magnetic resonance-guided (MR-guided) perfusion imaging within 6 h after symptom onset on endovascular thrombectomy outcomes in AIS patients. METHODS We prospectively collected the clinical information of consecutive AIS patients undergoing endovascular thrombectomy based on MR-guided perfusion imaging within 6 h after symptom onset from AISRNA and EVTRNA studies. The primary outcome was defined as the poor outcome (mRS > 2 within 90 days). The perfusion-weighted imaging/diffusion-weighted imaging (PWI/DWI) mismatch was assessed by an automated software. RESULTS We enrolled 84 patients (25 in the mismatch ≤ 1.8 group and 59 in the mismatch > 1.8 group). Significant difference was found between the mismatch > 1.8 group and the mismatch ≤ 1.8 group for the incidence of disabling stroke (mRS > 2) within 90 days (40.7% vs. 68.0%, OR: 3.099, 95% CI: 1.154-8.323, P = 0.025). Intracranial hemorrhage occurred in 8 patients (13.6%) in the mismatch > 1.8 group and 10 patients in the mismatch ≤ 1.8 group (40.0%) (P = 0.010). The risk of severe cerebral edema was 2/59 (3.4%) vs. 7/25 (28.0%) (P = 0.004). These findings remained stable after adjustment. CONCLUSIONS MR-guided perfusion imaging mismatch profiles within 6 h after symptom onset may be feasible to predictclinical outcomes and reduce clinically ineffective reperfusion after endovascular thrombectomy.
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Affiliation(s)
- Xiaohui Li
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, China
| | - Zhaomin Lu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, China
| | - Shuo Li
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, China
| | - Lin Zhu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, China
| | - Teng Jiang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, China
| | - Huiling Sun
- General Clinical Research Center, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, China
| | - Yuqin Pan
- General Clinical Research Center, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, China.
| | - Junshan Zhou
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, China.
| | - Qiwen Deng
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, China.
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.
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Deng T, Zhang T, Lu H, Chen J, Liu X, He W, Yao X. Evaluation and subgroup analysis of the efficacy and safety of intensive rosuvastatin therapy combined with dual antiplatelet therapy in patients with acute ischemic stroke. Eur J Clin Pharmacol 2023; 79:389-397. [PMID: 36580143 PMCID: PMC9941271 DOI: 10.1007/s00228-022-03442-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/12/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVES We investigated the efficacy of intensive rosuvastatin therapy plus 7-day dual antiplatelet therapy (DAPT) in reducing stroke recurrence for patients with acute ischemic stroke (AIS) and compared subgroups of patients. METHODS We enrolled patients with AIS whose time of onset to medication was ≤ 72 h, and the baseline scores of NIHSS (bNIHSS) were 0-10. The patients received intensive rosuvastatin therapy plus 7-day DAPT with aspirin and clopidogrel (study group) or rosuvastatin plus single antiplatelet therapy (SAPT, control group). The primary outcomes were recurrence of ischemic stroke, bleeding, statin-induced liver injury, and statin-associated myopathy (SAM) within 90 days. We also performed a subgroup analysis to assess the heterogeneity of the two therapy regimens in reducing recurrent stroke. RESULTS Recurrent stroke occurred in 10 patients in the study group and 42 patients in the control group (hazard ratio [HR], 0.373, 95% confidence interval [CI], 0.178-0.780; P = 0.009). Bleeding events occurred in 9 patients in the study group and 14 patients in the control group (HR, 1.019; 95%CI, 0.441-2.353; P = 0.966). Statin-induced liver injury and SAM were not recorded. Intensive rosuvastatin plus 7-day DAPT was generally effective in reducing the risk of recurrent stroke, except in the subgroup with bNIHSS ≤ 2. The therapy was particularly efficient in the elderly, male, high-bNIHSS, and hypertension, diabetes, and hyperlipidemia subgroups, with P < 0.02. CONCLUSIONS Without increasing bleeding and statin-associated adverse events, intensive rosuvastatin therapy plus 7-day DAPT significantly reduced the risk of recurrent stroke, especially for subgroups with high-risk factors. CLINICAL TRIAL REGISTRATION China Clinical Trial Registration Center (ChiCTR1800017809).
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Affiliation(s)
- Ting Deng
- Emergency Department, China Rehabilitation Research Center Beijing Bo’ai Hospital, Beijing, 100068 China
| | - Tong Zhang
- Neurology Department, China Rehabilitation Research Center Beijing Bo'ai Hospital, Beijing, 100068, China.
| | - Haitao Lu
- Neurology Department, China Rehabilitation Research Center Beijing Bo'ai Hospital, Beijing, 100068, China.
| | - Jingmian Chen
- Emergency Department, China Rehabilitation Research Center Beijing Bo’ai Hospital, Beijing, 100068 China
| | - Xiaomeng Liu
- Emergency Department, China Rehabilitation Research Center Beijing Bo’ai Hospital, Beijing, 100068 China
| | - Wei He
- Emergency Department, China Rehabilitation Research Center Beijing Bo’ai Hospital, Beijing, 100068 China
| | - Xiaohua Yao
- Emergency Department, China Rehabilitation Research Center Beijing Bo’ai Hospital, Beijing, 100068 China
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3
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Mishra NK, Liebeskind DS. Artificial Intelligence in Stroke. Artif Intell Med 2022. [DOI: 10.1007/978-3-030-64573-1_197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Fawaz AM, Wu S, Viswanathan D, Kaur K, Nuoman R, Nuoaman H, Adnan YA, Gandhi CD, Kurian C, Sahni R. Time to Wake-Up: Extending the Window for Management of Unknown-Onset Strokes. Cardiol Rev 2021; 29:26-32. [PMID: 32769626 DOI: 10.1097/crd.0000000000000336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The term "Wake-Up Stroke" is applied to a patient who displays no symptoms before sleep, but wakes with neurologic deficits suggestive of stroke. The current guidelines for acute ischemic stroke limit intravenous tissue plasminogen activator use to stroke patients in whom symptom onset or last known well is less than 4.5 hours. Approximately one-third of acute ischemic stroke patients present with unknown time of symptom onset and are often not eligible for intravenous reperfusion therapy in clinical practice. This review provides an overview of several earlier trials that used advanced neuroimaging to determine eligibility for reperfusion therapy in patients with unknown stroke onset. The reassuring results of these earlier trials that led to recent thrombolysis trials specifically targeted at "wake-up stroke" patients are discussed in this review. Ongoing studies aim to expand our knowledge regarding the safety and efficacy of thrombolysis in these patients.
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Affiliation(s)
- Al-Mufti Fawaz
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Sarah Wu
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Divya Viswanathan
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Kavneet Kaur
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Rolla Nuoman
- Department of Neurology, Maria Fareri Children's Hospital-Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Halla Nuoaman
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Yasir Ammar Adnan
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Chirag D Gandhi
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Christeena Kurian
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Ramandeep Sahni
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
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Hemodynamics in acute stroke: Cerebral and cardiac complications. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:295-317. [PMID: 33632449 DOI: 10.1016/b978-0-12-819814-8.00015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hemodynamics is the study of blood flow, where parameters have been defined to quantify blood flow and the relationship with systemic circulatory changes. Understanding these perfusion parameters, the relationship between different blood flow variables and the implications for ischemic injury are outlined in the ensuing discussion. This chapter focuses on the hemodynamic changes that occur in ischemic stroke, and their contribution to ischemic stroke pathophysiology. We discuss the interaction between cardiovascular response and hemodynamic changes in stroke. Studying hemodynamic changes has a key role in stroke prevention, therapeutic implications and prognostic importance in acute ischemic stroke: preexisting hemodynamic and autoregulatory impairments predict the occurrence of stroke. Hemodynamic failure predisposes to the formation of thromboemboli and accelerates infarction due to impairing compensatory mechanisms. In ischemic stroke involving occlusion of a large vessel, persistent collateral circulation leads to preservation of ischemic penumbra and therefore justifying endovascular thrombectomy. Following thrombectomy, impaired autoregulation may lead to reperfusion injury and hemorrhage.
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Artificial Intelligence in Stroke. Artif Intell Med 2021. [DOI: 10.1007/978-3-030-58080-3_197-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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7
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Moshayedi P, Saber H, Liebeskind DS. Is there Still a Time Window in the Treatment of Acute Stroke? Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-00628-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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8
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Zhou Y, Zhang R, Yan S, Zhang M, Chen Z, Hu H, Zhang M, Bivard A, Lin L, Parsons MW, Lou M. Identification of Corticospinal Tract Lesion for Predicting Outcome in Small Perfusion Stroke. Stroke 2019; 49:2683-2691. [PMID: 30355191 DOI: 10.1161/strokeaha.118.021426] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Whether patients with small perfusion lesions benefit from thrombolysis remains an uncertainty. We assessed acute ischemic stroke patients with a total perfusion lesion of <15 mL and tested the hypothesis the pattern of corticospinal tract (CST) involvement might predict outcome in thrombolysis-eligible patients. Methods- We used a prospectively collected cohort of acute ischemic stroke patients being assessed for thrombolysis at 7 centers. Three neurologists categorized the presence of hypoperfusion and infarction within CST. Excellent outcome was defined as 90-day modified Rankin Scale score 0 to 1. Results- Of 2654 patients, 407 had a perfusion lesion <15 mL and were clinically eligible for thrombolysis (243 being treated). Median National Institutes of Health Stroke Scale was 5.0, and 312 (76.7%) patients achieved excellent outcome. Alteplase treatment was an independent unfavorable factor for excellent outcome (alteplase-treated 72.0% versus untreated 83.5%; odds ratio, 0.541; P=0.025). For patients with CST hypoperfusion without CST infarction, alteplase treatment was an independent favorable factor for excellent outcome (alteplase-treated 75.6% versus untreated 47.1%; odds ratio, 4.096; P=0.045). Among patients with CST infarction, alteplase treatment was an independent unfavorable factor for excellent outcome (alteplase-treated 30.6% versus untreated 88.9%; odds ratio, 0.002; P=0.003). Among patients without either CST hypoperfusion or CST infarction, alteplase treatment was not an independent influencing factor for excellent outcome (alteplase-treated 80.1% versus untreated 87.7%; P=0.258). Conclusions- Only patients with CST hypoperfusion without CST infarction among eligible acute ischemic stroke patients with small perfusion lesions could benefit from thrombolysis, which needs to be confirmed in future prospective studies. Patient selection, including an assessment of lesion location rather than purely lesion volume, may be ideal.
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Affiliation(s)
- Ying Zhou
- From the Department of Neurology (Y.Z., R.Z., S.Y., Meixia Zhang, Z.C., H.H., M.L.), the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Ruiting Zhang
- From the Department of Neurology (Y.Z., R.Z., S.Y., Meixia Zhang, Z.C., H.H., M.L.), the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Shenqiang Yan
- From the Department of Neurology (Y.Z., R.Z., S.Y., Meixia Zhang, Z.C., H.H., M.L.), the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Meixia Zhang
- From the Department of Neurology (Y.Z., R.Z., S.Y., Meixia Zhang, Z.C., H.H., M.L.), the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Zhicai Chen
- From the Department of Neurology (Y.Z., R.Z., S.Y., Meixia Zhang, Z.C., H.H., M.L.), the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Haitao Hu
- From the Department of Neurology (Y.Z., R.Z., S.Y., Meixia Zhang, Z.C., H.H., M.L.), the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Minming Zhang
- Department of Radiology (Minming Zhang), the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Andrew Bivard
- Department of Neurology, John Hunter Hospital, University of Newcastle, Australia (A.B., L.L., M.W.P.)
| | - Longting Lin
- Department of Neurology, John Hunter Hospital, University of Newcastle, Australia (A.B., L.L., M.W.P.)
| | - Mark W Parsons
- Department of Neurology, John Hunter Hospital, University of Newcastle, Australia (A.B., L.L., M.W.P.)
| | - Min Lou
- From the Department of Neurology (Y.Z., R.Z., S.Y., Meixia Zhang, Z.C., H.H., M.L.), the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
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Peng JW, Liu Y, Meng G, Zhang JY, Yu LF. Effects of salvianolic acid on cerebral perfusion in patients after acute stroke: A single-center randomized controlled trial. Exp Ther Med 2018; 16:2600-2614. [PMID: 30186492 DOI: 10.3892/etm.2018.6444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 07/02/2018] [Indexed: 01/01/2023] Open
Abstract
Hypoperfusion following acute stroke is common in the infarct core and periphery tissues. The present study evaluated the efficacy of salvianolic acid (SA) on the cerebral perfusion of patients who had suffered from acute stroke using perfusion-weighted magnetic resonance imaging (PWI) to examine the blood perfusion of the affected brain tissue prior to and following treatment. Patients who were admitted to PLA 153 Central Hospital within 72 h of acute stroke symptom onset and had a Glasgow coma scale ≥5 were randomized into two groups: SA and control groups. Patients in the SA group were administered SA 0.13 g/day for 14 days. PWI was performed for all patients at admission and post-treatment. The National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) were applied to assess neurological function at admission and 3 months post treatment. A total of 159 patients were enrolled (85 patients in the SA group and 74 patients in the control group). A total of 62 patients in the SA group and 51 patients in the control group exhibited hypoperfusion in the ipsihemisphere of the diffusion-weighted magnetic resonance imaging (DWI) lesion. In addition, relative cerebral blood volume (rCBV), a ratio of the signal value of the region of interest in the same hemisphere of the DWI lesion to that of its mirror in the PWI CBV map, decreased significantly following treatment with SA compared with the control group in patients with hypoperfusion (P=0.02), which were indicated by PWI images at admission, in the DWI lesions or the surrounding areas. Additionally, there was no significant difference in patients with normal perfusion at admission in rCBV in DWI lesions or its surrounding area between the two groups at day 15. However, a significant improvement in NIHSS (P=0.001) and mRS (P=0.005) was indicated in the SA group compared with the control at day 90. The present study indicated that SA may improve the neurological dysfunction of patients with acute stroke, which may be explained by the increased perfusion of hypoperfused brain tissues.
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Affiliation(s)
- Jian-Wei Peng
- Department of Neurology, People's Liberation Army 153 Central Hospital, Zhengzhou, Henan 450041, P.R. China
| | - Yuan Liu
- Postgraduate Department, Xinxiang Medical College, Xinxiang, Henan 453003, P.R. China
| | - Gai Meng
- Department of Neurology, People's Liberation Army 153 Central Hospital, Zhengzhou, Henan 450041, P.R. China
| | - Jin-Yan Zhang
- Department of Neurology, People's Liberation Army 153 Central Hospital, Zhengzhou, Henan 450041, P.R. China
| | - Lian-Fang Yu
- Department of Radiology, People's Liberation Army 153 Central Hospital, Zhengzhou, Henan 450041, P.R. China
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Boldsen JK, Engedal TS, Pedraza S, Cho TH, Thomalla G, Nighoghossian N, Baron JC, Fiehler J, Østergaard L, Mouridsen K. Better Diffusion Segmentation in Acute Ischemic Stroke Through Automatic Tree Learning Anomaly Segmentation. Front Neuroinform 2018; 12:21. [PMID: 29910721 PMCID: PMC5996895 DOI: 10.3389/fninf.2018.00021] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 04/09/2018] [Indexed: 12/02/2022] Open
Abstract
Stroke is the second most common cause of death worldwide, responsible for 6.24 million deaths in 2015 (about 11% of all deaths). Three out of four stroke survivors suffer long term disability, as many cannot return to their prior employment or live independently. Eighty-seven percent of strokes are ischemic. As an increasing volume of ischemic brain tissue proceeds to permanent infarction in the hours following the onset, immediate treatment is pivotal to increase the likelihood of good clinical outcome for the patient. Triaging stroke patients for active therapy requires assessment of the volume of salvageable and irreversible damaged tissue, respectively. With Magnetic Resonance Imaging (MRI), diffusion-weighted imaging is commonly used to assess the extent of permanently damaged tissue, the core lesion. To speed up and standardize decision-making in acute stroke management we present a fully automated algorithm, ATLAS, for delineating the core lesion. We compare performance to widely used threshold based methodology, as well as a recently proposed state-of-the-art algorithm: COMBAT Stroke. ATLAS is a machine learning algorithm trained to match the lesion delineation by human experts. The algorithm utilizes decision trees along with spatial pre- and post-regularization to outline the lesion. As input data the algorithm takes images from 108 patients with acute anterior circulation stroke from the I-Know multicenter study. We divided the data into training and test data using leave-one-out cross validation to assess performance in independent patients. Performance was quantified by the Dice index. The median Dice coefficient of ATLAS algorithm was 0.6122, which was significantly higher than COMBAT Stroke, with a median Dice coefficient of 0.5636 (p < 0.0001) and the best possible performing methods based on thresholding of the diffusion weighted images (median Dice coefficient: 0.3951) or the apparent diffusion coefficient (median Dice coefficeint: 0.2839). Furthermore, the volume of the ATLAS segmentation was compared to the volume of the expert segmentation, yielding a standard deviation of the residuals of 10.25 ml compared to 17.53 ml for COMBAT Stroke. Since accurate quantification of the volume of permanently damaged tissue is essential in acute stroke patients, ATLAS may contribute to more optimal patient triaging for active or supportive therapy.
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Affiliation(s)
- Jens K Boldsen
- Department of Clinical Medicine, Center of Functional Integrative Neuroscience, Aarhus University, Aarhus, Denmark
| | - Thorbjørn S Engedal
- Department of Clinical Medicine, Center of Functional Integrative Neuroscience, Aarhus University, Aarhus, Denmark
| | - Salvador Pedraza
- Radiology Department, IDI, Hospital Dr Josep Trueta, Institut d'Investigació Biomèdica de Girona (IDIBGI), University of Girona, Girona, Spain
| | - Tae-Hee Cho
- Stroke Medicine Department, Hôpital Neurologique, Hospices Civils de Lyon, Lyon, France.,Creatis, Centre National de la Recherche Scientifique UMR 5220, Institut National de la Santé et de la Recherche Médicale U1206, INSA de Lyon, Université Lyon 1, Lyon, France
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Norbert Nighoghossian
- Stroke Medicine Department, Hôpital Neurologique, Hospices Civils de Lyon, Lyon, France.,Creatis, Centre National de la Recherche Scientifique UMR 5220, Institut National de la Santé et de la Recherche Médicale U1206, INSA de Lyon, Université Lyon 1, Lyon, France
| | - Jean-Claude Baron
- Department of Neurology, Sainte-Anne Hôpital, Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U894, Paris, France.,Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Leif Østergaard
- Department of Clinical Medicine, Center of Functional Integrative Neuroscience, Aarhus University, Aarhus, Denmark.,Department of Neuroradiology, Aarhus University Hospital, Aarhus, Denmark
| | - Kim Mouridsen
- Department of Clinical Medicine, Center of Functional Integrative Neuroscience, Aarhus University, Aarhus, Denmark
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Heiss WD. Contribution of Neuro-Imaging for Prediction of Functional Recovery after Ischemic Stroke. Cerebrovasc Dis 2017; 44:266-276. [PMID: 28869961 DOI: 10.1159/000479594] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 07/18/2017] [Indexed: 12/23/2022] Open
Abstract
Prediction measures of recovery and outcome after stroke perform with only modest levels of accuracy if based only on clinical data. Prediction scores can be improved by including morphologic imaging data, where size, location, and development of the ischemic lesion is best documented by magnetic resonance imaging. In addition to the primary lesion, the involvement of fiber tracts contributes to prognosis, and consequently the use of diffusion tensor imaging (DTI) to assess primary and secondary pathways improves the prediction of outcome and of therapeutic effects. The recovery of ischemic tissue and the progression of damage are dependent on the quality of blood supply. Therefore, the status of the supplying arteries and of the collateral flow is not only crucial for determining eligibility for acute interventions, but also has an impact on the potential to integrate areas surrounding the lesion that are not typically part of a functional network into the recovery process. The changes in these functional networks after a localized lesion are assessed by functional imaging methods, which additionally show altered pathways and activated secondary centers related to residual functions and demonstrate changes in activation patterns within these networks with improved performance. These strategies in some instances record activation in secondary centers of a network, for example, also in homolog contralateral areas, which might be inhibitory to the recovery of primary centers. Such findings might have therapeutic consequences, for example, image-guided inhibitory stimulation of these areas. In the future, a combination of morphological imaging including DTI of fiber tracts and activation studies during specific tasks might yield the best information on residual function, reserve capacity, and prospects for recovery after ischemic stroke.
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12
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Unknown onset ischemic strokes in patients last-seen-well >4.5 h: differences between wake-up and daytime-unwitnessed strokes. Acta Neurol Belg 2017; 117:637-642. [PMID: 28803427 PMCID: PMC5565646 DOI: 10.1007/s13760-017-0830-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 08/01/2017] [Indexed: 01/22/2023]
Abstract
Patients with unknown time of stroke onset (UOS) represent around one-third of ischemic stroke patients. These are patients with wake-up stroke (WUS) or daytime-unwitnessed stroke (DUS), often presenting outside the time-window for reperfusion therapy. UOS patients presenting between 4.5 and 12 h after time of last-seen-well were included. Clinical and imaging characteristics were compared between WUS and DUS patients. Good functional outcome was defined as a modified Rankin scale of ≤2 at follow-up. Sixty-one UOS patients were included: 42 WUS and 19 DUS patients. Stroke severity at presentation was mild to moderate with a median National Institutes of Health Stroke Scale of 5 in WUS and 6 in DUS patients. Time between last-seen-well and presentation at the hospital was shorter in patients with DUS compared to WUS (506 vs 362 min, p < 0.01). CT imaging results were similar, with a median Alberta Stroke Program Early CT Score of 10 for both WUS and DUS patients. After correction for age and NIHSS at presentation, no difference in good functional outcome was found between WUS (52%) and DUS (22%). In patients with unknown onset ischemic strokes presenting between 4.5 and 12 h after time of last-seen-well, clinical and radiological features were in large part similar between WUS and DUS. The outcome in the overall cohort was rather poor despite a favorable neuroimaging profile at presentation. These findings underscore the need for clinical trials in patients in whom stroke onset time is unknown.
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Abstract
Patients with wake-up strokes account for approximately 1 in 5 individuals presenting with an acute ischemic stroke. However, they are commonly excluded from acute stroke treatment. This article reviews the current understanding of wake-up strokes. A comparison of wake-up and awake-onset strokes demonstrated that they are physiologically, clinically, and radiologically similar. Use of advanced CT and MRI techniques may help extend acute stroke treatment options to patients with wake-up stroke.
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Affiliation(s)
- Jenny P Tsai
- Department of Neurology and Neurological Sciences, Stanford University Medical Centre, Stanford, CA
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Revisiting Current Golden Rules in Managing Acute Ischemic Stroke: Evaluation of New Strategies to Further Improve Treatment Selection and Outcome. AJR Am J Roentgenol 2017; 208:32-41. [DOI: 10.2214/ajr.16.16557] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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15
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Bivard A, Lou M, Levi CR, Krishnamurthy V, Cheng X, Aviv RI, McElduff P, Lin L, Kleinig T, O'Brien B, Butcher K, Jingfen Z, Jannes J, Dong Q, Parsons MW. Too good to treat? ischemic stroke patients with small computed tomography perfusion lesions may not benefit from thrombolysis. Ann Neurol 2016; 80:286-93. [PMID: 27352245 DOI: 10.1002/ana.24714] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 06/05/2016] [Accepted: 06/26/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Although commonly used in clinical practice, there remains much uncertainty about whether perfusion computed tomography (CTP) should be used to select stroke patients for acute reperfusion therapy. In this study, we tested the hypothesis that a small acute perfusion lesion predicts good clinical outcome regardless of thrombolysis administration. METHODS We used a prospectively collected cohort of acute ischemic stroke patients being assessed for treatment with IV-alteplase, who had CTP before a treatment decision. Volumetric CTP was retrospectively analyded to identify patients with a small perfusion lesion (<15ml in volume). The primary analysis was excellent 3-month outcome in patients with a small perfusion lesion who were treated with alteplase compared to those who were not treated. RESULTS Of 1526 patients, 366 had a perfusion lesion <15ml and were clinically eligible for alteplase (212 being treated and 154 not treated). Median acute National Institutes of Health Stroke Scale score was 8 in each group. Of the 366 patients with a small perfusion lesion, 227 (62%) were modified Rankin Scale (mRS) 0 to 1 at day 90. Alteplase-treated patients were less likely to achieve 90-day mRS 0 to 1 (57%) than untreated patients (69%; relative risk [RR] = 0.83; 95% confidence interval [CI], 0.71-0.97; p = 0.022) and did not have different rates of mRS 0 to 2 (72% treated patients vs 77% untreated; RR, 0.93; 95% CI, 0.82-1.95; p = 0.23). INTERPRETATION This large observational cohort suggests that a portion of ischemic stroke patients clinically eligible for alteplase therapy with a small perfusion lesion have a good natural history and may not benefit from treatment. Ann Neurol 2016;80:286-293.
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Affiliation(s)
- Andrew Bivard
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - Min Lou
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Christopher R Levi
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - Venkatesh Krishnamurthy
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - Xin Cheng
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Richard I Aviv
- Department of Medical Imaging, University of Toronto and Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Patrick McElduff
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - Longting Lin
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - Tim Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia
| | - Billy O'Brien
- Department of Neurology, Gosford Hospital, Gosford, Australia
| | - Kenneth Butcher
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Zhang Jingfen
- Department of Neurology, Baotou Central Hospital, Baotou, China
| | - Jim Jannes
- Department of Neurology, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Mark W Parsons
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
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16
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Stratégies et résultats de la segmentation volumique lésionnelle de l’AVC en IRM. J Neuroradiol 2016. [DOI: 10.1016/j.neurad.2016.01.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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17
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Legrand L, Tisserand M, Turc G, Edjlali M, Calvet D, Trystram D, Roca P, Naggara O, Mas JL, Méder JF, Baron JC, Oppenheim C. Fluid-Attenuated Inversion Recovery Vascular Hyperintensities–Diffusion-Weighted Imaging Mismatch Identifies Acute Stroke Patients Most Likely to Benefit From Recanalization. Stroke 2016; 47:424-7. [DOI: 10.1161/strokeaha.115.010999] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 11/30/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Fluid-attenuated inversion recovery vascular hyperintensities (FVH) beyond the boundaries of diffusion-weighted imaging (DWI) lesion (FVH-DWI mismatch) have been proposed as an alternative to perfusion-weighted imaging (PWI)-DWI mismatch. We aimed to establish whether FVH-DWI mismatch can identify patients most likely to benefit from recanalization.
Methods—
FVH-DWI mismatch was assessed in 164 patients with proximal middle cerebral artery occlusion before intravenous thrombolysis. PWI-DWI mismatch (PWI
Tmax>6sec
/DWI>1.8) was assessed in the 104 patients with available PWI data. We tested the associations between 24-hours complete recanalization on magnetic resonance angiography and 3-month favorable outcome (modified Rankin Scale score ≤2), stratified on FVH-DWI (or PWI-DWI) status.
Results—
FVH-DWI mismatch was present in 121/164 (74%) patients and recanalization in 50/164 (30%) patients. The odds ratio for favorable outcome with recanalization was 16.2 (95% confidence interval, 5.7–46.5;
P
<0.0001) in patients with FVH-DWI mismatch and 2.6 (95% confidence interval, 0.6–12.1;
P
=0.22) in those without FVH-DWI mismatch (
P
=0.048 for interaction). Recanalization was associated with favorable outcome in patients with PWI-DWI mismatch (odds ratios, 9.9; 95% confidence interval, 3.1–31.3;
P
=0.0001) and in patients without PWI-DWI mismatch (odds ratios, 7.0; 95% confidence interval, 1.1–44.1;
P
=0.047),
P
=0.76 for interaction.
Conclusion—
The FVH-DWI mismatch may rapidly identify patients with proximal occlusion most likely to benefit from recanalization.
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Affiliation(s)
- Laurence Legrand
- From the Departments of Radiology (L.L., M.T., M.E., D.T., P.R., O.N., J.-F.M., C.O.) and Neurology (G.T., D.C., J.-L.M., J.-C.B.), Université Paris-Descartes Sorbonne-Paris-Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, DHU Neurovasc, Paris, France
| | - Marie Tisserand
- From the Departments of Radiology (L.L., M.T., M.E., D.T., P.R., O.N., J.-F.M., C.O.) and Neurology (G.T., D.C., J.-L.M., J.-C.B.), Université Paris-Descartes Sorbonne-Paris-Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, DHU Neurovasc, Paris, France
| | - Guillaume Turc
- From the Departments of Radiology (L.L., M.T., M.E., D.T., P.R., O.N., J.-F.M., C.O.) and Neurology (G.T., D.C., J.-L.M., J.-C.B.), Université Paris-Descartes Sorbonne-Paris-Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, DHU Neurovasc, Paris, France
| | - Myriam Edjlali
- From the Departments of Radiology (L.L., M.T., M.E., D.T., P.R., O.N., J.-F.M., C.O.) and Neurology (G.T., D.C., J.-L.M., J.-C.B.), Université Paris-Descartes Sorbonne-Paris-Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, DHU Neurovasc, Paris, France
| | - David Calvet
- From the Departments of Radiology (L.L., M.T., M.E., D.T., P.R., O.N., J.-F.M., C.O.) and Neurology (G.T., D.C., J.-L.M., J.-C.B.), Université Paris-Descartes Sorbonne-Paris-Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, DHU Neurovasc, Paris, France
| | - Denis Trystram
- From the Departments of Radiology (L.L., M.T., M.E., D.T., P.R., O.N., J.-F.M., C.O.) and Neurology (G.T., D.C., J.-L.M., J.-C.B.), Université Paris-Descartes Sorbonne-Paris-Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, DHU Neurovasc, Paris, France
| | - Pauline Roca
- From the Departments of Radiology (L.L., M.T., M.E., D.T., P.R., O.N., J.-F.M., C.O.) and Neurology (G.T., D.C., J.-L.M., J.-C.B.), Université Paris-Descartes Sorbonne-Paris-Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, DHU Neurovasc, Paris, France
| | - Olivier Naggara
- From the Departments of Radiology (L.L., M.T., M.E., D.T., P.R., O.N., J.-F.M., C.O.) and Neurology (G.T., D.C., J.-L.M., J.-C.B.), Université Paris-Descartes Sorbonne-Paris-Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, DHU Neurovasc, Paris, France
| | - Jean-Louis Mas
- From the Departments of Radiology (L.L., M.T., M.E., D.T., P.R., O.N., J.-F.M., C.O.) and Neurology (G.T., D.C., J.-L.M., J.-C.B.), Université Paris-Descartes Sorbonne-Paris-Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, DHU Neurovasc, Paris, France
| | - Jean-Francois Méder
- From the Departments of Radiology (L.L., M.T., M.E., D.T., P.R., O.N., J.-F.M., C.O.) and Neurology (G.T., D.C., J.-L.M., J.-C.B.), Université Paris-Descartes Sorbonne-Paris-Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, DHU Neurovasc, Paris, France
| | - Jean-Claude Baron
- From the Departments of Radiology (L.L., M.T., M.E., D.T., P.R., O.N., J.-F.M., C.O.) and Neurology (G.T., D.C., J.-L.M., J.-C.B.), Université Paris-Descartes Sorbonne-Paris-Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, DHU Neurovasc, Paris, France
| | - Catherine Oppenheim
- From the Departments of Radiology (L.L., M.T., M.E., D.T., P.R., O.N., J.-F.M., C.O.) and Neurology (G.T., D.C., J.-L.M., J.-C.B.), Université Paris-Descartes Sorbonne-Paris-Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, Centre Hospitalier Sainte-Anne, DHU Neurovasc, Paris, France
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18
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Tisserand M, Naggara O, Legrand L, Mellerio C, Edjlali M, Lion S, Rodriguez-Régent C, Souillard-Scemama R, Jbanca CF, Trystram D, Méder JF, Oppenheim C. Patient “candidate” for thrombolysis: MRI is essential. Diagn Interv Imaging 2014; 95:1135-44. [DOI: 10.1016/j.diii.2014.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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