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Kniep H, Meyer L, Broocks G, Bechstein M, Austein F, McDonough RV, Brekenfeld C, Flottmann F, Deb-Chatterji M, Alegiani A, Hanning U, Thomalla G, Fiehler J, Gellissen S. How much of the outcome improvement after successful recanalization is explained by follow-up infarct volume reduction? J Neurointerv Surg 2024; 16:459-465. [PMID: 37230748 DOI: 10.1136/jnis-2023-020296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/15/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Follow-up infarct volume (FIV) is used as surrogate for treatment efficiency in mechanical thrombectomy (MT). However, previous works suggest that MT-related FIV reduction has only limited association with outcome comparing MT independently of recanalization success versus medical care. It remains unclear to what extent the relationship between successful recanalization versus persistent occlusion and functional outcome is explained by FIV reduction. OBJECTIVE To determine whether FIV mediates the relationship between successful recanalization and functional outcome. METHODS All patients from our institution enrolled in the German Stroke Registry (May 2015-December 2019) with anterior circulation stroke; availability of the relevant clinical data, and follow-up-CT were analyzed. The effect of FIV reduction on functional outcome (90-day modified Rankin Scale (mRS) score ≤2) after successful recanalization (Thrombolysis in Cerebral Infarction ≥2b) was quantified using mediation analysis. RESULTS 429 patients were included, of whom, 309 (72 %) had successful recanalization and 127 (39%) had good functional outcome. Good outcome was associated with age (OR=0.89, P<0.001), pre-stroke mRS score (OR=0.38, P<0.001), FIV (OR=0.98, P<0.001), hypertension (OR=2.08, P<0.05), and successful recanalization (OR=3.57, P<0.01). Using linear regression in the mediator pathway, FIV was associated with Alberta Stroke program Early CT Score (coefficient (Co)=-26.13, P<0.001), admission National Institutes of Health Stroke Scale score (Co=3.69, P<0.001), age (Co=-1.18, P<0.05), and successful recanalization (Co=-85.22, P<0.001). Successful recanalization increased the probability of good outcome by 23 percentage points (pp) (95% CI 16pp to 29pp). 56% (95% CI 38% to 78%) of the improvement in good outcome was explained by FIV reduction. CONCLUSION 56% (95% CI 38% to 78%) of outcome improvement after successful recanalization was explained by FIV reduction. Results corroborate pathophysiological assumptions and confirm the value of FIV as an imaging endpoint in clinical trials. 44% (95% CI 22% to 62%) of the improvement in outcome was not explained by FIV reduction and reflects the remaining mismatch between radiological and clinical outcome measures.
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Affiliation(s)
- Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friederike Austein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie V McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Schleswig-Holstein Campus Kiel, Kiel, Schleswig-Holstein, Germany
| | - Anna Alegiani
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellissen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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ter Schiphorst A, Turc G, Hassen WB, Oppenheim C, Baron JC. Incidence, severity and impact on functional outcome of persistent hypoperfusion despite large-vessel recanalization, a potential marker of impaired microvascular reperfusion: Systematic review of the clinical literature. J Cereb Blood Flow Metab 2024; 44:38-49. [PMID: 37871624 PMCID: PMC10905632 DOI: 10.1177/0271678x231209069] [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: 06/04/2023] [Revised: 09/02/2023] [Accepted: 10/02/2023] [Indexed: 10/25/2023]
Abstract
The reported incidence of persistent hypoperfusion despite complete recanalization as surrogate for impaired microvascular reperfusion (IMR) has varied widely among clinical studies, possibly due to differences in i) definition of complete recanalization, with only recent Thrombolysis in Cerebral Infarction (TICI) grading schemes allowing distinction between complete (TICI3) and partial recanalization with distal occlusions (TICI2c); ii) operational definition of IMR; and iii) consideration of potential alternative causes for hypoperfusion, notably carotid stenosis, re-occlusion and post-thrombectomy hemorrhage. We performed a systematic review to identify clinical studies that carried out brain perfusion imaging within 72 hrs post-thrombectomy for anterior circulation stroke and reported hypoperfusion rates separately for TICI3 and TICI2c grades. Authors were contacted if this data was missing. We identified eight eligible articles, altogether reporting 636 patients. The incidence of IMR after complete recanalization (i.e., TICI3) tended to decrease with the number of considered alternative causes of hypoperfusion: range 12.5-42.9%, 0-31.6% and 0-9.1% in articles that considered none, two or all three causes, respectively. No study reported the impact of IMR on functional outcome separately for TICI-3 patients. Based on this systematic review, IMR in true complete recanalization appears relatively rare, and reported incidence highly depends on definition used and consideration of confounding factors.
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Affiliation(s)
- Adrien ter Schiphorst
- Department of Neurology, University Hospital of Montpellier, CHU Gui de Chauliac, Montpellier, France
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Université Paris Cité, Inserm U1266, FHU NeuroVasc, Paris, France
| | - Wagih Ben Hassen
- Department of Neuroradiology, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Université Paris Cité, Inserm U1266, Paris, France
| | - Catherine Oppenheim
- Department of Neuroradiology, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Université Paris Cité, Inserm U1266, Paris, France
| | - Jean-Claude Baron
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Université Paris Cité, Inserm U1266, FHU NeuroVasc, Paris, France
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3
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Poli S, Mbroh J, Baron JC, Singhal AB, Strbian D, Molina C, Lemmens R, Turc G, Mikulik R, Michel P, Tatlisumak T, Audebert HJ, Dichgans M, Veltkamp R, Hüsing J, Graessner H, Fiehler J, Montaner J, Adeyemi AK, Althaus K, Arenillas JF, Bender B, Benedikt F, Broocks G, Burghaus I, Cardona P, Deb-Chatterji M, Cviková M, Defreyne L, De Herdt V, Detante O, Ernemann U, Flottmann F, García Guillamón L, Glauch M, Gomez-Exposito A, Gory B, Sylvie Grand S, Haršány M, Hauser TK, Heck O, Hemelsoet D, Hennersdorf F, Hoppe J, Kalmbach P, Kellert L, Köhrmann M, Kowarik M, Lara-Rodríguez B, Legris L, Lindig T, Luntz S, Lusk J, Mac Grory B, Manger A, Martinez-Majander N, Mengel A, Meyne J, Müller S, Mundiyanapurath S, Naggara O, Nedeltchev K, Nguyen TN, Nilsson MA, Obadia M, Poli K, Purrucker JC, Räty S, Richard S, Richter H, Schilte C, Schlemm E, Stöhr L, Stolte B, Sykora M, Thomalla G, Tomppo L, van Horn N, Zeller J, Ziemann U, Zuern CS, Härtig F, Tuennerhoff J. Penumbral Rescue by normobaric O = O administration in patients with ischemic stroke and target mismatch proFile (PROOF): Study protocol of a phase IIb trial. Int J Stroke 2024; 19:120-126. [PMID: 37515459 PMCID: PMC10759237 DOI: 10.1177/17474930231185275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 06/12/2023] [Indexed: 07/30/2023]
Abstract
RATIONALE Oxygen is essential for cellular energy metabolism. Neurons are particularly vulnerable to hypoxia. Increasing oxygen supply shortly after stroke onset could preserve the ischemic penumbra until revascularization occurs. AIMS PROOF investigates the use of normobaric oxygen (NBO) therapy within 6 h of symptom onset/notice for brain-protective bridging until endovascular revascularization of acute intracranial anterior-circulation occlusion. METHODS AND DESIGN Randomized (1:1), standard treatment-controlled, open-label, blinded endpoint, multicenter adaptive phase IIb trial. STUDY OUTCOMES Primary outcome is ischemic core growth (mL) from baseline to 24 h (intention-to-treat analysis). Secondary efficacy outcomes include change in NIHSS from baseline to 24 h, mRS at 90 days, cognitive and emotional function, and quality of life. Safety outcomes include mortality, intracranial hemorrhage, and respiratory failure. Exploratory analyses of imaging and blood biomarkers will be conducted. SAMPLE SIZE Using an adaptive design with interim analysis at 80 patients per arm, up to 456 participants (228 per arm) would be needed for 80% power (one-sided alpha 0.05) to detect a mean reduction of ischemic core growth by 6.68 mL, assuming 21.4 mL standard deviation. DISCUSSION By enrolling endovascular thrombectomy candidates in an early time window, the trial replicates insights from preclinical studies in which NBO showed beneficial effects, namely early initiation of near 100% inspired oxygen during short temporary ischemia. Primary outcome assessment at 24 h on follow-up imaging reduces variability due to withdrawal of care and early clinical confounders such as delayed extubation and aspiration pneumonia. TRIAL REGISTRATIONS ClinicalTrials.gov: NCT03500939; EudraCT: 2017-001355-31.
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Affiliation(s)
- Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tubingen, Germany
| | - Joshua Mbroh
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Jean-Claude Baron
- Department of Neurology, Hopital Sainte-Anne, Universite de Paris, Paris, France
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Carlos Molina
- Department of Neurology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Robin Lemmens
- Department of Neurosciences, Experimental Neurology, KU Leuven, University of Leuven, Leuven, Belgium
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Guillaume Turc
- Department of Neurology, Hopital Sainte-Anne, Universite de Paris, Paris, France
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences INSERM U1266 Universite Paris Cite FHU NeuroVasc, Paris, France
| | - Robert Mikulik
- Department of Neurology, St. Anne’s University Hospital Brno and Masaryk University, Brno, Czech Republic
| | - Patrik Michel
- Neurosciences Cliniques, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Turgut Tatlisumak
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Heinrich J Audebert
- Department of Neurology and Center for Stroke Research Berlin, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
- German Center for Neurodegenerative Diseases (DZNE, Munich), Munich, Germany
- German Centre for Cardiovascular Research (DZHK, Munich), Munich, Germany
| | - Roland Veltkamp
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany
- Department of Brain Sciences, Imperial College London, London, UK
| | - Johannes Hüsing
- Coordinating Centre for Clinical Trials, University of Heidelberg, Heidelberg, Germany
- Landeskrebsregister Nordrhein-Westfalen, Bochum, Germany
| | - Holm Graessner
- Center for Rare Diseases, Eberhard-Karls University, Tubingen, Germany
| | - Jens Fiehler
- Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
- Eppdata GmbH, Hamburg, Germany
| | - Joan Montaner
- Vall d’Hebron Institut de Recerca, Neurovascular Research Lab, Barcelona, Spain
| | | | | | | | - Benjamin Bender
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls University, Tubingen, Germany
| | - Frank Benedikt
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Gabriel Broocks
- Department of Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Ina Burghaus
- Coordinating Centre for Clinical Trials, University of Heidelberg, Heidelberg, Germany
| | - Pere Cardona
- Department of Neurology, Hospital University de Bellvitge, Barcelona, Spain
| | - Milani Deb-Chatterji
- Department of Neurology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Martina Cviková
- Department of Neurology, St. Anne’s University Hospital in Brno, Faculty of Medicine Masaryk University, Brno, Czech Republic
| | - Luc Defreyne
- Department of Vascular and Interventional Radiology, Ghent University Hospital, Ghent, Belgium
| | - Veerle De Herdt
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Olivier Detante
- Neurology, CHU Grenoble Alpes, Grenoble, France
- Inserm, U1216, Grenoble Institut Neurosciences, Université Grenoble Alpes, Grenoble, France
| | - Ulrike Ernemann
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls University, Tubingen, Germany
| | - Fabian Flottmann
- Department of Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Monika Glauch
- Center for Rare Diseases, Eberhard-Karls University, Tubingen, Germany
| | - Alexandra Gomez-Exposito
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hospital Regional Universitaire de Nancy, Universite de Lorraine, INSERM U1254, Nancy, France
| | - Sylvie Sylvie Grand
- Inserm, U1216, Grenoble Institut Neurosciences, Université Grenoble Alpes, Grenoble, France
- Neuroradiology / MRI Department, CHU Grenoble Alpes, Grenoble, France
| | - Michal Haršány
- Department of Neurology, St. Anne’s University Hospital in Brno, Faculty of Medicine Masaryk University, Brno, Czech Republic
- International Clinical Research Centre, St. Anne’s University Hospital in Brno, Brno, Czech Republic
| | - Till Karsten Hauser
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls University, Tubingen, Germany
| | - Olivier Heck
- Neuroradiology / MRI Department, CHU Grenoble Alpes, Grenoble, France
| | | | - Florian Hennersdorf
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls University, Tubingen, Germany
| | - Julia Hoppe
- Department of Neurology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Pia Kalmbach
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilian University (LMU), Munich, Germany
| | - Martin Köhrmann
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Markus Kowarik
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tubingen, Germany
| | | | - Loic Legris
- Neurology, CHU Grenoble Alpes, Grenoble, France
- Inserm, U1216, Grenoble Institut Neurosciences, Université Grenoble Alpes, Grenoble, France
| | - Tobias Lindig
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls University, Tubingen, Germany
| | - Steffen Luntz
- Coordinating Centre for Clinical Trials, University of Heidelberg, Heidelberg, Germany
| | - Jay Lusk
- Duke University School of Medicine, Durham, NC, USA
| | - Brian Mac Grory
- Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Andreas Manger
- Department of Anesthesiology and Intensive Care Medicine, Eberhard-Karls University, Tubingen, Germany
| | | | - Annerose Mengel
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Johannes Meyne
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Susanne Müller
- Department of Neurology, University Hospital of Ulm, Ulm, Germany
| | | | - Olivier Naggara
- Department of Neuroradiology, GHU Paris Psychiatrie et Neurosciences INSERM U1266 Universite Paris Cite FHU NeuroVasc, Paris, France
| | - Krassen Nedeltchev
- Department of Neurology, KSA Kantonsspital Aarau and University of Bern, Bern, Switzerland
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Center, Boston, MA, USA
- Department of Neurology, Boston Medical Center, Boston, MA, USA
| | - Maike A Nilsson
- Coordinating Centre for Clinical Trials, University of Heidelberg, Heidelberg, Germany
| | - Michael Obadia
- Department of Neurology and Stroke Center, Hopital fondation Adolphe de Rothschild, Paris, France
| | - Khouloud Poli
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Silja Räty
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Hardy Richter
- Department of Infectiology, Eberhard-Karls-University, Tuebingen, Germany
| | - Clotilde Schilte
- Department of Anaesthesia and Critical Care, CHU Grenoble Alpes, Grenoble, France
| | - Eckhard Schlemm
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Linda Stöhr
- European Clinical Research Infrastructure Network (ECRIN), Paris, France
| | - Benjamin Stolte
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Marek Sykora
- Department of Neurology, St. John’s Hospital, Vienna, Austria
| | - Götz Thomalla
- Department of Neurology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Liisa Tomppo
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Noel van Horn
- Department of Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Zeller
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tubingen, Germany
| | - Christine S Zuern
- Department of Cardiology, Universitatsspital Basel, Basel, Switzerland
| | - Florian Härtig
- Department of Anesthesiology and Intensive Care Medicine, Eberhard-Karls University, Tubingen, Germany
| | - Johannes Tuennerhoff
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tubingen, Germany
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4
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Hoving JW, van Voorst H, Kappelhof M, Tolhuisen M, Treurniet KM, LeCouffe NE, Rinkel LA, Koopman MS, Cavalcante F, Konduri PR, van den Wijngaard IR, Ghariq E, Anton Meijer FJ, Coutinho JM, Marquering HA, Roos YBWEM, Emmer BJ, Majoie CBLM. Infarct Evolution in Patients with Anterior Circulation Large-Vessel Occlusion Randomized to IV Alteplase and Endovascular Treatment versus Endovascular Treatment Alone. AJNR Am J Neuroradiol 2023; 44:434-440. [PMID: 36958803 PMCID: PMC10084906 DOI: 10.3174/ajnr.a7826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/31/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND AND PURPOSE Infarct evolution after endovascular treatment varies widely among patients with stroke and may be affected by baseline characteristics and procedural outcomes. Moreover, IV alteplase and endovascular treatment may influence the relationship of these factors to infarct evolution. We aimed to assess whether the infarct evolution between baseline and follow-up imaging was different for patients who received IVT and EVT versus EVT alone. MATERIALS AND METHODS We included patients from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN)-NO IV trial with baseline CTP and follow-up imaging. Follow-up infarct volume was segmented on 24-hour or 1-week follow-up DWI or NCCT. Infarct evolution was defined as the follow-up lesion volume: CTP core volume. Substantial infarct growth was defined as an increase in follow-up infarct volume of >10 mL. We assessed whether infarct evolution was different for patients with IV alteplase and endovascular treatment versus endovascular treatment alone and evaluated the association of baseline characteristics and procedural outcomes with infarct evolution using multivariable regression. RESULTS From 228 patients with CTP results available, 145 patients had follow-up imaging and were included in our analysis. For patients with IV alteplase and endovascular treatment versus endovascular treatment alone, the baseline median CTP core volume was 17 (interquartile range = 4-35) mL versus 11 (interquartile range = 6-24) mL. The median follow-up infarct volume was 13 (interquartile range, 4-48) mL versus 17 (interquartile range = 4-50) mL. Collateral status and occlusion location were negatively associated with substantial infarct growth in patients with and without IV alteplase before endovascular treatment. CONCLUSIONS No statistically significant difference in infarct evolution was found in directly admitted patients who received IV alteplase and endovascular treatment within 4.5 hours of symptom onset versus patients who underwent endovascular treatment alone. Collateral status and occlusion location may be useful predictors of infarct evolution prognosis in patients eligible for IV alteplase who underwent endovascular treatment.
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Affiliation(s)
- J W Hoving
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - H van Voorst
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - M Kappelhof
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - M Tolhuisen
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - K M Treurniet
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Department of Radiology (K.M.T., I.R.v.d.W., E.G.), The Hague Medical Centers, The Hague, the Netherlands
| | - N E LeCouffe
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - L A Rinkel
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - M S Koopman
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - F Cavalcante
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - P R Konduri
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - I R van den Wijngaard
- Department of Radiology (K.M.T., I.R.v.d.W., E.G.), The Hague Medical Centers, The Hague, the Netherlands
| | - E Ghariq
- Department of Radiology (K.M.T., I.R.v.d.W., E.G.), The Hague Medical Centers, The Hague, the Netherlands
| | - F J Anton Meijer
- Department of Radiology (F.J.A.M.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - J M Coutinho
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - H A Marquering
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - Y B W E M Roos
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - B J Emmer
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - C B L M Majoie
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
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Follow-Up Infarct Volume Prediction by CTP-Based Hypoperfusion Index, and the Discrepancy between Small Follow-Up Infarct Volume and Poor Functional Outcome-A Multicenter Study. Diagnostics (Basel) 2023; 13:diagnostics13010152. [PMID: 36611444 PMCID: PMC9818307 DOI: 10.3390/diagnostics13010152] [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: 11/16/2022] [Accepted: 12/29/2022] [Indexed: 01/04/2023] Open
Abstract
(1) Background: Follow-up infarct volume (FIV) may have implications for prognostication in acute ischemic stroke patients. Factors predicting the discrepancy between FIV and 90-day outcomes are poorly understood. We aimed to develop a comprehensive predictive model of FIV and explore factors associated with the discrepancy. (2) Methods: Patients with acute anterior circulation large vessel occlusion were included. Baseline clinical and CT features were extracted and analyzed, including the CTP-based hypoperfusion index (HI) and the NCCT-based e-ASPECT, measured by automated software. FIV was assessed on follow-up NCCT at 3−7 days. Multiple linear regression was used to construct the predictive model. Subgroup analysis was performed to explore factors associated with poor outcomes (90-mRS scores 3−6) in small FIV (<70 mL). (3) Results: There were 170 patients included. Baseline e-ASPECT, infarct core volume, hypoperfusion volume, HI, baseline international normalized ratio, and successful recanalization were associated with FIV and included in constructing the predictive model. Baseline NIHSS, baseline hypertension, stroke history, and current tobacco use were associated with poor outcomes in small FIV. (4) Conclusions: A comprehensive predictive model (including HI) of FIV was constructed. We also emphasized the importance of hypertension and smoking status at baseline for the functional outcomes in patients with a small FIV.
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Konduri P, Bucker A, Boers A, Dutra B, Samuels N, Treurniet K, Berkhemer O, Yoo A, van Zwam W, van Oostenbrugge R, van der Lugt A, Dippel D, Roos Y, Bot J, Majoie C, Marquering H. Risk factors of late lesion growth after acute ischemic stroke treatment. Front Neurol 2022; 13:977608. [PMID: 36277932 PMCID: PMC9581245 DOI: 10.3389/fneur.2022.977608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/01/2022] [Indexed: 11/13/2022] Open
Abstract
Background Even days after treatment of acute ischemic stroke due to a large vessel occlusion, the infarct lesion continues to grow. This late, subacute growth is associated with unfavorable functional outcome. In this study, we aim to identify patient characteristics that are risk factors of late, subacute lesion growth. Methods Patients from the MR CLEAN trial cohort with good quality 24 h and 1-week follow up non-contrast CT scans were included. Late Lesion growth was defined as the difference between the ischemic lesion volume assessed after 1-week and 24-h. To identify risk factors, patient characteristics associated with lesion growth (categorized in quartiles) in univariable ordinal analysis (p < 0.1) were included in a multivariable ordinal regression model. Results In the 226 patients that were included, the median lesion growth was 22 (IQR 10–45) ml. In the multivariable model, lower collateral capacity [aOR: 0.62 (95% CI: 0.44–0.87); p = 0.01], longer time to treatment [aOR: 1.04 (1–1.08); p = 0.04], unsuccessful recanalization [aOR: 0.57 (95% CI: 0.34–0.97); p = 0.04], and larger midline shift [aOR: 1.18 (95% CI: 1.02–1.36); p = 0.02] were associated with late lesion growth. Conclusion Late, subacute, lesion growth occurring between 1 day and 1 week after ischemic stroke treatment is influenced by lower collateral capacity, longer time to treatment, unsuccessful recanalization, and larger midline shift. Notably, these risk factors are similar to the risk factors of acute lesion growth, suggesting that understanding and minimizing the effects of the predictors for late lesion growth could be beneficial to mitigate the effects of ischemia.
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Affiliation(s)
- Praneeta Konduri
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
- *Correspondence: Praneeta Konduri
| | - Amber Bucker
- Department of Radiology, University Medical Center Groningen, Groningen, Netherlands
| | - Anna Boers
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
- Nico-Lab, Amsterdam, Netherlands
| | - Bruna Dutra
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
| | - Noor Samuels
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Kilian Treurniet
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
- Department of Radiology, Haaglanden Medisch Centrum, The Hague, Netherlands
| | - Olvert Berkhemer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Albert Yoo
- Department of Radiology, Texas Stroke Institute, Dallas-Fort Worth, Dallas, TX, United States
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
| | - Robert van Oostenbrugge
- Department of Neurology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Diederik Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Yvo Roos
- Department of Neurology, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
| | - Joost Bot
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit van Amsterdam, Amsterdam, Netherlands
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
| | - Henk Marquering
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
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Kim Y, Khose S, Zaidat OO, Hassan AE, Fifi JT, Nanda A, Atchie B, Woodward B, Doerfler A, Tomasello A, Yoo AJ, Sheth SA. Duration of Ischemia Affects Outcomes Independent of Infarct Size in Stroke. STROKE (HOBOKEN, N.J.) 2022; 2:e000163. [PMID: 37377482 PMCID: PMC10296784 DOI: 10.1161/svin.121.000163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 02/09/2022] [Indexed: 06/29/2023]
Abstract
BACKGROUND Delays in endovascular reperfusion for patients with large vessel occlusion stroke are known to worsen outcomes, and the mechanism is believed to be time-dependent expansion of the ischemic infarction. In this study, we hypothesize that delays in onset to reperfusion (OTR) assert an effect on outcomes independent of effects of final infarct (FI). METHODS We performed a subgroup analysis from the prospective multicenter COMPLETE (International Acute Ischemic Stroke Registry With the Penumbra System Aspiration Including the 3D Revascularization Device; Penumbra, Inc) registry for 257 patients with anterior circulation large vessel occlusion who underwent endovascular therapy with successful reperfusion (modified treatment in cerebral infarction score 2b/3). FI was measured by Alberta Stroke Program Early CT score and volume on 24- to 48-hour computed tomography or magnetic resonance imaging. The likelihood of 90-day good functional outcome (modified Rankin scale 0-2) was assessed by OTR and absolute risk difference (ARD) was estimated using multivariable logistic regressions adjusting for patient characteristics including FI. RESULTS In univariable analysis, longer OTR was associated with a decreased likelihood of good functional outcome (ARD -3% [95% CI -4.5 to -1.0]/h delay). In multivariable analysis accounting for FI, the association between OTR and functional outcome remained significant (ARD -2% [95% CI -3.5 to -0.4]/h delay) with similar ARD. This finding was maintained in the subset of patients with FI imaging using CT only, using Alberta Stroke Program Early CT Score or volumetric FI measurements, and also in patients with larger versus smaller FIs. CONCLUSIONS The impact of OTR on outcomes appears to be mostly through a mechanism that is independent of FI. Our findings suggest that although the field has moved toward imaging infarct core definitions of eligibility for endovascular treatment, time remains an important predictor of outcome, independent of infarct core.
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Affiliation(s)
- Youngran Kim
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Swapnil Khose
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Osama O Zaidat
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Ameer E Hassan
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Johanna T Fifi
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Ashish Nanda
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Benjamin Atchie
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Britton Woodward
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Arnd Doerfler
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Alejandro Tomasello
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Albert J Yoo
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
| | - Sunil A Sheth
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.)
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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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Xu XQ, Chu Y, Shen GC, Ma G, Lu SS, Liu S, Shi HB, Wu FY. Prognostic value of ASPECTS on post-treatment diffusion-weighted imaging for acute ischemic stroke patients after endovascular thrombectomy: comparison with infarction volume. Eur Radiol 2022; 32:8079-8088. [PMID: 35678858 DOI: 10.1007/s00330-022-08888-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/29/2022] [Accepted: 05/16/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To assess the prognostic value of Alberta Stroke Program Early Computed Tomography Score (ASPECTS) on post-treatment diffusion-weighted imaging (DWI) for acute ischemic stroke (AIS) patients after endovascular thrombectomy (EVT) and compare it with that of infarction volume. METHODS Ninety-eight consecutive AIS patients who underwent EVT and post-treatment DWI were retrospectively enrolled. ASPECTS and infarction volume were evaluated based on post-treatment DWI, respectively. Good clinical outcome was defined as modified Rankin Scale score of 0-2 at 90 days. Predictors of good clinical outcome were evaluated using univariate and multivariate logistic regression analysis. Prognostic value of post-treatment DWI ASPECTS and infarction volume were assessed and compared using receiver-operating-characteristic curves and the DeLong method. RESULTS Favorable outcome was achieved in 62 (63.3%) patients. A strong correlation was found between post-treatment DWI ASPECTS and infarction volume (ρ = -0.847). Due to strong correlation and potential collinearity, two multivariate logistic regression models were respectively developed which included post-treatment DWI ASPECTS or infarction volume. As a result, post-treatment DWI ASPECTS (OR, 2.401; 95%CI, 1.567-3.678; p < 0.001) and infarction volume (OR, 0.982; 95%CI, 0.846-0.998; p = 0.002) were both independent predictors of good clinical outcome. Setting post-treatment DWI ASPECTS ≥ 6 as a cut-off value, optimal performance (AUC = 0.836; sensitivity, 87.1%; specificity, 66.7%) could be obtained in predicting good clinical outcome, which was comparable with that of infarction volume (cut-off volume, ≤ 94.87 ml; AUC = 0.821; sensitivity, 90.3%; specificity, 55.6%). CONCLUSIONS Post-treatment DWI ASPECTS might be a potential surrogate of infarction volume and be effective in predicting the clinical outcome of AIS patients after EVT. KEY POINTS • Post-treatment DWI ASPECTS correlated significantly with infarction volume. • A post-treatment DWI ASPECTS ≥ 6 best predicts good outcomes for AIS patients after EVT. • Post-treatment DWI ASPECTS has the potential in substituting infarction volume in predicting the clinical outcome of AIS patients.
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Affiliation(s)
- Xiao-Quan Xu
- Department of Radiology, First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd, Nanjing, China
| | - Yue Chu
- Department of Radiology, First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd, Nanjing, China
| | - Guang-Chen Shen
- Department of Radiology, First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd, Nanjing, China
| | - Gao Ma
- Department of Radiology, First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd, Nanjing, China
| | - Shan-Shan Lu
- Department of Radiology, First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd, Nanjing, China
| | - Sheng Liu
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hai-Bin Shi
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Fei-Yun Wu
- Department of Radiology, First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd, Nanjing, China.
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Prognostic value of post-treatment fluid-attenuated inversion recovery vascular hyperintensity in ischemic stroke after endovascular thrombectomy. Eur Radiol 2022; 32:8067-8076. [PMID: 35665844 DOI: 10.1007/s00330-022-08886-1] [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] [Received: 01/23/2022] [Revised: 04/10/2022] [Accepted: 05/16/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To explore the value of post-treatment fluid-attenuated inversion recovery vascular hyperintensity (FVH) in predicting clinical outcome in patients with acute ischemic stroke (AIS) after endovascular thrombectomy (EVT). METHODS This retrospective study reviewed data from consecutive patients with large vessel occlusion of anterior circulation between July 2017 and February 2021. Together with other variables, status of post-treatment FVH was assessed for each patient. Good outcome was defined as a 3-month modified Rankin Scale score of 0-2. Chi-square test, Fisher's exact test, independent-samples t test, multivariate logistic regression analysis, and receiver operating characteristic analysis were used as appropriate. RESULTS Among 84 included patients, 48 (57.1%) patients showed post-treatment FVH. Post-treatment FVH significantly correlated with incomplete recanalization (p < 0.05) and low Alberta Stroke Project Early CT Changes Score on post-treatment diffusion-weighted imaging (p < 0.05). Higher incidence of hemorrhage transformation was observed in patients with post-treatment FVH than those without (27.1% vs. 16.7%); however, the difference did not reach significance (p = 0.259). Successful recanalization (odds ratio [OR], 0.024; 95% confidence interval [CI] 0.003-0.194; p < 0.05), lower National Institutes of Health Stroke Scale scores at admission (NIHSSpre) (OR, 1.196; 95% CI, 1.017-1.406; p < 0.05), and no post-treatment FVH (OR, 74.690; 95% CI, 4.624-1206.421; p < 0.05) were found to be independent predictors of good outcomes. Combined models integrating all three independent predictors (recanalization+NIHSSpre+post-treatment FVH) significantly outperformed the combined model without post-treatment FVH (recanalization+NIHSSpre) in predicting clinical outcome (p = 0.004). CONCLUSIONS Post-treatment FVH may be an effective prognostic marker associated with clinical outcome in patients with AIS after EVT. KEY POINTS • Post-treatment FVH correlates with incomplete recanalization and higher infarct volume. • Post-treatment FVH is independently associated with an unfavorable outcome. • Post-treatment FVH may provide prognostic information in patients with AIS after EVT.
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11
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Park PSW, Chan R, Senanayake C, Tsui S, Pope A, Dewey HM, Choi PMC. Large Vessel Occlusion Sites Affect Agreement Between Outputs of Three Computed Tomography Perfusion Software Packages. J Stroke Cerebrovasc Dis 2022; 31:106482. [PMID: 35429702 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106482] [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] [Received: 02/28/2022] [Revised: 03/21/2022] [Accepted: 03/28/2022] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Computed tomography perfusion (CTP) data are important for hyperacute stroke decision making. Available comparisons between outputs of different CTP software packages show variable outcomes. Evaluation for factors associated with agreement between the volume estimates is limited. We assessed for differences in core and penumbra volume estimates of three CTP software packages - AutoMIStar, RAPID, and Vitrea - and analyzed factors associated with agreement between the volume estimates. MATERIALS AND METHODS Differences between software estimates of penumbra and core volumes were calculated for each patient with suspected acute ischemic stroke who underwent CTP. Exploratory hierarchical clustering and principal component analysis were performed to identify factors of decreased volume estimate agreement. Two-sample t-tests were performed, stratified by large vessel occlusion (LVO) location. RESULTS 579 CTP studies were performed; 267 were normal, 139 artifacts, with 172 included in the final analysis. 79/172 had LVO of internal carotid artery (ICA, n = 20), M1 (n = 38) and proximal M2 (n = 21). LVO was the only factor associated with decreased software package agreement, and proximal LVO location was associated with general trend of increasing mean differences and standard deviations between software packages (range of mean differences [SD]: non-LVO, -17-6 [4-33] ml; M2, -40-13 [5-39] ml; M1, -43-26 [16-58] ml; ICA, -76-39 [22-97] ml). CONCLUSIONS Core and penumbra volume estimates can be affected by LVO location significantly between CTP software packages.
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Affiliation(s)
- Peter S W Park
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Level 2, 5 Arnold St., Box Hill, Victoria 3128, Australia; Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia.
| | - Robbie Chan
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Level 2, 5 Arnold St., Box Hill, Victoria 3128, Australia
| | - Channa Senanayake
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Level 2, 5 Arnold St., Box Hill, Victoria 3128, Australia
| | - Stanley Tsui
- Medical Imaging, Eastern Health, Box Hill Hospital, Victoria, Australia
| | - Alun Pope
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Helen M Dewey
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Level 2, 5 Arnold St., Box Hill, Victoria 3128, Australia; Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Philip M C Choi
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Level 2, 5 Arnold St., Box Hill, Victoria 3128, Australia; Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
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12
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Fainardi E, Busto G, Rosi A, Scola E, Casetta I, Bernardoni A, Saletti A, Arba F, Nencini P, Limbucci N, Mangiafico S, Demchuk A, Almekhlafi MA, Goyal M, Lee TY, Menon BK, Morotti A. T max Volumes Predict Final Infarct Size and Functional Outcome in Ischemic Stroke Patients Receiving Endovascular Treatment. Ann Neurol 2022; 91:878-888. [PMID: 35285078 PMCID: PMC9322332 DOI: 10.1002/ana.26354] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 03/01/2022] [Accepted: 03/07/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The objective of this paper was to explore the utility of time to maximum concentration (Tmax )-based target mismatch on computed tomography perfusion (CTP) in predicting radiological and clinical outcomes in patients with acute ischemic stroke (AIS) with anterior circulation large vessel occlusion (LVO) selected for endovascular treatment (EVT). METHODS Patients with AIS underwent CTP within 24 hours from onset followed by EVT. Critically hypoperfused tissue and ischemic core volumes were automatically calculated using Tmax thresholds >9.5 seconds and >16 seconds, respectively. The difference between Tmax > 9.5 seconds and Tmax > 16 seconds volumes and the ratio between Tmax > 9.5 seconds and Tmax > 16 seconds volumes were considered ischemic penumbra and Tmax mismatch ratio, respectively. Final infarct volume (FIV) was measured on follow-up non-contrast computed tomography (CT) at 24 hours. Favorable clinical outcome was defined as 90-day modified Rankin Scale 0 to 2. Predictors of FIV and outcome were assessed with multivariable logistic regression. Optimal Tmax volumes for identification of good outcome was defined using receiver operating curves. RESULTS A total of 393 patients were included, of whom 298 (75.8%) achieved successful recanalization and 258 (65.5%) achieved good outcome. In multivariable analyses, all Tmax parameters were independent predictors of FIV and outcome. Tmax > 16 seconds volume had the strongest association with FIV (beta coefficient = 0.596 p <0.001) and good outcome (odds ratio [OR] = 0.96 per 1 ml increase, 95% confidence interval [CI] = 0.95-0.97, p < 0.001). Tmax > 16 seconds volume had the highest discriminative ability for good outcome (area under the curve [AUC] = 0.88, 95% CI = 0.842-0.909). A Tmax > 16 seconds volume of ≤67 ml best identified subjects with favorable outcome (sensitivity = 0.91 and specificity = 0.73). INTERPRETATION Tmax target mismatch predicts radiological and clinical outcomes in patients with AIS with LVO receiving EVT within 24 hours from onset. ANN NEUROL 2022;91:878-888.
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Affiliation(s)
- Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”University of FlorenceFlorence
| | - Giorgio Busto
- Neuroradiology Unit, Department of RadiologyCareggi University HospitalFlorenceItaly
| | - Andrea Rosi
- Division of Diagnostic and Interventional Neuroradiology, Department of DiagnosticsGeneva University HospitalsGenevaSwitzerland
| | - Elisa Scola
- Neuroradiology Unit, Department of RadiologyCareggi University HospitalFlorenceItaly
| | - Ilaria Casetta
- Section of Neurological, Psychiatric, and Psychological Sciences, Department of Biomedical and Specialist Surgical SciencesUniversity of FerraraFerraraItaly
| | - Andrea Bernardoni
- Neuroradiology Unit, Department of RadiologyArcispedale S. AnnaFerraraItaly
| | - Andrea Saletti
- Neuroradiology Unit, Department of RadiologyArcispedale S. AnnaFerraraItaly
| | | | | | - Nicola Limbucci
- Interventional Neuroradiology Unit, Department of RadiologyCareggi University HospitalFlorenceItaly
| | - Salvatore Mangiafico
- Neuroradiologia Diagnostica ed Interventisitca, IRCCS Neuromed, Istituto Neurologico MediterraneoPozzilliItaly
| | - Andrew Demchuk
- The Calgary Stroke Program, Department of Clinical NeurosciencesUniversity of CalgaryCalgaryAlbertaCanada,Department of RadiologyUniversity of CalgaryCalgaryAlbertaCanada,Hotchkiss Brain Institute, University of CalgaryCalgaryAlbertaCanada
| | - Mohammed A Almekhlafi
- The Calgary Stroke Program, Department of Clinical NeurosciencesUniversity of CalgaryCalgaryAlbertaCanada,Department of RadiologyUniversity of CalgaryCalgaryAlbertaCanada,Hotchkiss Brain Institute, University of CalgaryCalgaryAlbertaCanada
| | - Mayank Goyal
- The Calgary Stroke Program, Department of Clinical NeurosciencesUniversity of CalgaryCalgaryAlbertaCanada,Department of RadiologyUniversity of CalgaryCalgaryAlbertaCanada,Hotchkiss Brain Institute, University of CalgaryCalgaryAlbertaCanada
| | - Ting Y. Lee
- Lawson Health Research Institute and Robarts Research InstituteLondonOntarioCanada
| | - Bijoy K. Menon
- The Calgary Stroke Program, Department of Clinical NeurosciencesUniversity of CalgaryCalgaryAlbertaCanada,Department of RadiologyUniversity of CalgaryCalgaryAlbertaCanada,Hotchkiss Brain Institute, University of CalgaryCalgaryAlbertaCanada
| | - Andrea Morotti
- Department of Clinical and Experimental Sciences, Neurology UnitUniversity of BresciaBresciaItaly
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13
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Kniep H, Meyer L, Bechstein M, Broocks G, Guerreiro H, van Horn N, Brekenfeld C, Flottmann F, Deb-Chatterji M, Alegiani A, Thomalla G, Hanning U, Fiehler J, Gellißen S. How Much of the Thrombectomy Related Improvement in Functional Outcome Is Already Apparent at 24 Hours and at Hospital Discharge? Stroke 2022; 53:2828-2837. [PMID: 35549377 DOI: 10.1161/strokeaha.121.037888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Early neurological status has been described as predictor of functional outcome in patients with anterior circulation stroke after mechanical thrombectomy. It remains unclear to what proportion the improvement of functional outcome at day 90 is already apparent at 24 hours and at hospital discharge and how later factors impact outcome. METHODS All patients enrolled in the German Stroke Registry (June 2015-December 2019) with anterior circulation stroke and availability of baseline data and neurological status were included. A mediation analysis was conducted to investigate the effect of successful recanalization (Thrombolysis in Cerebral Infarction scale score ≥2b) on good functional outcome (modified Rankin Scale score ≤2 at day 90) with mediation through neurological status (National Institutes of Health Stroke Scale [NIHSS] at 24 hours and at hospital discharge). RESULTS Three thousand fifty-seven patients fulfilled the inclusion criteria, thereof 2589 (85%) with successful recanalization and 1180 (39%) with good functional outcome. In a multivariate logistic regression analysis, probability of good outcome was significantly associated with age (odds ratio [95% CI], 0.95 [0.94-0.96]), prestroke modified Rankin Scale (0.48 [0.42-0.55]), admission-NIHSS (0.96 [0.94-0.98]), 24-hour NIHSS (0.83 [0.81-0.84]), diabetes (0.56 [0.43-0.72]), proximal middle cerebral artery occlusions (0.78 [0.62-0.97]), passes (0.88 [0.82-0.95]), Alberta Stroke Program Early CT Score (1.07 [1.00-1.14]), successful recanalization (2.39 [1.68-3.43]), intracerebral hemorrhage (0.51 [0.35-0.73]), and recurrent strokes (0.54 [0.32-0.92]). Mediation analysis showed a 20 percentage points (95% CI' 17-24 percentage points) increase of probability of good functional outcome after successful recanalization. Fifty-four percent (95% CI' 44%-66%) of the improvement in functional outcome was explained by 24-hour NIHSS and 75% (95% CI' 62%-90%) by NIHSS at hospital discharge. CONCLUSIONS Fifty-four percent of the improvement in functional outcome after successful recanalization is apparent in NIHSS at 24 hours, 75% in NIHSS at hospital discharge. Other unknown factors not apparent in NIHSS at the 2 time points investigated account for the remaining effect on long term outcome, suggesting, among others, clinical relevance of delayed neurological improvement and deterioration. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03356392.
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Affiliation(s)
- Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Helena Guerreiro
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany. (M.D.-C., A.A., G.T.)
| | - Anna Alegiani
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany (A.A)
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany. (M.D.-C., A.A., G.T.)
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
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14
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Predictors of home discharge after mechanical thrombectomy in patients with acute ischemic stroke: Usefulness of National Institutes of Health Stroke Scale sub-items assessed 24 h postoperatively. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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15
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Variability assessment of manual segmentations of ischemic lesion volume on 24-h non-contrast CT. Neuroradiology 2021; 64:1165-1173. [PMID: 34812917 DOI: 10.1007/s00234-021-02855-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/04/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Infarct lesion volume (ILV) may serve as an imaging biomarker for clinical outcomes in the early post-treatment stage in patients with acute ischemic stroke. The aim of this study was to evaluate the inter- and intra-rater reliability of manual segmentation of ILV on follow-up non-contrast CT (NCCT) scans. METHODS Fifty patients from the Prove-IT study were randomly selected for this analysis. Three raters manually segmented ILV on 24-h NCCT scans, slice by slice, three times. The reference standard for ILV was generated by the Simultaneous Truth And Performance Level estimation (STAPLE) algorithm. Intra- and inter-rater reliability was evaluated, using metrics of intraclass correlation coefficient (ICC) regarding lesion volume and the Dice similarity coefficient (DSC). RESULTS Median age of the 50 subjects included was 74.5 years (interquartile range [IQR] 67-80), 54% were women, median baseline National Institutes of Health Stroke Scale was 18 (IQR 11-22), median baseline ASPECTS was 9 (IQR 6-10). The mean reference standard ILV was 92.5 ml (standard deviation (SD) ± 100.9 ml). The manually segmented ILV ranged from 88.2 ± 91.5 to 135.5 ± 119.9 ml (means referring to the variation between readers, SD within readers). Inter-rater ICC was 0.83 (95%CI: 0.76-0.88); intra-rater ICC ranged from 0.85 (95%CI: 0.72-0.92) to 0.95 (95%CI: 0.91-0.97). The mean DSC among the three readers ranged from 65.5 ± 22.9 to 76.4 ± 17.1% and the mean overall DSC was 72.8 ± 23.0%. CONCLUSION Manual ILV measurements on follow-up CT scans are reliable to measure the radiological outcome despite some variability.
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16
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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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17
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Zhou T, Yi T, Li T, Zhu L, Li Y, Li Z, Wang M, Li Q, He Y, Yang P, Zhang Y, Li Z, Zhang Y, Ye X, Chen W, Wang S, Liu J. Predictors of futile recanalization in patients undergoing endovascular treatment in the DIRECT-MT trial. J Neurointerv Surg 2021; 14:752-755. [PMID: 34475255 DOI: 10.1136/neurintsurg-2021-017765] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/23/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Futile recanalization-when patients have a successful recanalization but fail to achieve a satisfactory functional outcome- is a common phenomenon of endovascular treatment of acute ischemic stroke (AIS). The present study aimed to identify the predictors of futile recanalization in AIS patients who received endovascular treatment. METHODS This is a post-hoc analysis of the DIRECT-MT trial. Demographics, clinical characteristics, acute stroke workflow interval times, biochemical parameters, and imaging characteristics were compared between futile and meaningful recanalization groups. Multivariate analysis was performed to identify the predictors of futile recanalization. RESULTS Futile recanalization was observed in 277 patients. In multivariable logistic regression analysis, older age (p<0.001), higher baseline systolic blood pressure (SBP) (p=0.032), incomplete reperfusion defined by extended Thrombolysis In Cerebral Infarction (eTICI) grades (p=0.020), and larger final infarct volume (FIV) (p<0.001) were independent predictors of futile recanalization. CONCLUSIONS Old age, high baseline SBP, incomplete reperfusion defined by eTICI, and large FIV were independent predictors of futile recanalization after endovascular therapy for AIS.
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Affiliation(s)
- Tengfei Zhou
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China.,Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Tingyu Yi
- Department of Neurology, Zhangzhou Municipal Hospital of Fujian Province and Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Tianxiao Li
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China .,Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Liangfu Zhu
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Yucheng Li
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Zhaoshuo Li
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Meiyun Wang
- Department of Radiology, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Qiang Li
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Yingkun He
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Pengfei Yang
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yongwei Zhang
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Zifu Li
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yongxin Zhang
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Xiaofei Ye
- Department of Statistics, Naval Medical University, Shanghai, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Municipal Hospital of Fujian Province and Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Shouchun Wang
- Department of Neurology, The First Affiliated Hospital of Jilin University, Changchun, China
| | - Jianmin Liu
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
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18
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Sila D, Lenski M, Vojtková M, Elgharbawy M, Charvát F, Rath S. Efficacy of Mechanical Thrombectomy using Penumbra ACE TM Aspiration Catheter Compared to Stent Retriever Solitaire TM FR in Patients with Acute Ischemic Stroke. Brain Sci 2021; 11:brainsci11040504. [PMID: 33923489 PMCID: PMC8073348 DOI: 10.3390/brainsci11040504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 04/07/2021] [Accepted: 04/12/2021] [Indexed: 12/24/2022] Open
Abstract
Background: Mechanical thrombectomy is the standard therapy in patients with acute ischemic stroke (AIS). The primary aim of our study was to compare the procedural efficacy of the direct aspiration technique, using Penumbra ACETM aspiration catheter, and the stent retriever technique, with a SolitaireTM FR stent. Secondarily, we investigated treatment-dependent and treatment-independent factors that predict a good clinical outcome. Methods: We analyzed our series of mechanical thrombectomies using a SolitaireTM FR stent and a Penumbra ACETM catheter. The clinical and radiographic data of 76 patients were retrospectively reviewed. Using binary logistic regression, we looked for the predictors of a good clinical outcome. Results: In the Penumbra ACETM group we achieved significantly higher rates of complete vessel recanalization with lower device passage counts, shorter recanalization times, shorter procedure times and shorter fluoroscopy times (p < 0.001) compared to the SolitaireTM FR group. We observed no significant difference in good clinical outcomes (52.4% vs. 56.4%, p = 0.756). Predictors of a good clinical outcome were lower initial NIHSS scores, pial arterial collateralization on admission head CT angiography scan, shorter recanalization times and device passage counts. Conclusions: The aspiration technique using Penumbra ACETM catheter is comparable to the stent retriever technique with SolitaireTM FR regarding clinical outcomes.
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Affiliation(s)
- Dalibor Sila
- Department of Neurosurgery and Interventional Neuroradiology, Donau-Isar Klinikum, Perlasberger Str. 41, 94469 Deggendorf, Germany;
- Correspondence: ; Tel.: +49-(0)991-3803867
| | - Markus Lenski
- Neurosurgical Clinic, Campus Grosshadern, Clinic of the University of Munich (LMU), Marchioninistrasse 15, 81377 Munich, Germany;
| | - Maria Vojtková
- Department of Statistics, Faculty of Economic Informatics, University of Economics in Bratislava, Dolnozemska cesta 1/b, 85235 Bratislava, Slovakia;
| | - Mustafa Elgharbawy
- Department of Radiology and Interventional Radiology, Donau-Isar Klinikum, Perlasberger Str. 41, 94469 Deggendorf, Germany;
| | - František Charvát
- Radiodiagnostic Departement, Military University Hospital Prague, U Vojenské nemocnice 1200, 16902 Praha, Czech Republic;
| | - Stefan Rath
- Department of Neurosurgery and Interventional Neuroradiology, Donau-Isar Klinikum, Perlasberger Str. 41, 94469 Deggendorf, Germany;
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19
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Kerleroux B, Tomasino C, Soriano D, Rodrigues PG, Moura FS, Cottier JP, Bibi R, Herbreteau D, Hak JF, Ifergan H, Janot K, Annan M, Boulouis G, Narata AP. EASY score (Eloquent, Age and baseline SYmptoms score) for outcome prediction in patients with acute ischemic stroke. Clin Neurol Neurosurg 2021; 205:106626. [PMID: 33873121 DOI: 10.1016/j.clineuro.2021.106626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/01/2021] [Accepted: 03/28/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE A pragmatic tool for the early and reliable prediction of recovery in patients with acute ischemic stroke is needed. We aimed to test the addition of brain eloquent areas involvement in variables predicting poor outcome, using a simple scoring system. METHODS Retrospective study of patients with anterior circulation acute ischemic stroke treated with best medical treatment and/or endovascular reperfusion. Primary outcome measure was 3-months poor outcome (mRs 3-6). We developed a prognostic model based on clinical data and a quantitative scoring system of the main eloquent brain areas involved on early follow-up CT, and analyzed its accuracy to predict poor outcome comparatively to three other prognostic models. The final model was used to develop a score for outcome prediction based on the multivariable analysis. RESULTS A total of 197 patients were included (poor outcome = 62; mean age 67 ± 15.1 years; 44% females). Independent predictors of poor outcome were increasing age (p < 0.001), baseline NIHSS (p = 0.03), and the involvement of two brain areas: posterior limb of internal capsule (p < 0.001) and postero-superior corona radiata (p < 0.001). This model showed to be the most accurate to predict poor outcome (Balance Accuracy = 77.74%; C-Statistic = 0.891). The derived risk score attributing points for each of these variables (EASY score) showed similar performances (Balance Accuracy = 82.11%; C-Statistic = 0.90). CONCLUSION The EASY score is an easy-to-apply and accurate tool to predict the 3-months functional outcome after ischemic stroke, relying on simple clinical features and the assessment of two key eloquent brain areas on early follow-up CT.
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Affiliation(s)
- Basile Kerleroux
- Neuroradiology Department, CHRU de Tours, 2 bd Tonnelé, Tours, France; Neuroradiology Department, CH Sainte-Anne, 1 Rue Cabanis, Paris, France.
| | | | - Diogo Soriano
- Engineering, Modeling and Applied Social Sciences Center - ABC Federal University Santo André, SP, Brazil
| | - Paula G Rodrigues
- Engineering, Modeling and Applied Social Sciences Center - ABC Federal University Santo André, SP, Brazil
| | - Fernando Silva Moura
- Engineering, Modeling and Applied Social Sciences Center - ABC Federal University Santo André, SP, Brazil
| | | | - Richard Bibi
- Neuroradiology Department, CHRU de Tours, 2 bd Tonnelé, Tours, France
| | - Denis Herbreteau
- Neuroradiology Department, CHRU de Tours, 2 bd Tonnelé, Tours, France
| | - Jean François Hak
- Neuroradiology Department, CH Sainte-Anne, 1 Rue Cabanis, Paris, France; Neuroradiology Department, CHU La Timone, 264 Rue Saint Pierre, 13005, Marseille, France
| | - Héloïse Ifergan
- Neuroradiology Department, CHRU de Tours, 2 bd Tonnelé, Tours, France
| | - Kévin Janot
- Neuroradiology Department, CHRU de Tours, 2 bd Tonnelé, Tours, France
| | - Mariam Annan
- Neurology CHRU de Tours, 2 bd Tonnelé, Tours, France
| | - Grégoire Boulouis
- Neuroradiology Department, CHRU de Tours, 2 bd Tonnelé, Tours, France; Neuroradiology Department, CH Sainte-Anne, 1 Rue Cabanis, Paris, France
| | - Ana Paula Narata
- Department of Neuroradiology, University Hospital of Southampton, Tremona Rd, Southampton, UK
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20
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Cimflova P, Kral J, Volny O, Horn M, Ojha P, Cabal M, Kasickova L, Havelka J, Jonszta T, Bar M, Qiu W. MRI Diffusion-Weighted Imaging to Measure Infarct Volume: Assessment of Manual Segmentation Variability. J Neuroimaging 2021; 31:541-550. [PMID: 33783929 DOI: 10.1111/jon.12850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND PURPOSE Manual segmentation of infarct volume on follow-up MRI diffusion-weighted imaging (MRI-DWI) is considered the gold standard but is prone to rater variability. We assess the variability of manual segmentations of MRI-DWI infarct volume. METHODS Consecutive patients (May 2018 to May 2019) with the anterior circulation stroke and endovascularly treated were enrolled. All patients underwent 24- to 32-hour follow-up MRI. Three users manually segmented DWI infarct volumes slice by slice twice. The reference standard of DWI infarct volume was generated by the STAPLE algorithm. Intra- and interrater reliability was evaluated using the intraclass correlation coefficient (ICC) by comparing manual segmentations with the reference standard. Spatial measurements were evaluated using metrics of the Dice similarity coefficient (DSC). Volumetric measurements were compared using the lesion volume. RESULTS The dataset consisted of 44 patients, mean (SD) age was 70.1 years (±10.3), 43% were women, and median baseline NIHSS score was 16. Among three users, the mean DSC for MRI-DWI infarct volume segmentations ranged from 80.6% ± 11.7% to 88.6% ± 7.5%, and the mean absolute volume difference was 2.8 ± 6.8 to 13.0 ± 14.0 ml. Interrater ICC among the users for DSC and infarct volume was .86 (95% confidence interval [95% CI]: .78-.91) and .997 (95% CI: .995-.998). Intrarater ICC for the three users was .83 (95% CI: .69-.93), .84 (95% CI: .72-.91), and .80 (95% CI: .64-.89) for DSC, and .99 (95% CI: .987-.996), .991 (95% CI: .983-.995), and .996 (95% CI: .993-.998) for infarct volume. CONCLUSIONS Manual segmentation of infarct volume on follow-up MRI-DWI shows excellent agreement and good spatial overlap with the reference standard, suggesting its usefulness for measuring infarct volume on 24- to 32-hour MRI-DWI.
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Affiliation(s)
- Petra Cimflova
- Departments of Clinical Neurosciences, Calgary Stroke Program, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Department of Medical Imaging, St. Anne´s University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic.,International Clinical Research Center, Stroke Research Program, St. Anne´s University Hospital, Brno, Czech Republic.,Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Jiri Kral
- Department of Neurology, University Hospital Ostrava, Ostrava, Czech Republic.,Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ondrej Volny
- Departments of Clinical Neurosciences, Calgary Stroke Program, Cumming School of Medicine, University of Calgary, Calgary, Canada.,International Clinical Research Center, Stroke Research Program, St. Anne´s University Hospital, Brno, Czech Republic.,Department of Neurology, University Hospital Ostrava, Ostrava, Czech Republic
| | - MacKenzie Horn
- Departments of Clinical Neurosciences, Calgary Stroke Program, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Piyush Ojha
- Departments of Clinical Neurosciences, Calgary Stroke Program, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Martin Cabal
- Department of Neurology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Linda Kasickova
- Department of Neurology, University Hospital Ostrava, Ostrava, Czech Republic.,Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jaroslav Havelka
- Department of Radiology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Tomas Jonszta
- Department of Radiology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Michal Bar
- Department of Neurology, University Hospital Ostrava, Ostrava, Czech Republic.,Faculty of Medicine, Ostrava University, Ostrava, Czech Republic
| | - Wu Qiu
- Departments of Clinical Neurosciences, Calgary Stroke Program, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Canada
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21
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Ter Schiphorst A, Charron S, Hassen WB, Provost C, Naggara O, Benzakoun J, Seners P, Turc G, Baron JC, Oppenheim C. Tissue no-reflow despite full recanalization following thrombectomy for anterior circulation stroke with proximal occlusion: A clinical study. J Cereb Blood Flow Metab 2021; 41:253-266. [PMID: 32960688 PMCID: PMC8370008 DOI: 10.1177/0271678x20954929] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Despite early thrombectomy, a sizeable fraction of acute stroke patients with large vessel occlusion have poor outcome. The no-reflow phenomenon, i.e. impaired microvascular reperfusion despite complete recanalization, may contribute to such "futile recanalizations". Although well reported in animal models, no-reflow is still poorly characterized in man. From a large prospective thrombectomy database, we included all patients with intracranial proximal occlusion, complete recanalization (modified thrombolysis in cerebral infarction score 2c-3), and availability of both baseline and 24 h follow-up MRI including arterial spin labeling perfusion mapping. No-reflow was operationally defined as i) hypoperfusion ≥40% relative to contralateral homologous region, assessed with both visual (two independent investigators) and automatic image analysis, and ii) infarction on follow-up MRI. Thirty-three patients were eligible (median age: 70 years, NIHSS: 18, and stroke onset-to-recanalization delay: 208 min). The operational criteria were met in one patient only, consistently with the visual and automatic analyses. This patient recanalized 160 min after stroke onset and had excellent functional outcome. In our cohort of patients with complete and stable recanalization following thrombectomy for intracranial proximal occlusion, severe ipsilateral hypoperfusion on follow-up imaging associated with newly developed infarction was a rare occurrence. Thus, no-reflow may be infrequent in human stroke and may not substantially contribute to futile recanalizations.
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Affiliation(s)
- Adrien Ter Schiphorst
- INSERM U1266, Institut de Psychiatrie et Neurosciences de Paris, Université de Paris, Paris, France.,Department of Neurology, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Sylvain Charron
- INSERM U1266, Institut de Psychiatrie et Neurosciences de Paris, Université de Paris, Paris, France.,Department of Neuroradiology, Hôpital Sainte-Anne, Université de Paris, Paris, France
| | - Wagih Ben Hassen
- INSERM U1266, Institut de Psychiatrie et Neurosciences de Paris, Université de Paris, Paris, France.,Department of Neuroradiology, Hôpital Sainte-Anne, Université de Paris, Paris, France
| | - Corentin Provost
- INSERM U1266, Institut de Psychiatrie et Neurosciences de Paris, Université de Paris, Paris, France.,Department of Neuroradiology, Hôpital Sainte-Anne, Université de Paris, Paris, France
| | - Olivier Naggara
- INSERM U1266, Institut de Psychiatrie et Neurosciences de Paris, Université de Paris, Paris, France.,Department of Neuroradiology, Hôpital Sainte-Anne, Université de Paris, Paris, France
| | - Joseph Benzakoun
- INSERM U1266, Institut de Psychiatrie et Neurosciences de Paris, Université de Paris, Paris, France.,Department of Neuroradiology, Hôpital Sainte-Anne, Université de Paris, Paris, France
| | - Pierre Seners
- INSERM U1266, Institut de Psychiatrie et Neurosciences de Paris, Université de Paris, Paris, France.,Department of Neurology, Hôpital Sainte-Anne, Université de Paris, Paris, France
| | - Guillaume Turc
- INSERM U1266, Institut de Psychiatrie et Neurosciences de Paris, Université de Paris, Paris, France.,Department of Neurology, Hôpital Sainte-Anne, Université de Paris, Paris, France
| | - Jean-Claude Baron
- INSERM U1266, Institut de Psychiatrie et Neurosciences de Paris, Université de Paris, Paris, France.,Department of Neurology, Hôpital Sainte-Anne, Université de Paris, Paris, France
| | - Catherine Oppenheim
- INSERM U1266, Institut de Psychiatrie et Neurosciences de Paris, Université de Paris, Paris, France.,Department of Neuroradiology, Hôpital Sainte-Anne, Université de Paris, Paris, France
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22
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Post-stroke ASPECTS predicts outcome after thrombectomy. Neuroradiology 2020; 63:769-775. [PMID: 33025040 DOI: 10.1007/s00234-020-02576-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Infarct growth and final infarct volume are established outcome modifiers following endovascular thrombectomy (EVT) for patients with large vessel occlusion stroke (LVO). Simple techniques for final infarct volume measurement are lacking, and therefore, we tested whether post-EVT ASPECTS can be used for prognostic evaluation after EVT. METHODS Infarct size at baseline was measured in a prospective cohort of patients with LVO that underwent EVT with the ASPECTS score on admission non-contrast CT. Final infarct size was assessed with a post-EVT ASPECTS (ASPECTS-POST) obtained from a follow-up CT 24-72 h post-EVT. The best performing ASPECTS-POST was chosen based on comparisons of different thresholds. Outcome measures included survival rates and modified Rankin Score at 90 days. RESULTS A total of 272 patients were included and 166 of them had an ASPECTS-POST ≥ 7. ASPECTS-POST ≥ 7 was associated with increased likelihood of favorable outcome at 90 days (67% vs. 21%, p < 0.001) with sensitivity, specificity, and positive and negative predictive values of 86%, 58%, 61%, and 85%, respectively. On multivariate analysis, ASPECTS-POST ≥ 7 was found to be a significant modifier of favorable outcome (Odds Ratio [OR] 6.2, 95% confidence intervals [CI] 3.1-12.4) and survival (OR 5.8 95% CI 2.4-14.3). CONCLUSION ASPECTS can be rapidly and easily obtained from the post-EVT NCCT and ASPECTS-POST ≥ 7 correlates with good outcome.
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23
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Machine learning volumetry of ischemic brain lesions on CT after thrombectomy—prospective diagnostic accuracy study in ischemic stroke patients. Neuroradiology 2020; 62:1239-1245. [DOI: 10.1007/s00234-020-02419-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/26/2020] [Indexed: 10/24/2022]
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24
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Boers AMM, Jansen IGH, Brown S, Lingsma HF, Beenen LFM, Devlin TG, Román LS, Heo JH, Ribó M, Almekhlafi MA, Liebeskind DS, Teitelbaum J, Cuadras P, du Mesnil de Rochemont R, Beaumont M, Brown MM, Yoo AJ, Donnan GA, Mas JL, Oppenheim C, Dowling RJ, Moulin T, Agrinier N, Lopes DK, Aja Rodríguez L, Compagne KCJ, Al-Ajlan FS, Madigan J, Albers GW, Soize S, Blasco J, Davis SM, Nogueira RG, Dávalos A, Menon BK, van der Lugt A, Muir KW, Roos YBWEM, White P, Mitchell PJ, Demchuk AM, van Zwam WH, Jovin TG, van Oostenbrugge RJ, Dippel DWJ, Campbell BCV, Guillemin F, Bracard S, Hill MD, Goyal M, Marquering HA, Majoie CBLM. Mediation of the Relationship Between Endovascular Therapy and Functional Outcome by Follow-up Infarct Volume in Patients With Acute Ischemic Stroke. JAMA Neurol 2019; 76:194-202. [PMID: 30615038 DOI: 10.1001/jamaneurol.2018.3661] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Importance The positive treatment effect of endovascular therapy (EVT) is assumed to be caused by the preservation of brain tissue. It remains unclear to what extent the treatment-related reduction in follow-up infarct volume (FIV) explains the improved functional outcome after EVT in patients with acute ischemic stroke. Objective To study whether FIV mediates the relationship between EVT and functional outcome in patients with acute ischemic stroke. Design, Setting, and Participants Patient data from 7 randomized multicenter trials were pooled. These trials were conducted between December 2010 and April 2015 and included 1764 patients randomly assigned to receive either EVT or standard care (control). Follow-up infarct volume was assessed on computed tomography or magnetic resonance imaging after stroke onset. Mediation analysis was performed to examine the potential causal chain in which FIV may mediate the relationship between EVT and functional outcome. A total of 1690 patients met the inclusion criteria. Twenty-five additional patients were excluded, resulting in a total of 1665 patients, including 821 (49.3%) in the EVT group and 844 (50.7%) in the control group. Data were analyzed from January to June 2017. Main Outcome and Measure The 90-day functional outcome via the modified Rankin Scale (mRS). Results Among 1665 patients, the median (interquartile range [IQR]) age was 68 (57-76) years, and 781 (46.9%) were female. The median (IQR) time to FIV measurement was 30 (24-237) hours. The median (IQR) FIV was 41 (14-120) mL. Patients in the EVT group had significantly smaller FIVs compared with patients in the control group (median [IQR] FIV, 33 [11-99] vs 51 [18-134] mL; P = .007) and lower mRS scores at 90 days (median [IQR] score, 3 [1-4] vs 4 [2-5]). Follow-up infarct volume was a predictor of functional outcome (adjusted common odds ratio, 0.46; 95% CI, 0.39-0.54; P < .001). Follow-up infarct volume partially mediated the relationship between treatment type with mRS score, as EVT was still significantly associated with functional outcome after adjustment for FIV (adjusted common odds ratio, 2.22; 95% CI, 1.52-3.21; P < .001). Treatment-reduced FIV explained 12% (95% CI, 1-19) of the relationship between EVT and functional outcome. Conclusions and Relevance In this analysis, follow-up infarct volume predicted functional outcome; however, a reduced infarct volume after treatment with EVT only explained 12% of the treatment benefit. Follow-up infarct volume as measured on computed tomography and magnetic resonance imaging is not a valid proxy for estimating treatment effect in phase II and III trials of acute ischemic stroke.
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Affiliation(s)
- Anna M M Boers
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands.,Department of Robotics and Mechatronics, University of Twente, Enschede, the Netherlands
| | - Ivo G H Jansen
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Scott Brown
- Altair Biostatistics, Mooresville, North Carolina
| | - Hester F Lingsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ludo F M Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Thomas G Devlin
- Department of Neurology, Erlanger Hospital, University of Tennessee at Chattanooga
| | - Luis San Román
- Department of Interventional Neuroradiology, Hospital Clinic of Barcelona, Barcelona, Catalonia, Spain
| | - Ji-Hoe Heo
- Department of Neurology, Yonsei University, Seoul, South Korea
| | - Marc Ribó
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Catalonia, Spain
| | - Mohammed A Almekhlafi
- Department of Neurology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Jeanne Teitelbaum
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
| | - Patricia Cuadras
- Department of Radiology, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | | | - Marine Beaumont
- Inserm CIC-IT 1433, University of Lorraine and University Hospital of Nancy, Nancy, France
| | - Martin M Brown
- Institute of Neurology, University College London, London, United Kingdom
| | - Albert J Yoo
- Division of Neurointervention, Texas Stroke Institute, Dallas
| | - Geoffrey A Donnan
- The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Jean Louis Mas
- Department of Neurology, Sainte-Anne Hospital and Paris-Descartes University, INSERM U894, Paris, France
| | - Catherine Oppenheim
- Department of Neuroradiology, Sainte-Anne Hospital and Paris-Descartes University, INSERM U894, Paris, France
| | - Richard J Dowling
- Department of Radiology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Thierry Moulin
- Department of Neurology, University Hospital of Besançon, University of Franche-Comté, Besançon, France
| | - Nelly Agrinier
- Inserm, Centre Hospitalier Régional et Universitaire de Nancy, Université de Lorraine, CIC1433-Epidémiologie Clinique, Nancy, France
| | - Demetrius K Lopes
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Lucía Aja Rodríguez
- Neuroradiology Department, Hospital Universitari de Bellvitge, Barcelona, Catalonia, Spain
| | - Kars C J Compagne
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.,Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Fahad S Al-Ajlan
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Gregory W Albers
- Department of Neurology, Stanford Stroke Center, Palo Alto, California
| | - Sebastien Soize
- Department of Neuroradiology, University Hospital of Reims, Reims, France
| | - Jordi Blasco
- Department of Interventional Neuroradiology, Hospital Clinic of Barcelona, Barcelona, Catalonia, Spain
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Raul G Nogueira
- Department of Neurology, Neurosurgery and Radiology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - Antoni Dávalos
- Department of Neuroscience, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Bijoy K Menon
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, Alberta, Canada
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Phil White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Peter J Mitchell
- Department of Radiology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, Alberta, Canada
| | - Wim H van Zwam
- Department of Radiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Tudor G Jovin
- Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert J van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Francis Guillemin
- Inserm, Centre Hospitalier Régional et Universitaire de Nancy, Université de Lorraine, CIC1433-Epidémiologie Clinique, Nancy, France
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, INSERM U947, University of Lorraine and University Hospital of Nancy, Nancy, France
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, Alberta, Canada
| | - Mayank Goyal
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, Alberta, Canada
| | - Henk A Marquering
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
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25
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Rao V, Christensen S, Yennu A, Mlynash M, Zaharchuk G, Heit J, Marks MP, Lansberg MG, Albers GW. Ischemic Core and Hypoperfusion Volumes Correlate With Infarct Size 24 Hours After Randomization in DEFUSE 3. Stroke 2019; 50:626-631. [PMID: 30727840 DOI: 10.1161/strokeaha.118.023177] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Accurate prediction of the subsequent infarct volume early after stroke onset helps determine appropriate interventions and prognosis. In the DEFUSE 3 trial (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke), we evaluated the accuracy of baseline ischemic core and hypoperfusion volumes for predicting infarct volume 24 hours after randomization to endovascular thrombectomy versus medical management. We also assessed if the union of baseline ischemic core and the volume of persistent hypoperfusion at 24 hours after randomization predicts infarct volume. Methods- Patients in DEFUSE 3 with computed tomography perfusion imaging or magnetic resonance diffusion weighted imaging/perfusion imaging acquired at baseline and at 24 hours after randomization were included. Ischemic core and Tmax >6s hypoperfusion volumes at baseline and follow-up were calculated using RAPID software and compared with the infarct volumes obtained 24 hours after randomization. Patients were stratified by reperfusion status for analyses. Results- Of 125 eligible patients, 59 patients with >90% reperfusion had a strong correlation between baseline ischemic core volume and infarct volume 24 hours postrandomization ( r=0.83; P<0.0001), and 14 patients with <10% reperfusion had a strong correlation between baseline Tmax >6s volume and infarct volume 24 hours postrandomization ( r=0.77; P<0.001). In the 52 patients with 10% to 90% reperfusion, as well as in all 125 patients, the union of the baseline ischemic core and the follow-up Tmax >6s perfusion volume was highly correlated with infarct volume 24 hours postrandomization (for N=125; r=0.83; P<0.0001), with a median absolute difference of 21.3 mL between observed and predicted infarct volumes. Conclusions- The union of the irreversibly injured ischemic core and persistently hypoperfused tissue volumes, as identified by computed tomography perfusion or magnetic resonance diffusion weighted imaging/perfusion, predicted infarct volume at 24 hours after randomization in DEFUSE 3 patients. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT02586415.
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Affiliation(s)
- Vaishnavi Rao
- From the Department of Neurology and Neurological Sciences (V.R., S.C., A.Y., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, CA
| | - Søren Christensen
- From the Department of Neurology and Neurological Sciences (V.R., S.C., A.Y., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, CA
| | - Amarnath Yennu
- From the Department of Neurology and Neurological Sciences (V.R., S.C., A.Y., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, CA
| | - Michael Mlynash
- From the Department of Neurology and Neurological Sciences (V.R., S.C., A.Y., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, CA
| | - Greg Zaharchuk
- Department of Diagnostic Radiology (G.Z., J.H., M.P.M.), Stanford University School of Medicine, CA
| | - Jeremy Heit
- Department of Diagnostic Radiology (G.Z., J.H., M.P.M.), Stanford University School of Medicine, CA
| | - Michael P Marks
- Department of Diagnostic Radiology (G.Z., J.H., M.P.M.), Stanford University School of Medicine, CA
| | - Maarten G Lansberg
- From the Department of Neurology and Neurological Sciences (V.R., S.C., A.Y., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, CA
| | - Gregory W Albers
- From the Department of Neurology and Neurological Sciences (V.R., S.C., A.Y., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, CA
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26
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Leslie-Mazwi TM, Hamilton S, Mlynash M, Patel AB, Schwamm LH, Lansberg MG, Marks M, Hirsch JA, Albers GW. DEFUSE 3 Non-DAWN Patients. Stroke 2019; 50:618-625. [PMID: 30727856 DOI: 10.1161/strokeaha.118.023310] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background and Purpose- DAWN (Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention With Trevo) and DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke) established thrombectomy for patients with emergent large vessel occlusions presenting 6 to 24 hours after symptom onset. Given the greater inclusivity of DEFUSE 3, we evaluated the effect of thrombectomy in DEFUSE 3 patients who would have been excluded from DAWN. Methods- Eligibility criteria of the DAWN trial were applied to DEFUSE 3 patient data to identify DEFUSE 3 patients not meeting DAWN criteria (DEFUSE 3 non-DAWN). Reasons for DAWN exclusion in DEFUSE 3 were infarct core too large, National Institutes of Health Stroke Scale (NIHSS) score 6 to 9, and modified Rankin Scale score of 2. Subgroups were compared with the DEFUSE 3 non-DAWN and entire DEFUSE 3 cohorts. Results- There were 71 DEFUSE 3 non-DAWN patients; 31 patients with NIHSS 6 to 9, 33 with core too large, and 13 with premorbid modified Rankin Scale score of 2 (some patients met multiple criteria). For core-too-large patients, median 24-hour infarct volume was 119 mL (interquartile range, 74.6-180) versus 31.5 mL (interquartile range, 17.6-64.3) for core-not-too-large patients ( P<0.001). Complications and functional outcomes were similar between the groups. Thrombectomy in core-too-large patients compared with the remaining DEFUSE 3 non-DAWN patients conveyed benefit for functional outcome (odds ratio, 20.9; CI, 1.3-337.8). Comparing the NIHSS 6 to 9 group with the NIHSS ≥10 patients, modified Rankin Scale score 0 to 2 outcomes were achieved in 74% versus 22% ( P<0.001), with mortality in 6% versus 23% ( P=0.024), respectively. For patients with NIHSS 6 to 9 compared with the remaining DEFUSE 3 non-DAWN patients, thrombectomy trended toward a better chance of functional outcome (odds ratio, 1.86; CI, 0.36-9.529). Conclusions- Patients with pretreatment core infarct volumes <70 mL but too large for inclusion by DAWN criteria demonstrate benefit from endovascular therapy. More permissive pretreatment core thresholds in core-clinical mismatch selection paradigms may be appropriate. In contrast to data supporting a beneficial treatment effect across the full range of NIHSS scores in the entire DEFUSE 3 population, only a trend toward benefit of thrombectomy in patients with NIHSS 6 to 9 was found in this small subgroup.
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Affiliation(s)
- Thabele M Leslie-Mazwi
- From the Neuroscience Institute, Massachusetts General Hospital, Boston (T.M.L.-M., A.B.P., L.H.S., J.A.H.)
| | - Scott Hamilton
- Stanford Stroke Center, Stanford University Medical Center, Palo Alto, CA (S.H., M. Mlynash, M.G.L., M. Marks, G.W.A.)
| | - Michael Mlynash
- Stanford Stroke Center, Stanford University Medical Center, Palo Alto, CA (S.H., M. Mlynash, M.G.L., M. Marks, G.W.A.)
| | - Aman B Patel
- From the Neuroscience Institute, Massachusetts General Hospital, Boston (T.M.L.-M., A.B.P., L.H.S., J.A.H.)
| | - Lee H Schwamm
- From the Neuroscience Institute, Massachusetts General Hospital, Boston (T.M.L.-M., A.B.P., L.H.S., J.A.H.)
| | - Maarten G Lansberg
- Stanford Stroke Center, Stanford University Medical Center, Palo Alto, CA (S.H., M. Mlynash, M.G.L., M. Marks, G.W.A.)
| | - Michael Marks
- Stanford Stroke Center, Stanford University Medical Center, Palo Alto, CA (S.H., M. Mlynash, M.G.L., M. Marks, G.W.A.)
| | - Joshua A Hirsch
- From the Neuroscience Institute, Massachusetts General Hospital, Boston (T.M.L.-M., A.B.P., L.H.S., J.A.H.)
| | - Gregory W Albers
- Stanford Stroke Center, Stanford University Medical Center, Palo Alto, CA (S.H., M. Mlynash, M.G.L., M. Marks, G.W.A.)
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A practical protocol for shortening reconstruction time of volumetric data and imaging bilateral middle cerebral arteries for thrombectomy in acute ischemic stroke using an 80-row computed tomography scanner. Neuroradiology 2019; 62:97-100. [PMID: 31720754 DOI: 10.1007/s00234-019-02306-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022]
Abstract
Time-consuming reconstruction of volumetric data by area-detector-computed tomography (ADCT) scanning and narrow coverage of small-row ADCT may hinder volumetric scanning in acute stroke stage. To design a practical protocol of volumetric scanning for thrombectomy using an 80-row ADCT. An imaging protocol that focuses on the middle cerebral arteries by tilting the gantry of an 80-row ADCT with 0.5-mm-thick detectors can shorten the reconstruction time by 1.0-mm thickness scanning without subtraction. The reconstruction time of small volumetric data was 69 second. This practical protocol is applicable before thrombectomy in different stroke centres with narrow-coverage ADCT scanners.
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Tsivgoulis G, Katsanos AH, Schellinger PD, Köhrmann M, Caso V, Palaiodimou L, Magoufis G, Arthur A, Fischer U, Alexandrov AV. Advanced Neuroimaging in Stroke Patient Selection for Mechanical Thrombectomy. Stroke 2019; 49:3067-3070. [PMID: 30571421 DOI: 10.1161/strokeaha.118.022540] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- There is clinical equipoise about the use of advanced imaging for selecting acute ischemic stroke patients eligible for mechanical thrombectomy (MT) during the first 6 hours from symptom onset. However, accumulating evidence indicates that advanced neuroimaging represents an invaluable and time-independent prognostic factor. Methods- We performed a systematic review and meta-analysis of available randomized clinical trials to evaluate the impact of patient selection with advanced neuroimaging on the 3-month: (1) functional independence (modified Rankin Scale score, 0-2), (2) favorable functional outcome (modified Rankin Scale scores, 0-1), (3) all-cause mortality, and (4) functional improvement (assessed with ordinal analysis of the modified Rankin Scale-scores). We compared patients with perfusion imaging documented penumbra to patients who did not have documented penumbra or perfusion imaging. Results- Among the 10 eligible randomized clinical trials (2227 total patients, mean age: 67 years), 5 studies reported the use of advanced imaging. Studies using advanced neuroimaging showed higher treatment effects of MT on 3-month functional independence (odds ratio [OR], 3.79; 95% CI, 2.71-5.28 versus OR, 1.89; 95% CI, 1.52-2.35; P for subgroup differences <0.001), favorable functional outcome (OR, 3.16; 95% CI, 1.94-5.14 versus OR, 1.75; 95% CI, 1.30-2.34; P for subgroup differences=0.04), and functional improvement (common OR, 2.66; 95% CI, 1.95-3.63 versus common OR, 1.60; 95% CI, 1.32-1.95; P for subgroup differences=0.007) compared with studies using conventional neuroimaging. The pooled rate of successful reperfusion after MT was higher in studies with advanced neuroimaging ( P for subgroup differences=0.003). No difference in the mortality and symptomatic intracranial hemorrhage rates was found between the 2 groups. No evidence of heterogeneity was documented in all reported analyses. Conclusions- The present indirect comparisons indicate that acute ischemic stroke patient selection for MT using advanced neuroimaging appears to be associated with improved clinical outcomes. The use of advanced neuroimaging for both the selection and prediction of prognosis for MT candidates should not depend on the elapsed time from symptom onset.
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Affiliation(s)
- Georgios Tsivgoulis
- From the Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Greece (G.T., A.H.K., L.P.).,Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis.,Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute (A.A.), University of Tennessee Health Science Center, Memphis.,Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany (P.D.S.).,Department of Neurology, Universitätsklinikum Essen, Germany (M.K.).,Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (V.C.).,Stroke Unit, Metropolitan Hospital, Piraeus, Greece (G.M.).,Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Switzerland (U.F.)
| | - Aristeidis H Katsanos
- From the Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Greece (G.T., A.H.K., L.P.).,Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis.,Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute (A.A.), University of Tennessee Health Science Center, Memphis.,Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany (P.D.S.).,Department of Neurology, Universitätsklinikum Essen, Germany (M.K.).,Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (V.C.).,Stroke Unit, Metropolitan Hospital, Piraeus, Greece (G.M.).,Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Switzerland (U.F.)
| | - Peter D Schellinger
- From the Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Greece (G.T., A.H.K., L.P.).,Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis.,Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute (A.A.), University of Tennessee Health Science Center, Memphis.,Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany (P.D.S.).,Department of Neurology, Universitätsklinikum Essen, Germany (M.K.).,Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (V.C.).,Stroke Unit, Metropolitan Hospital, Piraeus, Greece (G.M.).,Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Switzerland (U.F.)
| | - Martin Köhrmann
- From the Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Greece (G.T., A.H.K., L.P.).,Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis.,Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute (A.A.), University of Tennessee Health Science Center, Memphis.,Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany (P.D.S.).,Department of Neurology, Universitätsklinikum Essen, Germany (M.K.).,Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (V.C.).,Stroke Unit, Metropolitan Hospital, Piraeus, Greece (G.M.).,Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Switzerland (U.F.)
| | - Valeria Caso
- From the Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Greece (G.T., A.H.K., L.P.).,Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis.,Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute (A.A.), University of Tennessee Health Science Center, Memphis.,Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany (P.D.S.).,Department of Neurology, Universitätsklinikum Essen, Germany (M.K.).,Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (V.C.).,Stroke Unit, Metropolitan Hospital, Piraeus, Greece (G.M.).,Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Switzerland (U.F.)
| | - Lina Palaiodimou
- From the Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Greece (G.T., A.H.K., L.P.).,Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis.,Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute (A.A.), University of Tennessee Health Science Center, Memphis.,Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany (P.D.S.).,Department of Neurology, Universitätsklinikum Essen, Germany (M.K.).,Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (V.C.).,Stroke Unit, Metropolitan Hospital, Piraeus, Greece (G.M.).,Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Switzerland (U.F.)
| | - Georgios Magoufis
- From the Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Greece (G.T., A.H.K., L.P.).,Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis.,Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute (A.A.), University of Tennessee Health Science Center, Memphis.,Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany (P.D.S.).,Department of Neurology, Universitätsklinikum Essen, Germany (M.K.).,Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (V.C.).,Stroke Unit, Metropolitan Hospital, Piraeus, Greece (G.M.).,Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Switzerland (U.F.)
| | - Adam Arthur
- From the Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Greece (G.T., A.H.K., L.P.).,Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis.,Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute (A.A.), University of Tennessee Health Science Center, Memphis.,Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany (P.D.S.).,Department of Neurology, Universitätsklinikum Essen, Germany (M.K.).,Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (V.C.).,Stroke Unit, Metropolitan Hospital, Piraeus, Greece (G.M.).,Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Switzerland (U.F.)
| | - Urs Fischer
- From the Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Greece (G.T., A.H.K., L.P.).,Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis.,Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute (A.A.), University of Tennessee Health Science Center, Memphis.,Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany (P.D.S.).,Department of Neurology, Universitätsklinikum Essen, Germany (M.K.).,Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (V.C.).,Stroke Unit, Metropolitan Hospital, Piraeus, Greece (G.M.).,Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Switzerland (U.F.)
| | - Andrei V Alexandrov
- From the Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Greece (G.T., A.H.K., L.P.).,Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis.,Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute (A.A.), University of Tennessee Health Science Center, Memphis.,Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany (P.D.S.).,Department of Neurology, Universitätsklinikum Essen, Germany (M.K.).,Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (V.C.).,Stroke Unit, Metropolitan Hospital, Piraeus, Greece (G.M.).,Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Switzerland (U.F.)
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Meier R, Lux P, Med B, Jung S, Fischer U, Gralla J, Reyes M, Wiest R, McKinley R, Kaesmacher J. Neural Network-derived Perfusion Maps for the Assessment of Lesions in Patients with Acute Ischemic Stroke. Radiol Artif Intell 2019; 1:e190019. [PMID: 33937801 DOI: 10.1148/ryai.2019190019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 06/03/2019] [Accepted: 06/14/2019] [Indexed: 11/11/2022]
Abstract
Purpose To perform a proof-of-concept study to investigate the clinical utility of perfusion maps derived from convolutional neural networks (CNNs) for the workup of patients with acute ischemic stroke presenting with a large vessel occlusion. Materials and Methods Data on endovascularly treated patients with acute ischemic stroke (n = 151; median age, 68 years [interquartile range, 59-75 years]; 82 of 151 [54.3%] women) were retrospectively extracted from a single-center institutional prospective registry (between January 2011 and December 2015). Dynamic susceptibility perfusion imaging data were processed by applying a commercially available reference method and in parallel by a recently proposed CNN method to automatically infer time to maximum of the tissue residue function (Tmax) perfusion maps. The outputs were compared by using quantitative markers of tissue at risk derived from manual segmentations of perfusion lesions from two expert raters. Results Strong correlations of lesion volumes (Tmax > 4 seconds, > 6 seconds, and > 8 seconds; R = 0.865-0.914; P < .001) and good spatial overlap of respective lesion segmentations (Dice coefficients, 0.70-0.85) between the CNN method and reference output were observed. Eligibility for late-window reperfusion treatment was feasible with use of the CNN method, with complete interrater agreement for the CNN method (Cohen κ = 1; P < .001), although slight discrepancies compared with the reference-based output were observed (Cohen κ = 0.609-0.64; P < .001). The CNN method tended to underestimate smaller lesion volumes, leading to a disagreement between the CNN and reference method in five of 45 patients (9%). Conclusion Compared with standard deconvolution-based processing of raw perfusion data, automatic CNN-derived Tmax perfusion maps can be applied to patients who have acute ischemic large vessel occlusion stroke, with similar clinical utility.© RSNA, 2019Supplemental material is available for this article.
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Affiliation(s)
- Raphael Meier
- Support Center for Advanced Neuroimaging-University Institute of Diagnostic and Interventional Neuroradiology (R. Meier, P.L., J.G., R.W., R. McKinley, J.K.), Department of Neurology (S.J., U.F., J.K.), Institute for Surgical Technology and Biomechanics (M.R.), and Institute for Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Inselspital and University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Paula Lux
- Support Center for Advanced Neuroimaging-University Institute of Diagnostic and Interventional Neuroradiology (R. Meier, P.L., J.G., R.W., R. McKinley, J.K.), Department of Neurology (S.J., U.F., J.K.), Institute for Surgical Technology and Biomechanics (M.R.), and Institute for Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Inselspital and University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - B Med
- Support Center for Advanced Neuroimaging-University Institute of Diagnostic and Interventional Neuroradiology (R. Meier, P.L., J.G., R.W., R. McKinley, J.K.), Department of Neurology (S.J., U.F., J.K.), Institute for Surgical Technology and Biomechanics (M.R.), and Institute for Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Inselspital and University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Simon Jung
- Support Center for Advanced Neuroimaging-University Institute of Diagnostic and Interventional Neuroradiology (R. Meier, P.L., J.G., R.W., R. McKinley, J.K.), Department of Neurology (S.J., U.F., J.K.), Institute for Surgical Technology and Biomechanics (M.R.), and Institute for Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Inselspital and University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Urs Fischer
- Support Center for Advanced Neuroimaging-University Institute of Diagnostic and Interventional Neuroradiology (R. Meier, P.L., J.G., R.W., R. McKinley, J.K.), Department of Neurology (S.J., U.F., J.K.), Institute for Surgical Technology and Biomechanics (M.R.), and Institute for Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Inselspital and University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Jan Gralla
- Support Center for Advanced Neuroimaging-University Institute of Diagnostic and Interventional Neuroradiology (R. Meier, P.L., J.G., R.W., R. McKinley, J.K.), Department of Neurology (S.J., U.F., J.K.), Institute for Surgical Technology and Biomechanics (M.R.), and Institute for Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Inselspital and University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Mauricio Reyes
- Support Center for Advanced Neuroimaging-University Institute of Diagnostic and Interventional Neuroradiology (R. Meier, P.L., J.G., R.W., R. McKinley, J.K.), Department of Neurology (S.J., U.F., J.K.), Institute for Surgical Technology and Biomechanics (M.R.), and Institute for Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Inselspital and University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Roland Wiest
- Support Center for Advanced Neuroimaging-University Institute of Diagnostic and Interventional Neuroradiology (R. Meier, P.L., J.G., R.W., R. McKinley, J.K.), Department of Neurology (S.J., U.F., J.K.), Institute for Surgical Technology and Biomechanics (M.R.), and Institute for Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Inselspital and University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Richard McKinley
- Support Center for Advanced Neuroimaging-University Institute of Diagnostic and Interventional Neuroradiology (R. Meier, P.L., J.G., R.W., R. McKinley, J.K.), Department of Neurology (S.J., U.F., J.K.), Institute for Surgical Technology and Biomechanics (M.R.), and Institute for Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Inselspital and University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Johannes Kaesmacher
- Support Center for Advanced Neuroimaging-University Institute of Diagnostic and Interventional Neuroradiology (R. Meier, P.L., J.G., R.W., R. McKinley, J.K.), Department of Neurology (S.J., U.F., J.K.), Institute for Surgical Technology and Biomechanics (M.R.), and Institute for Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Inselspital and University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
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Affiliation(s)
- Turgay Dalkara
- From the Department of Neurology, Faculty of Medicine and Institute of Neurological Sciences and Psychiatry, Hacettepe University, Ankara, Turkey; and Department of Radiology, Massachusetts General Hospital, Harvard University, Boston
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Brooks OW, King RM, Nossek E, Marosfoi M, Caroff J, Chueh JY, Puri AS, Gounis MJ. A canine model of mechanical thrombectomy in stroke. J Neurointerv Surg 2019; 11:1243-1248. [DOI: 10.1136/neurintsurg-2019-014969] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 04/20/2019] [Accepted: 04/24/2019] [Indexed: 02/03/2023]
Abstract
PurposeTo develop a preclinical model of stroke with a large vessel occlusion treated with mechanical thrombectomy.Materials and methodsAn ischemic stroke model was created in dogs by the introduction of an autologous clot into the middle cerebral artery (MCA). A microcatheter was navigated to the clot and a stent retriever thrombectomy was performed with the goal to achieve Thrombolysis in Cerebral Ischemia (TICI) 2b/3 reperfusion. Perfusion and diffusion MRI was acquired after clot placement and following thrombectomy to monitor the progression of restricted diffusion as well as changes in ischemia as a result of mechanical thrombectomy. Post-mortem histology was done to confirm MCA territory infarct volume.ResultsInitial MCA occlusion with TICI 0 flow was documented in all six hound-cross dogs entered into the study. TICI 2b/3 revascularization was achieved with one thrombectomy pass in four of six animals (67%). Intra-procedural events including clot autolysis leading to spontaneous revascularization (n=1) and unresolved vasospasm (n=1) accounted for thrombectomy failure. In one case, iatrogenic trauma during microcatheter navigation resulted in a direct arteriovenous fistula at the level of the cavernous carotid. Analysis of MRI indicated that a volume of tissue from the initial perfusion deficit was spared with reperfusion following thrombectomy, and there was also a volume of tissue that infarcted between MRI and ultimate recanalization.ConclusionWe describe a large animal stroke model in which mechanical thrombectomy can be performed. This model may facilitate, in a preclinical setting, optimization of complex multimodal stroke treatment paradigms for clinical translation.
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Malhotra A, Wu X. Letter by Malhotra and Wu Regarding Article, "Advanced Neuroimaging in Stroke Patient Selection for Mechanical Thrombectomy". Stroke 2019; 50:e130. [PMID: 30896370 DOI: 10.1161/strokeaha.119.024825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT
| | - Xiao Wu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT
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Wareham J, Flood R, Phan K, Crossley R, Mortimer A. A systematic review and meta-analysis of observational evidence for the use of bailout self-expandable stents following failed anterior circulation stroke thrombectomy. J Neurointerv Surg 2018; 11:675-682. [PMID: 30415225 DOI: 10.1136/neurintsurg-2018-014459] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 10/18/2018] [Accepted: 10/19/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND The crucial role of thrombectomy in the management of emergent large vessel occlusive stroke is not disputed but there is a technical failure rate in a significant minority of patients whose outcomes are often poor. Our objective was to perform a systematic review and meta-analysis to assess the safety and efficacy of permanent self-expandable stent deployment as a bailout procedure in cases of failed anterior circulation thrombectomy. METHODS Two independent reviewers searched the Pubmed (Medline) database for studies reporting outcomes following failed endovascular thrombectomy with subsequent rescue therapy employing self-expandable stents. RESULTS Eight studies (one prospective, seven retrospective) originating from Europe, Asia, and America comprising 160 patients met the inclusion criteria. Estimated baseline National Institutes of Health Stroke Scale score was 17.1 (95% CI 15.7 to 18.4). Following failed thrombetcomy and stent deployment, the rate of favorable outcome (modified Rankin Scale score 0-2) was 43% (95% CI 34% to 53%). Pooled mortality was 21% (95% CI 13% to 33%). Successful recanalization (Thrombolysis in Cerebral Infarction (TICI) 2b-3 or Thrombolysis in Myocardial Infarction (TIMI) 2-3) was 71% (95% CI 63% to 77%). Symptomatic intracerebral hemorrhage was seen in 12% (95% CI 7% to 18%). The Solitaire stent (Medtronic) was the most commonly deployed stent following failed thrombectomy attempts (66%; 95% CI 31% to 89%). Pre- or post-stent angioplasty was performed in 39%of patients (95% CI 29% to 48%). Glycoprotein IIb/IIIa inhibitors were used in 89% (95% CI 71% to 97%). 95% of patients received postprocedural antiplatelet therapy. CONCLUSION A rescue stent procedure seems reasonable as a last resort following failed thrombectomy but currently the level of evidence is limited. Prospective registries may aid in guiding future recommendations.
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Affiliation(s)
- James Wareham
- Department of Neuroradiology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Richard Flood
- Department of Neuroradiology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Kevin Phan
- NeuroSpine Surgery Research Group (NSURG), Neuro Spine Clinic, Sydney, New South Wales, Australia
| | - Robert Crossley
- Department of Neuroradiology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Alex Mortimer
- Department of Neuroradiology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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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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Sheth SA, Malhotra K, Liebeskind DS, Liang CW, Yoo AJ, Jahan R, Nogueira RG, Pereira V, Gralla J, Albers G, Goyal M, Saver JL. Regional Contributions to Poststroke Disability in Endovascular Therapy. INTERVENTIONAL NEUROLOGY 2018; 7:533-543. [PMID: 30410533 DOI: 10.1159/000492400] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 07/23/2018] [Indexed: 01/19/2023]
Abstract
Background and Purpose The relative contribution of each Alberta Stroke Program Early CT Score (ASPECTS) region to poststroke disability likely varies across regions. Determining the relative weights of each ASPECTS region may improve patient selection for endovascular stroke therapy (EST). Methods In the combined Solitaire Flow Restoration with the Intention for Thrombectomy (SWIFT), Solitaire Flow Restoration Thrombectomy for Acute Revascularization (STAR), and Solitaire Flow Restoration with the Intention for Thrombectomy as Primary Endovascular Treatment (SWIFT PRIME) databases, we identified patients treated with the Solitaire stent retriever. Using 24-h CT scan, a multivariate ordinal regression was used to determine the relative contribution of each ASPECTS region to clinical outcome separately in each hemisphere. The coefficients from the regression were used to create a weighted ASPECTS (wASPECTS), which was compared with the original ASPECTS to predict 90-day modified Rankin Scale disability outcomes in an independent validation cohort. Results Among 342 patients treated with EST, the average age was 67 years, 57% were female, and the median National Institutes of Health Stroke Scale (NIHSS) score was 17 (IQR 13-20). The median ASPECTS at presentation was 8 (IQR 7-10). The most commonly involved ASPECTS regions on 24-h CT were the lentiform nuclei (70%), insula (55%), and caudate (52%). In multivariate analysis, preservation of M6 (β = 9.7) and M4 (β = 4.4) regions in the right hemisphere was most strongly predictive of good outcome. For the left hemisphere, M6 (β = 5.5), M5 (β = 4.1), and M3 (β = 3.1) generated the greatest parameter estimates, though they did not reach statistical significance. A wASPECTS incorporating all 20 parameter estimates resulted in improved discrimination against the original ASPECTS in the independent cohort (C-statistic 0.78 vs. 0.67, right hemisphere). Conclusions For both right and left hemisphere, preservation of the high cortical regions was more strongly associated with improved outcomes compared to the deep regions. Our findings support taking into consideration the location and relative weightings of the involved ASPECTS regions when evaluating a patient for EST.
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Affiliation(s)
- Sunil A Sheth
- Department of Neurology, UT Health McGovern School of Medicine, Houston, Texas, USA
| | - Konark Malhotra
- Department of Neurology, Charleston Area Medical Center, West Virginia University, Charleston, West Virginia, USA
| | - David S Liebeskind
- Department of Neurology and Stroke Center, University of California, Los Angeles, California, USA
| | - Conrad W Liang
- Department of Neurosurgery, Kaiser Permanente, Fontana, California, USA
| | | | - Reza Jahan
- Division of Interventional Neuroradiology, University of California, Los Angeles, California, USA
| | - Raul G Nogueira
- Department of Neurology, Emory University, Atlanta, Georgia, USA
| | - Vitor Pereira
- Divisions of Neuroradiology and Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Greg Albers
- Department of Neurology, Stanford University, Stanford, California, USA
| | - Mayank Goyal
- Diagnostic and Interventional Neuroradiology, University of Calgary, Calgary, Alberta, Canada
| | - Jeffrey L Saver
- Department of Neurology and Stroke Center, University of California, Los Angeles, California, USA
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Boers AMM, Jansen IGH, Beenen LFM, Devlin TG, San Roman L, Heo JH, Ribó M, Brown S, Almekhlafi MA, Liebeskind DS, Teitelbaum J, Lingsma HF, van Zwam WH, Cuadras P, du Mesnil de Rochemont R, Beaumont M, Brown MM, Yoo AJ, van Oostenbrugge RJ, Menon BK, Donnan GA, Mas JL, Roos YBWEM, Oppenheim C, van der Lugt A, Dowling RJ, Hill MD, Davalos A, Moulin T, Agrinier N, Demchuk AM, Lopes DK, Aja Rodríguez L, Dippel DWJ, Campbell BCV, Mitchell PJ, Al-Ajlan FS, Jovin TG, Madigan J, Albers GW, Soize S, Guillemin F, Reddy VK, Bracard S, Blasco J, Muir KW, Nogueira RG, White PM, Goyal M, Davis SM, Marquering HA, Majoie CBLM. Association of follow-up infarct volume with functional outcome in acute ischemic stroke: a pooled analysis of seven randomized trials. J Neurointerv Surg 2018; 10:1137-1142. [DOI: 10.1136/neurintsurg-2017-013724] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 02/26/2018] [Accepted: 03/02/2018] [Indexed: 11/04/2022]
Abstract
BackgroundFollow-up infarct volume (FIV) has been recommended as an early indicator of treatment efficacy in patients with acute ischemic stroke. Questions remain about the optimal imaging approach for FIV measurement.ObjectiveTo examine the association of FIV with 90-day modified Rankin Scale (mRS) score and investigate its dependency on acquisition time and modality.MethodsData of seven trials were pooled. FIV was assessed on follow-up (12 hours to 2 weeks) CT or MRI. Infarct location was defined as laterality and involvement of the Alberta Stroke Program Early CT Score regions. Relative quality and strength of multivariable regression models of the association between FIV and functional outcome were assessed. Dependency of imaging modality and acquisition time (≤48 hours vs >48 hours) was evaluated.ResultsOf 1665 included patients, 83% were imaged with CT. Median FIV was 41 mL (IQR 14–120). A large FIV was associated with worse functional outcome (OR=0.88(95% CI 0.87 to 0.89) per 10 mL) in adjusted analysis. A model including FIV, location, and hemorrhage type best predicted mRS score. FIV of ≥133 mL was highly specific for unfavorable outcome. FIV was equally strongly associated with mRS score for assessment on CT and MRI, even though large differences in volume were present (48 mL (IQR 15–131) vs 22 mL (IQR 8–71), respectively). Associations of both early and late FIV assessments with outcome were similar in strength (ρ=0.60(95% CI 0.56 to 0.64) and ρ=0.55(95% CI 0.50 to 0.60), respectively).ConclusionsIn patients with an acute ischemic stroke due to a proximal intracranial occlusion of the anterior circulation, FIV is a strong independent predictor of functional outcome and can be assessed before 48 hours, oneither CT or MRI.
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Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, McTaggart RA, Torbey MT, Kim-Tenser M, Leslie-Mazwi T, Sarraj A, Kasner SE, Ansari SA, Yeatts SD, Hamilton S, Mlynash M, Heit JJ, Zaharchuk G, Kim S, Carrozzella J, Palesch YY, Demchuk AM, Bammer R, Lavori PW, Broderick JP, Lansberg MG. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. N Engl J Med 2018; 378:708-718. [PMID: 29364767 PMCID: PMC6590673 DOI: 10.1056/nejmoa1713973] [Citation(s) in RCA: 3001] [Impact Index Per Article: 500.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Thrombectomy is currently recommended for eligible patients with stroke who are treated within 6 hours after the onset of symptoms. METHODS We conducted a multicenter, randomized, open-label trial, with blinded outcome assessment, of thrombectomy in patients 6 to 16 hours after they were last known to be well and who had remaining ischemic brain tissue that was not yet infarcted. Patients with proximal middle-cerebral-artery or internal-carotid-artery occlusion, an initial infarct size of less than 70 ml, and a ratio of the volume of ischemic tissue on perfusion imaging to infarct volume of 1.8 or more were randomly assigned to endovascular therapy (thrombectomy) plus standard medical therapy (endovascular-therapy group) or standard medical therapy alone (medical-therapy group). The primary outcome was the ordinal score on the modified Rankin scale (range, 0 to 6, with higher scores indicating greater disability) at day 90. RESULTS The trial was conducted at 38 U.S. centers and terminated early for efficacy after 182 patients had undergone randomization (92 to the endovascular-therapy group and 90 to the medical-therapy group). Endovascular therapy plus medical therapy, as compared with medical therapy alone, was associated with a favorable shift in the distribution of functional outcomes on the modified Rankin scale at 90 days (odds ratio, 2.77; P<0.001) and a higher percentage of patients who were functionally independent, defined as a score on the modified Rankin scale of 0 to 2 (45% vs. 17%, P<0.001). The 90-day mortality rate was 14% in the endovascular-therapy group and 26% in the medical-therapy group (P=0.05), and there was no significant between-group difference in the frequency of symptomatic intracranial hemorrhage (7% and 4%, respectively; P=0.75) or of serious adverse events (43% and 53%, respectively; P=0.18). CONCLUSIONS Endovascular thrombectomy for ischemic stroke 6 to 16 hours after a patient was last known to be well plus standard medical therapy resulted in better functional outcomes than standard medical therapy alone among patients with proximal middle-cerebral-artery or internal-carotid-artery occlusion and a region of tissue that was ischemic but not yet infarcted. (Funded by the National Institute of Neurological Disorders and Stroke; DEFUSE 3 ClinicalTrials.gov number, NCT02586415 .).
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Affiliation(s)
- Gregory W Albers
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Michael P Marks
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Stephanie Kemp
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Soren Christensen
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Jenny P Tsai
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Santiago Ortega-Gutierrez
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Ryan A McTaggart
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Michel T Torbey
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - May Kim-Tenser
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Thabele Leslie-Mazwi
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Amrou Sarraj
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Scott E Kasner
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Sameer A Ansari
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Sharon D Yeatts
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Scott Hamilton
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Michael Mlynash
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Jeremy J Heit
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Greg Zaharchuk
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Sun Kim
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Janice Carrozzella
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Yuko Y Palesch
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Andrew M Demchuk
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Roland Bammer
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Philip W Lavori
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Joseph P Broderick
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
| | - Maarten G Lansberg
- From the Departments of Neurology and Neurological Sciences (G.W.A., S. Kemp, S.C., J.P.T., S.H., M.M., M.G.L.), Diagnostic Radiology (M.P.M., J.J.H., G.Z.), Radiology (R.B.), and Biomedical Data Science (P.W.L.), Stanford University School of Medicine, Stanford, and the Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles (M.K.-T.) - both in California; the Departments of Neurology, Anesthesia, Neurosurgery, and Radiology, University of Iowa, Ames (S.O.-G.); the Departments of Diagnostic Imaging, Neurology, and Neurosurgery, Warren Alpert School of Medicine at Brown University and Rhode Island Hospital, Providence (R.A.M.); the Departments of Neurology and Neurosurgery, Ohio State University, Columbus (M.T.T.), and the University of Cincinnati Gardner Neuroscience Institute and the Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati (J.C., J.P.B.) - both in Ohio; the Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston (T.L.-M.); the Department of Neurology, University of Texas Health Science Center, Houston (A.S.); the Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.); the Departments of Radiology, Neurology, and Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago (S.A.A.); the Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y., Y.Y.P.); the Department of Neurology, New York University School of Medicine, New York (S. Kim); and the Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada (A.M.D.)
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Dekker L, Geraedts VJ, Hund H, Cannegieter SC, Nogueira RG, Goyal M, van den Wijngaard IR. Importance of Reperfusion Status after Intra-Arterial Thrombectomy for Prediction of Outcome in Anterior Circulation Large Vessel Stroke. INTERVENTIONAL NEUROLOGY 2018; 7:137-147. [PMID: 29719551 DOI: 10.1159/000486246] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 11/30/2017] [Indexed: 01/19/2023]
Abstract
Background Reperfusion status after intra-arterial thrombectomy (IAT) is a critical predictor of functional outcome after acute ischemic stroke. However, most prognostic models have not included a detailed assessment of reperfusion status after IAT. Objective The aim of this work was to assess the association between successful reperfusion and clinical outcome. Methods Clinical, radiological, and procedural variables of patients treated with IAT were extracted from our prospective stroke registry. The association with functional outcome using the modified Rankin Scale (mRS) after 3 months was assessed using multivariable logistic regression. An extension of the modified TICI score, eTICI, was used to classify reperfusion status. The prognostic value of reperfusion status after IAT in addition to age, stroke severity, imaging characteristics, treatment with intravenous thrombolysis, and time from symptom onset to the end of IAT was assessed with logistic regression and summarized with receiver operating characteristic curves. Results In total, 119 patients were included (mean age 66 years). In multivariable analysis, age >80 years (OR 6.8, 95% CI 1.2-39.8), NIHSS at presentation >15 (OR 7.3, 95% CI 2.3-23.5), and incomplete reperfusion status (eTICI score <2C; OR 10.3, 95% CI 3.5-30.6) were the strongest predictors of a poor outcome (mRS 3-6). Adding reperfusion status to the model improved the prognostic accuracy (AUC 0.88, 95% CI 0.91-0.94). Our results indicate a large difference between using an eTICI cutoff of ≥2C versus ≥2B: a cutoff ≥2C improved the predictive value for a good clinical outcome (2C: positive predictive value, PPV, 0.78; 2B: PPV 0.32). Conclusion Our results promote using reperfusion status for assessing prognosis in ischemic stroke patients treated with IAT. A model using eTICI ≥2C had greater PPV than eTICI ≥2B and could improve prognostic accuracy.
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Affiliation(s)
- Luuk Dekker
- Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands.,Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Victor J Geraedts
- Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands.,Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hajo Hund
- Department of Radiology, Haaglanden Medical Center, The Hague, the Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mayank Goyal
- Department of Neurosciences, Radiology and Community Health Services, University of Calgary, Calgary, Alberta, Canada
| | - Ido R van den Wijngaard
- Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands.,Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
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39
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Albers GW. Late Window Paradox. Stroke 2018; 49:768-771. [PMID: 29367336 DOI: 10.1161/strokeaha.117.020200] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 12/03/2017] [Accepted: 12/05/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Gregory W Albers
- From the Department of Neurology, Stanford University, Palo Alto, CA.
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Xie Y, Oppenheim C, Guillemin F, Gautheron V, Gory B, Raoult H, Soize S, Felblinger J, Hossu G, Bracard S. Pretreatment lesional volume impacts clinical outcome and thrombectomy efficacy. Ann Neurol 2018; 83:178-185. [DOI: 10.1002/ana.25133] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 12/28/2017] [Accepted: 12/29/2017] [Indexed: 11/12/2022]
Affiliation(s)
- Yu Xie
- IADI, U1254, INSERM, Université de Lorraine, CHRU Nancy; Nancy France
| | - Catherine Oppenheim
- Department of Neuroradiology; Sainte-Anne Hospital and Paris-Descartes University, INSERM U894; Paris France
| | - Francis Guillemin
- CIC 1433 Epidémiologie Clinique, INSERM, Université de Lorraine, CHRU Nancy; Nancy France
| | - Vincent Gautheron
- Department of Neuroradiology; Sainte-Anne Hospital and Paris-Descartes University, INSERM U894; Paris France
| | - Benjamin Gory
- INSERM U1237, “Physiopathology and Imaging for Neurological Disorders (PhIND)”, GIP Cyceron; Caen France
| | - Hélène Raoult
- Department of Neuroradiology; University Hospital of Rennes; Rennes France
| | - Sébastien Soize
- Department of Neuroradiology; University Hospital of Reims; Reims France
| | - Jacques Felblinger
- IADI, U1254, INSERM, Université de Lorraine, CHRU Nancy; Nancy France
- CIC 1433 Innovation Technologique, INSERM, Université de Lorraine, CHRU Nancy; Nancy France
| | - Gabriela Hossu
- CIC 1433 Innovation Technologique, INSERM, Université de Lorraine, CHRU Nancy; Nancy France
| | - Serge Bracard
- IADI, U1254, INSERM, Université de Lorraine, CHRU Nancy; Nancy France
- Department of Diagnostic and Interventional Neuroradiology; CHRU Nancy; Nancy France
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Motyer R, Asadi H, Thornton J, Nicholson P, Kok HK. Current evidence for endovascular therapy in stroke and remaining uncertainties. J Intern Med 2018; 283:2-15. [PMID: 28727192 DOI: 10.1111/joim.12653] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Class 1 level A evidence now supports endovascular thrombectomy as best practice in the management of large vessel occlusion acute ischaemic stroke. However, significant questions pertaining to initial imaging, radiological assessment, patient selection and therapeutic limits remain unanswered. A specific cohort of patients who benefit from endovascular thrombectomy has been established, although current uncertainties regarding selection of those not meeting top-tier evidence criteria may potentially deny certain patients the benefit of intervention. This is of particular relevance in patients presenting in a delayed manner. Whilst superior outcomes are achieved with reduced time to endovascular reperfusion, denying patients intervention based on symptom duration alone may not be appropriate. Advanced understanding of ischaemic stroke pathophysiology supports an individualized approach to patient evaluation, given variance in the rate of ischaemic core progression and the extent of salvageable penumbra. Physiological imaging techniques may therefore be utilized to better inform patient selection for endovascular thrombectomy and evidence suggests that a transition from time-based to tissue-based therapeutic thresholds may be of greater value. Multiple ongoing randomized controlled trials aim to further define the benefit of endovascular thrombectomy and it is hoped that these results will advance, and possibly broaden, patient selection criteria to ensure that maximum benefit from the intervention may be achieved.
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Affiliation(s)
- R Motyer
- Department of Radiology, Interventional Neuroradiology Service, Beaumont Hospital, Dublin, Ireland.,Faculty of Radiologists, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - H Asadi
- Department of Radiology, Interventional Neuroradiology Service, Austin Hospital, Melbourne, VIC, Australia.,Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, VIC, Australia.,Faculty of Health, School of Medicine, Deakin University, Waurn Ponds, VIC, Australia
| | - J Thornton
- Department of Radiology, Interventional Neuroradiology Service, Beaumont Hospital, Dublin, Ireland.,Faculty of Radiologists, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - P Nicholson
- Department of Radiology, Interventional Neuroradiology Service, Beaumont Hospital, Dublin, Ireland.,Faculty of Radiologists, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - H K Kok
- Faculty of Radiologists, Royal College of Surgeons in Ireland, Dublin, Ireland.,Department of Interventional Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Saposnik G, Strbian D. Enlightenment and Challenges Offered by DAWN Trial (DWI or CTP Assessment With Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention With Trevo). Stroke 2017; 49:498-500. [PMID: 29242390 DOI: 10.1161/strokeaha.117.018560] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 11/20/2017] [Accepted: 11/21/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Gustavo Saposnik
- From the Division of Neurology, Department of Medicine and Outcomes and Decision Neuroscience Research Unit, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, ON, Canada (G.S.); Laboratory for Social and Neural Systems Research, Department of Economics, University of Zurich, Switzerland (G.S.); and Department of Neurology, Helsinki University Central Hospital, Finland (D.S.).
| | - Daniel Strbian
- From the Division of Neurology, Department of Medicine and Outcomes and Decision Neuroscience Research Unit, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, ON, Canada (G.S.); Laboratory for Social and Neural Systems Research, Department of Economics, University of Zurich, Switzerland (G.S.); and Department of Neurology, Helsinki University Central Hospital, Finland (D.S.)
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43
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Simonsen CZ, Mikkelsen IK, Karabegovic S, Kristensen PK, Yoo AJ, Andersen G. Predictors of Infarct Growth in Patients with Large Vessel Occlusion Treated with Endovascular Therapy. Front Neurol 2017; 8:574. [PMID: 29163339 PMCID: PMC5670343 DOI: 10.3389/fneur.2017.00574] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 10/13/2017] [Indexed: 11/25/2022] Open
Abstract
Introduction Endovascular therapy (EVT) is now evidence based in anterior circulation stroke caused by large vessel occlusion. Outcome is related to infarct size, but data on predictors of infarct growth is limited. We analyzed our cohort of EVT treated patients primarily selected by magnetic resonance imaging (MRI) to examine predictors of infarct growth and the association between infarct size and outcome. Methods We identified 342 patients with anterior circulation stroke from 2004 to 2014 in our prospectively collected EVT database. Baseline infarct size was available for 281 (measured by MRI) while final infarct size was available for 312 patients. Functional outcome was defined by modified Rankin Score (mRS) after 90 days and good outcome was defined as mRS 0–2. Predictors of infarct growth were examined by regression analysis. Results Successful reperfusion [odds ratio (OR) 0.17, 95% confidence interval (CI) (0.09–0.33)] was the strongest predictor of reduction of infarct growth. Receiving intravenous thrombolysis and a short time span from symptom onset to scanning also reduced infarct growth. Occlusion of the internal carotid artery (ICA) intracranially predicted infarct growth (OR = 7.29, 95% CI: 2.36–22.53). EVT under general anesthesia and having a NIHSS between 10 and 15 were also associated with infarct growth. Discussion Failure of reperfusion resulted in an average infarct growth of approximately 50 ml. Lack of reperfusion generally results in a poor outcome likely due to infarct growth. Occlusion of the intracranial ICA and EVT under general anesthesia predicted infarct growth, while successful reperfusion, getting intraveneous thrombolysis, and a short time span from onset to scan protected against growth. A median infarct size of 52 ml best discriminates between a good and a bad outcome.
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Affiliation(s)
- Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Irene K Mikkelsen
- Center for Functionally Integrative Neuroscience, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Albert J Yoo
- Neuroendovascular Service, Texas Stroke Institute, Dallas, TX, United States
| | - Grethe Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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Jadhav AP, Diener HC, Bonafe A, Pereira VM, Levy EI, Baxter BW, Jovin TG, Nogueira RG, Yavagal DR, Cognard C, Purcell DD, Menon BK, Jahan R, Saver JL, Goyal M. Correlation between Clinical Outcomes and Baseline CT and CT Angiographic Findings in the SWIFT PRIME Trial. AJNR Am J Neuroradiol 2017; 38:2270-2276. [PMID: 29025724 DOI: 10.3174/ajnr.a5406] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 07/19/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Patient selection for endovascular therapy remains a great challenge in clinic practice. We sought to determine the effect of baseline CT and angiography on outcomes in the Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) trial and to identify patients who would benefit from endovascular stroke therapy. MATERIALS AND METHODS The primary end point was a 90-day modified Rankin Scale score of 0-2. Subgroup and classification and regression tree analysis was performed on baseline ASPECTS, site of occlusion, clot length, collateral status, and onset-to-treatment time. RESULTS Smaller baseline infarct (n = 145) (ASPECTS 8-10) was associated with better outcomes in patients treated with thrombectomy versus IV tPA alone (66% versus 41%; rate ratio, 1.62) compared with patients with larger baseline infarcts (n = 44) (ASPECTS 6-7) (42% versus 21%; rate ratio, 1.98). The benefit of thrombectomy over IV tPA alone did not differ significantly by ASPECTS. Stratification by occlusion location also showed benefit with thrombectomy across all groups. Improved outcomes after thrombectomy occurred in patients with clot lengths of ≥8 mm (71% versus 43%; rate ratio, 1.67). Outcomes stratified by collateral status had a benefit with thrombectomy across all groups: none-fair collaterals (33% versus 0%), good collaterals (58% versus 44%), and excellent collaterals (82% versus 28%). Using a 3-level classification and regression tree analysis, we observed optimal outcomes in patients with favorable baseline ASPECTS, complete/near-complete recanalization (TICI 2b/3), and early treatment (mean mRS, 1.35 versus 3.73), while univariate and multivariate logistic regression showed significantly better results in patients with higher ASPECTS. CONCLUSIONS While benefit was seen with endovascular therapy across multiple subgroups, the greatest response was observed in patients with a small baseline core infarct, excellent collaterals, and early treatment.
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Affiliation(s)
- A P Jadhav
- From Department of Neurology and Neurological Surgery (A.P.J., T.G.J.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - H-C Diener
- Department of Neurology (H.-C.D,), University Hospital of University Duisburg-Essen, Essen, Germany
| | - A Bonafe
- Department of Neuroradiology (A.B.), Hôpital Gui-de-Chauliac, Montpellier, France
| | - V M Pereira
- Division of Neuroradiology and Division of Neurosurgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - E I Levy
- Department of Neurosurgery (E.I.L.), State University of New York at Buffalo, Buffalo, New York
| | - B W Baxter
- Department of Radiology (B.W.B.), Erlanger Hospital at University of Tennessee, Chattanooga, Tennessee
| | - T G Jovin
- From Department of Neurology and Neurological Surgery (A.P.J., T.G.J.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - R G Nogueira
- Department of Neurology (R.G.N.), Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - D R Yavagal
- Department of Neurology and Neurosurgery (D.R.Y.), University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida
| | - C Cognard
- Department of Diagnostic and Therapeutic Neuroradiology (C.C.), University Hospital of Toulouse, Toulouse, France
| | - D D Purcell
- BioClinica (D.D.P.), Newark, California.,Department of Radiology (D.D.P.), California Pacific Medical Center, San Francisco, California.,Division of Neuroradiology (D.D.P.), University of California San Francisco, San Francisco, California
| | - B K Menon
- Neurology and Neurosurgery (B.K.M.), University of Calgary, Calgary, Alberta, Canada
| | - R Jahan
- Division of Interventional Neuroradiology (R.J.)
| | - J L Saver
- Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine at the University of California Los Angeles, University of California, Los Angeles, Los Angeles, California
| | - M Goyal
- Departments of Radiology and Clinical Neurosciences (M.G.)
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Ernst M, Boers AM, Aigner A, Berkhemer OA, Yoo AJ, Roos YB, Dippel DW, van der Lugt A, van Oostenbrugge RJ, van Zwam WH, Fiehler J, Marquering HA, Majoie CB. Association of Computed Tomography Ischemic Lesion Location With Functional Outcome in Acute Large Vessel Occlusion Ischemic Stroke. Stroke 2017; 48:2426-2433. [DOI: 10.1161/strokeaha.117.017513] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 06/23/2017] [Accepted: 07/11/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Marielle Ernst
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., J.F.) and Institute of Medical Biometry and Epidemiology (A.A.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Radiology (A.M.M.B., O.A.B., H.A.M., C.B.L.M.M.), Biomedical Engineering and Physics (A.M.M.B., H.A.M.), and Neurology (Y.B.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Robotics and Mechatronics, University of Twente, Enschede, the Netherlands (A.M.M.B.); Division of
| | - Anna M.M. Boers
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., J.F.) and Institute of Medical Biometry and Epidemiology (A.A.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Radiology (A.M.M.B., O.A.B., H.A.M., C.B.L.M.M.), Biomedical Engineering and Physics (A.M.M.B., H.A.M.), and Neurology (Y.B.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Robotics and Mechatronics, University of Twente, Enschede, the Netherlands (A.M.M.B.); Division of
| | - Annette Aigner
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., J.F.) and Institute of Medical Biometry and Epidemiology (A.A.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Radiology (A.M.M.B., O.A.B., H.A.M., C.B.L.M.M.), Biomedical Engineering and Physics (A.M.M.B., H.A.M.), and Neurology (Y.B.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Robotics and Mechatronics, University of Twente, Enschede, the Netherlands (A.M.M.B.); Division of
| | - Olvert A. Berkhemer
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., J.F.) and Institute of Medical Biometry and Epidemiology (A.A.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Radiology (A.M.M.B., O.A.B., H.A.M., C.B.L.M.M.), Biomedical Engineering and Physics (A.M.M.B., H.A.M.), and Neurology (Y.B.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Robotics and Mechatronics, University of Twente, Enschede, the Netherlands (A.M.M.B.); Division of
| | - Albert J. Yoo
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., J.F.) and Institute of Medical Biometry and Epidemiology (A.A.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Radiology (A.M.M.B., O.A.B., H.A.M., C.B.L.M.M.), Biomedical Engineering and Physics (A.M.M.B., H.A.M.), and Neurology (Y.B.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Robotics and Mechatronics, University of Twente, Enschede, the Netherlands (A.M.M.B.); Division of
| | - Yvo B. Roos
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., J.F.) and Institute of Medical Biometry and Epidemiology (A.A.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Radiology (A.M.M.B., O.A.B., H.A.M., C.B.L.M.M.), Biomedical Engineering and Physics (A.M.M.B., H.A.M.), and Neurology (Y.B.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Robotics and Mechatronics, University of Twente, Enschede, the Netherlands (A.M.M.B.); Division of
| | - Diederik W.J. Dippel
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., J.F.) and Institute of Medical Biometry and Epidemiology (A.A.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Radiology (A.M.M.B., O.A.B., H.A.M., C.B.L.M.M.), Biomedical Engineering and Physics (A.M.M.B., H.A.M.), and Neurology (Y.B.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Robotics and Mechatronics, University of Twente, Enschede, the Netherlands (A.M.M.B.); Division of
| | - Aad van der Lugt
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., J.F.) and Institute of Medical Biometry and Epidemiology (A.A.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Radiology (A.M.M.B., O.A.B., H.A.M., C.B.L.M.M.), Biomedical Engineering and Physics (A.M.M.B., H.A.M.), and Neurology (Y.B.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Robotics and Mechatronics, University of Twente, Enschede, the Netherlands (A.M.M.B.); Division of
| | - Robert J. van Oostenbrugge
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., J.F.) and Institute of Medical Biometry and Epidemiology (A.A.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Radiology (A.M.M.B., O.A.B., H.A.M., C.B.L.M.M.), Biomedical Engineering and Physics (A.M.M.B., H.A.M.), and Neurology (Y.B.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Robotics and Mechatronics, University of Twente, Enschede, the Netherlands (A.M.M.B.); Division of
| | - Wim H. van Zwam
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., J.F.) and Institute of Medical Biometry and Epidemiology (A.A.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Radiology (A.M.M.B., O.A.B., H.A.M., C.B.L.M.M.), Biomedical Engineering and Physics (A.M.M.B., H.A.M.), and Neurology (Y.B.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Robotics and Mechatronics, University of Twente, Enschede, the Netherlands (A.M.M.B.); Division of
| | - Jens Fiehler
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., J.F.) and Institute of Medical Biometry and Epidemiology (A.A.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Radiology (A.M.M.B., O.A.B., H.A.M., C.B.L.M.M.), Biomedical Engineering and Physics (A.M.M.B., H.A.M.), and Neurology (Y.B.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Robotics and Mechatronics, University of Twente, Enschede, the Netherlands (A.M.M.B.); Division of
| | - Henk A. Marquering
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., J.F.) and Institute of Medical Biometry and Epidemiology (A.A.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Radiology (A.M.M.B., O.A.B., H.A.M., C.B.L.M.M.), Biomedical Engineering and Physics (A.M.M.B., H.A.M.), and Neurology (Y.B.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Robotics and Mechatronics, University of Twente, Enschede, the Netherlands (A.M.M.B.); Division of
| | - Charles B.L.M. Majoie
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., J.F.) and Institute of Medical Biometry and Epidemiology (A.A.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Radiology (A.M.M.B., O.A.B., H.A.M., C.B.L.M.M.), Biomedical Engineering and Physics (A.M.M.B., H.A.M.), and Neurology (Y.B.R.), Academic Medical Center, Amsterdam, the Netherlands; Department of Robotics and Mechatronics, University of Twente, Enschede, the Netherlands (A.M.M.B.); Division of
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Simpkins AN, Dias C, Norato G, Kim E, Leigh R. Early Change in Stroke Size Performs Best in Predicting Response to Therapy. Cerebrovasc Dis 2017; 44:141-149. [PMID: 28683442 DOI: 10.1159/000477945] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 05/31/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Reliable imaging biomarkers of response to therapy in acute stroke are needed. The final infarct volume and percent of early reperfusion have been used for this purpose. Early fluctuation in stroke size is a recognized phenomenon, but its utility as a biomarker for response to therapy has not been established. This study examined the clinical relevance of early change in stroke volume and compared it with the final infarct volume and percent of early reperfusion in identifying early neurologic improvement (ENI). METHODS Acute stroke patients, enrolled between 2013 and 2014 with serial magnetic resonance imaging (MRI) scans (pretreatment baseline, 2 h post, and 24 h post), who received thrombolysis were included in the analysis. Early change in stroke volume, infarct volume at 24 h on diffusion, and percent of early reperfusion were calculated from the baseline and 2 h MRI scans were compared. ENI was defined as ≥4 point decrease in National Institutes of Health Stroke Scales within 24 h. Logistic regression models and receiver operator characteristics analysis were used to compare the efficacy of 3 imaging biomarkers. RESULTS Serial MRIs of 58 acute stroke patients were analyzed. Early change in stroke volume was significantly associated with ENI by logistic regression analysis (OR 0.93, p = 0.048) and remained significant after controlling for stroke size and severity (OR 0.90, p = 0.032). Thus, for every 1 mL increase in stroke volume, there was a 10% decrease in the odds of ENI, while for every 1 mL decrease in stroke volume, there was a 10% increase in the odds of ENI. Neither infarct volume at 24 h nor percent of early reperfusion were significantly associated with ENI by logistic regression. Receiver-operator characteristic analysis identified early change in stroke volume as the only biomarker of the 3 that performed significantly different than chance (p = 0.03). CONCLUSIONS Early fluctuations in stroke size may represent a more reliable biomarker for response to therapy than the more traditional measures of final infarct volume and percent of early reperfusion.
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Affiliation(s)
- Alexis Nétis Simpkins
- Neuro Vascular Brain Imaging Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
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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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48
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Menjot de Champfleur N, Saver JL, Goyal M, Jahan R, Diener HC, Bonafe A, Levy EI, Pereira VM, Cognard C, Yavagal DR, Albers GW. Efficacy of Stent-Retriever Thrombectomy in Magnetic Resonance Imaging Versus Computed Tomographic Perfusion-Selected Patients in SWIFT PRIME Trial (Solitaire FR With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke). Stroke 2017; 48:1560-1566. [PMID: 28465460 DOI: 10.1161/strokeaha.117.016669] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 03/06/2017] [Accepted: 03/15/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The majority of patients enrolled in SWIFT PRIME trial (Solitaire FR With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke) had computed tomographic perfusion (CTP) imaging before randomization; 34 patients were randomized after magnetic resonance imaging (MRI). METHODS Patients with middle cerebral artery and distal carotid occlusions were randomized to treatment with tPA (tissue-type plasminogen activator) alone or tPA+stentriever thrombectomy. The primary outcome was the distribution of the modified Rankin Scale score at 90 days. Patients with the target mismatch profile for enrollment were identified on MRI and CTP. RESULTS MRI selection was performed in 34 patients; CTP in 139 patients. Baseline National Institutes of Health Stroke Scale score was 17 in both groups. Target mismatch profile was present in 95% (MRI) versus 83% (CTP). A higher percentage of the MRI group was transferred from an outside hospital (P=0.02), and therefore, the time from stroke onset to randomization was longer in the MRI group (P=0.003). Time from emergency room arrival to randomization did not differ in CTP versus MRI-selected patients. Baseline ischemic core volumes were similar in both groups. Reperfusion rates (>90%/TICI [Thrombolysis in Cerebral Infarction] score 3) did not differ in the stentriever-treated patients in the MRI versus CTP groups. The primary efficacy analysis (90-day mRS score) demonstrated a statistically significant benefit in both subgroups (MRI, P=0.02; CTP, P=0.01). Infarct growth was reduced in the stentriever-treated group in both MRI and CTP groups. CONCLUSIONS Time to randomization was significantly longer in MRI-selected patients; however, site arrival to randomization times were not prolonged, and the benefits of endovascular therapy were similar. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01657461.
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Affiliation(s)
- Nicolas Menjot de Champfleur
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Radiology (M.G.) and Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada; 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; Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (A.B., N.M.d.C.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging (V.M.P.) and Department of Surgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.).
| | - Jeffrey L Saver
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Radiology (M.G.) and Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada; 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; Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (A.B., N.M.d.C.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging (V.M.P.) and Department of Surgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Mayank Goyal
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Radiology (M.G.) and Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada; 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; Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (A.B., N.M.d.C.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging (V.M.P.) and Department of Surgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Reza Jahan
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Radiology (M.G.) and Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada; 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; Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (A.B., N.M.d.C.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging (V.M.P.) and Department of Surgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Hans-Christoph Diener
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Radiology (M.G.) and Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada; 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; Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (A.B., N.M.d.C.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging (V.M.P.) and Department of Surgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Alain Bonafe
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Radiology (M.G.) and Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada; 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; Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (A.B., N.M.d.C.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging (V.M.P.) and Department of Surgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Elad I Levy
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Radiology (M.G.) and Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada; 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; Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (A.B., N.M.d.C.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging (V.M.P.) and Department of Surgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Vitor M Pereira
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Radiology (M.G.) and Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada; 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; Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (A.B., N.M.d.C.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging (V.M.P.) and Department of Surgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Christophe Cognard
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Radiology (M.G.) and Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada; 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; Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (A.B., N.M.d.C.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging (V.M.P.) and Department of Surgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Dileep R Yavagal
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Radiology (M.G.) and Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada; 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; Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (A.B., N.M.d.C.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging (V.M.P.) and Department of Surgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Gregory W Albers
- From the Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (G.W.A.); Department of Radiology (M.G.) and Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada; 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; Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (A.B., N.M.d.C.); Department of Neurology, University Hospital of University Duisburg-Essen, Germany (H.-C.D.); Department of Neurosurgery, State University of New York at Buffalo (E.I.L.); Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging (V.M.P.) and Department of Surgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.); and Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
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Bucker A, Boers AM, Bot JC, Berkhemer OA, Lingsma HF, Yoo AJ, van Zwam WH, van Oostenbrugge RJ, van der Lugt A, Dippel DW, Roos YB, Majoie CB, Marquering HA. Associations of Ischemic Lesion Volume With Functional Outcome in Patients With Acute Ischemic Stroke. Stroke 2017; 48:1233-1240. [DOI: 10.1161/strokeaha.116.015156] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 01/26/2017] [Accepted: 02/07/2017] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Ischemic lesion volume (ILV) on noncontrast computed tomography at 1 week can be used as a secondary outcome measure in patients with acute ischemic stroke. Twenty-four–hour ILV on noncontrast computed tomography has greater availability and potentially allows earlier estimation of functional outcome. We aimed to assess lesion growth 24 hours after stroke onset and compare the associations of 24-hour and 1-week ILV with functional outcome.
Methods—
We included 228 patients from MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), who received noncontrast computed tomography at 24-hour and 1-week follow-up on which ILV was measured. Relative and absolute lesion growth was determined. Logistic regression models were constructed either including the 24-hour or including the 1-week ILV. Ordinal and dichotomous (0–2 and 3–6) modified Rankin scale scores were, respectively, used as primary and secondary outcome measures.
Results—
Median ILV was 42 mL (interquartile range, 21–95 mL) and 64 mL (interquartile range: 30–120 mL) at 24 hours and 1 week, respectively. Relative lesion growth exceeding 30% occurred in 121 patients (53%) and absolute lesion growth exceeding 20 mL occurred in 83 patients (36%). Both the 24-hour and 1-week ILVs were similarly significantly associated with functional outcome (both
P
<0.001). In the logistic analyses, the areas under the curve of the receiver–operator characteristic curves were similar: 0.85 (95% confidence interval, 0.80–0.90) and 0.87 (95% confidence interval, 0.82–0.91) for including the 24-hour and 1-week ILV, respectively.
Conclusions—
Growth of ILV is common 24-hour poststroke onset. Nevertheless, the 24-hour ILV proved to be a valuable secondary outcome measure as it is equally strongly associated with functional outcome as the 1-week ILV.
Clinical Trial Registration—
URL:
http://www.isrctn.com
. Unique identifier: ISRCTN10888758.
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Affiliation(s)
- Amber Bucker
- From the Department of Radiology (A.B., A.M.B., O.A.B., C.B.L.M.M., H.A.M.), Department of Biomedical Engineering & Physics (A.B., A.M.B., H.A.M.), and Department of Neurology (Y.B.W.E.M.R.), Academic Medical Center, the Netherlands; Department of Robotics and Mechatronics, University of Twente, the Netherlands (A.M.B.); Department of Radiology, VU Medical Center, the Netherlands (J.C.J.B.); Department of Public Health (H.F.L., D.W.J.D.), Department of Radiology (A.v.d.L.), and Department of
| | - Anna M. Boers
- From the Department of Radiology (A.B., A.M.B., O.A.B., C.B.L.M.M., H.A.M.), Department of Biomedical Engineering & Physics (A.B., A.M.B., H.A.M.), and Department of Neurology (Y.B.W.E.M.R.), Academic Medical Center, the Netherlands; Department of Robotics and Mechatronics, University of Twente, the Netherlands (A.M.B.); Department of Radiology, VU Medical Center, the Netherlands (J.C.J.B.); Department of Public Health (H.F.L., D.W.J.D.), Department of Radiology (A.v.d.L.), and Department of
| | - Joseph C.J. Bot
- From the Department of Radiology (A.B., A.M.B., O.A.B., C.B.L.M.M., H.A.M.), Department of Biomedical Engineering & Physics (A.B., A.M.B., H.A.M.), and Department of Neurology (Y.B.W.E.M.R.), Academic Medical Center, the Netherlands; Department of Robotics and Mechatronics, University of Twente, the Netherlands (A.M.B.); Department of Radiology, VU Medical Center, the Netherlands (J.C.J.B.); Department of Public Health (H.F.L., D.W.J.D.), Department of Radiology (A.v.d.L.), and Department of
| | - Olvert A. Berkhemer
- From the Department of Radiology (A.B., A.M.B., O.A.B., C.B.L.M.M., H.A.M.), Department of Biomedical Engineering & Physics (A.B., A.M.B., H.A.M.), and Department of Neurology (Y.B.W.E.M.R.), Academic Medical Center, the Netherlands; Department of Robotics and Mechatronics, University of Twente, the Netherlands (A.M.B.); Department of Radiology, VU Medical Center, the Netherlands (J.C.J.B.); Department of Public Health (H.F.L., D.W.J.D.), Department of Radiology (A.v.d.L.), and Department of
| | - Hester F. Lingsma
- From the Department of Radiology (A.B., A.M.B., O.A.B., C.B.L.M.M., H.A.M.), Department of Biomedical Engineering & Physics (A.B., A.M.B., H.A.M.), and Department of Neurology (Y.B.W.E.M.R.), Academic Medical Center, the Netherlands; Department of Robotics and Mechatronics, University of Twente, the Netherlands (A.M.B.); Department of Radiology, VU Medical Center, the Netherlands (J.C.J.B.); Department of Public Health (H.F.L., D.W.J.D.), Department of Radiology (A.v.d.L.), and Department of
| | - Albert J. Yoo
- From the Department of Radiology (A.B., A.M.B., O.A.B., C.B.L.M.M., H.A.M.), Department of Biomedical Engineering & Physics (A.B., A.M.B., H.A.M.), and Department of Neurology (Y.B.W.E.M.R.), Academic Medical Center, the Netherlands; Department of Robotics and Mechatronics, University of Twente, the Netherlands (A.M.B.); Department of Radiology, VU Medical Center, the Netherlands (J.C.J.B.); Department of Public Health (H.F.L., D.W.J.D.), Department of Radiology (A.v.d.L.), and Department of
| | - Wim H. van Zwam
- From the Department of Radiology (A.B., A.M.B., O.A.B., C.B.L.M.M., H.A.M.), Department of Biomedical Engineering & Physics (A.B., A.M.B., H.A.M.), and Department of Neurology (Y.B.W.E.M.R.), Academic Medical Center, the Netherlands; Department of Robotics and Mechatronics, University of Twente, the Netherlands (A.M.B.); Department of Radiology, VU Medical Center, the Netherlands (J.C.J.B.); Department of Public Health (H.F.L., D.W.J.D.), Department of Radiology (A.v.d.L.), and Department of
| | - Robert J. van Oostenbrugge
- From the Department of Radiology (A.B., A.M.B., O.A.B., C.B.L.M.M., H.A.M.), Department of Biomedical Engineering & Physics (A.B., A.M.B., H.A.M.), and Department of Neurology (Y.B.W.E.M.R.), Academic Medical Center, the Netherlands; Department of Robotics and Mechatronics, University of Twente, the Netherlands (A.M.B.); Department of Radiology, VU Medical Center, the Netherlands (J.C.J.B.); Department of Public Health (H.F.L., D.W.J.D.), Department of Radiology (A.v.d.L.), and Department of
| | - Aad van der Lugt
- From the Department of Radiology (A.B., A.M.B., O.A.B., C.B.L.M.M., H.A.M.), Department of Biomedical Engineering & Physics (A.B., A.M.B., H.A.M.), and Department of Neurology (Y.B.W.E.M.R.), Academic Medical Center, the Netherlands; Department of Robotics and Mechatronics, University of Twente, the Netherlands (A.M.B.); Department of Radiology, VU Medical Center, the Netherlands (J.C.J.B.); Department of Public Health (H.F.L., D.W.J.D.), Department of Radiology (A.v.d.L.), and Department of
| | - Diederik W.J. Dippel
- From the Department of Radiology (A.B., A.M.B., O.A.B., C.B.L.M.M., H.A.M.), Department of Biomedical Engineering & Physics (A.B., A.M.B., H.A.M.), and Department of Neurology (Y.B.W.E.M.R.), Academic Medical Center, the Netherlands; Department of Robotics and Mechatronics, University of Twente, the Netherlands (A.M.B.); Department of Radiology, VU Medical Center, the Netherlands (J.C.J.B.); Department of Public Health (H.F.L., D.W.J.D.), Department of Radiology (A.v.d.L.), and Department of
| | - Yvo B.W.E.M. Roos
- From the Department of Radiology (A.B., A.M.B., O.A.B., C.B.L.M.M., H.A.M.), Department of Biomedical Engineering & Physics (A.B., A.M.B., H.A.M.), and Department of Neurology (Y.B.W.E.M.R.), Academic Medical Center, the Netherlands; Department of Robotics and Mechatronics, University of Twente, the Netherlands (A.M.B.); Department of Radiology, VU Medical Center, the Netherlands (J.C.J.B.); Department of Public Health (H.F.L., D.W.J.D.), Department of Radiology (A.v.d.L.), and Department of
| | - Charles B.L.M. Majoie
- From the Department of Radiology (A.B., A.M.B., O.A.B., C.B.L.M.M., H.A.M.), Department of Biomedical Engineering & Physics (A.B., A.M.B., H.A.M.), and Department of Neurology (Y.B.W.E.M.R.), Academic Medical Center, the Netherlands; Department of Robotics and Mechatronics, University of Twente, the Netherlands (A.M.B.); Department of Radiology, VU Medical Center, the Netherlands (J.C.J.B.); Department of Public Health (H.F.L., D.W.J.D.), Department of Radiology (A.v.d.L.), and Department of
| | - Henk A. Marquering
- From the Department of Radiology (A.B., A.M.B., O.A.B., C.B.L.M.M., H.A.M.), Department of Biomedical Engineering & Physics (A.B., A.M.B., H.A.M.), and Department of Neurology (Y.B.W.E.M.R.), Academic Medical Center, the Netherlands; Department of Robotics and Mechatronics, University of Twente, the Netherlands (A.M.B.); Department of Radiology, VU Medical Center, the Netherlands (J.C.J.B.); Department of Public Health (H.F.L., D.W.J.D.), Department of Radiology (A.v.d.L.), and Department of
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50
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Millán M, Remollo S, Quesada H, Renú A, Tomasello A, Minhas P, Pérez de la Ossa N, Rubiera M, Llull L, Cardona P, Al-Ajlan F, Hernández M, Assis Z, Demchuk AM, Jovin T, Dávalos A. Vessel Patency at 24 Hours and Its Relationship With Clinical Outcomes and Infarct Volume in REVASCAT Trial (Randomized Trial of Revascularization With Solitaire FR Device Versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting Within Eight Hours of Symptom Onset). Stroke 2017; 48:983-989. [PMID: 28292867 DOI: 10.1161/strokeaha.116.015455] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 12/30/2016] [Accepted: 02/01/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Higher rates of target vessel patency at 24 hours were noted in the thrombectomy group compared with control group in recent randomized trials. As a prespecified secondary end point, we aimed to assess 24-hour revascularization rates by treatment groups and occlusion site as they related to clinical outcome and 24-hour infarct volume in REVASCAT (Randomized Trial of Revascularization With Solitaire FR Device Versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting Within Eight Hours of Symptom Onset). METHODS Independent core laboratory adjudicated vessel status according to modified arterial occlusive lesion classification at 24 hours on computed tomographic/magnetic resonance (94.2%/5.8%) angiography and 24-hour infarct volume on computed tomography were studied (95/103 patients in the thrombectomy group versus 94/103 in the control group, respectively). Complete revascularization was defined as modified arterial occlusive lesion grade 3. Its effect on clinical outcome was analyzed by ordinal logistic regression. RESULTS Complete revascularization was achieved in 70.5% of the solitaire group and in 22.3% of the control group (P<0.001). Significant differences in complete revascularization rates were found for terminus internal carotid artery, M1, and tandem occlusions (all P<0.001) but not for M2 occlusions. In the thrombectomy group, 2 out of 63 patients (3.1%) with modified Thrombolysis in Cerebral Infarction 2b/3 after thrombectomy showed arterial reocclusion (modified arterial occlusive lesion grade 0/1) at 24 hours. Complete revascularization was associated with improved outcome in both thrombectomy (adjusted odds ratio, 4.5; 95% confidence interval, 1.9-10.9) and control groups (adjusted odds ratio, 2.7; 95% confidence interval, 1.0-6.7). Revascularization (modified arterial occlusive lesion grade 2/3) was associated with smaller infarct volumes in either treatment arm. CONCLUSIONS Complete revascularization at 24 hours is a powerful predictor of favorable clinical outcome, whereas revascularization of any type results in reduced infarct volume in both thrombectomy and control groups. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01692379.
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Affiliation(s)
- Mònica Millán
- From the Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Spain (M.M., S.R., N.P.d.l.O., M.H., A.D.); Stroke Unit, Neurology Department, Hospital de Bellvitge, L'Hospitalet de Llobregat (Barcelona), Spain (H.Q., P.C.); Stroke Unit, Neurology Department, Hospital Clínic, Barcelona, Spain (A.R., L.L.); Radiology Department (A.T.) and Stroke Unit, Neurology Department (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Calgary Stroke Program, Hotchkiss Brain Institute, Department of Clinical Neurosciences and Radiology, University of Calgary (P.M., F.A.-A., Z.A., A.M.D.); and Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.).
| | - Sebastià Remollo
- From the Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Spain (M.M., S.R., N.P.d.l.O., M.H., A.D.); Stroke Unit, Neurology Department, Hospital de Bellvitge, L'Hospitalet de Llobregat (Barcelona), Spain (H.Q., P.C.); Stroke Unit, Neurology Department, Hospital Clínic, Barcelona, Spain (A.R., L.L.); Radiology Department (A.T.) and Stroke Unit, Neurology Department (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Calgary Stroke Program, Hotchkiss Brain Institute, Department of Clinical Neurosciences and Radiology, University of Calgary (P.M., F.A.-A., Z.A., A.M.D.); and Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.)
| | - Helena Quesada
- From the Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Spain (M.M., S.R., N.P.d.l.O., M.H., A.D.); Stroke Unit, Neurology Department, Hospital de Bellvitge, L'Hospitalet de Llobregat (Barcelona), Spain (H.Q., P.C.); Stroke Unit, Neurology Department, Hospital Clínic, Barcelona, Spain (A.R., L.L.); Radiology Department (A.T.) and Stroke Unit, Neurology Department (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Calgary Stroke Program, Hotchkiss Brain Institute, Department of Clinical Neurosciences and Radiology, University of Calgary (P.M., F.A.-A., Z.A., A.M.D.); and Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.)
| | - Arturo Renú
- From the Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Spain (M.M., S.R., N.P.d.l.O., M.H., A.D.); Stroke Unit, Neurology Department, Hospital de Bellvitge, L'Hospitalet de Llobregat (Barcelona), Spain (H.Q., P.C.); Stroke Unit, Neurology Department, Hospital Clínic, Barcelona, Spain (A.R., L.L.); Radiology Department (A.T.) and Stroke Unit, Neurology Department (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Calgary Stroke Program, Hotchkiss Brain Institute, Department of Clinical Neurosciences and Radiology, University of Calgary (P.M., F.A.-A., Z.A., A.M.D.); and Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.)
| | - Alejandro Tomasello
- From the Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Spain (M.M., S.R., N.P.d.l.O., M.H., A.D.); Stroke Unit, Neurology Department, Hospital de Bellvitge, L'Hospitalet de Llobregat (Barcelona), Spain (H.Q., P.C.); Stroke Unit, Neurology Department, Hospital Clínic, Barcelona, Spain (A.R., L.L.); Radiology Department (A.T.) and Stroke Unit, Neurology Department (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Calgary Stroke Program, Hotchkiss Brain Institute, Department of Clinical Neurosciences and Radiology, University of Calgary (P.M., F.A.-A., Z.A., A.M.D.); and Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.)
| | - Priyanka Minhas
- From the Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Spain (M.M., S.R., N.P.d.l.O., M.H., A.D.); Stroke Unit, Neurology Department, Hospital de Bellvitge, L'Hospitalet de Llobregat (Barcelona), Spain (H.Q., P.C.); Stroke Unit, Neurology Department, Hospital Clínic, Barcelona, Spain (A.R., L.L.); Radiology Department (A.T.) and Stroke Unit, Neurology Department (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Calgary Stroke Program, Hotchkiss Brain Institute, Department of Clinical Neurosciences and Radiology, University of Calgary (P.M., F.A.-A., Z.A., A.M.D.); and Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.)
| | - Natalia Pérez de la Ossa
- From the Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Spain (M.M., S.R., N.P.d.l.O., M.H., A.D.); Stroke Unit, Neurology Department, Hospital de Bellvitge, L'Hospitalet de Llobregat (Barcelona), Spain (H.Q., P.C.); Stroke Unit, Neurology Department, Hospital Clínic, Barcelona, Spain (A.R., L.L.); Radiology Department (A.T.) and Stroke Unit, Neurology Department (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Calgary Stroke Program, Hotchkiss Brain Institute, Department of Clinical Neurosciences and Radiology, University of Calgary (P.M., F.A.-A., Z.A., A.M.D.); and Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.)
| | - Marta Rubiera
- From the Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Spain (M.M., S.R., N.P.d.l.O., M.H., A.D.); Stroke Unit, Neurology Department, Hospital de Bellvitge, L'Hospitalet de Llobregat (Barcelona), Spain (H.Q., P.C.); Stroke Unit, Neurology Department, Hospital Clínic, Barcelona, Spain (A.R., L.L.); Radiology Department (A.T.) and Stroke Unit, Neurology Department (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Calgary Stroke Program, Hotchkiss Brain Institute, Department of Clinical Neurosciences and Radiology, University of Calgary (P.M., F.A.-A., Z.A., A.M.D.); and Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.)
| | - Laura Llull
- From the Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Spain (M.M., S.R., N.P.d.l.O., M.H., A.D.); Stroke Unit, Neurology Department, Hospital de Bellvitge, L'Hospitalet de Llobregat (Barcelona), Spain (H.Q., P.C.); Stroke Unit, Neurology Department, Hospital Clínic, Barcelona, Spain (A.R., L.L.); Radiology Department (A.T.) and Stroke Unit, Neurology Department (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Calgary Stroke Program, Hotchkiss Brain Institute, Department of Clinical Neurosciences and Radiology, University of Calgary (P.M., F.A.-A., Z.A., A.M.D.); and Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.)
| | - Pedro Cardona
- From the Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Spain (M.M., S.R., N.P.d.l.O., M.H., A.D.); Stroke Unit, Neurology Department, Hospital de Bellvitge, L'Hospitalet de Llobregat (Barcelona), Spain (H.Q., P.C.); Stroke Unit, Neurology Department, Hospital Clínic, Barcelona, Spain (A.R., L.L.); Radiology Department (A.T.) and Stroke Unit, Neurology Department (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Calgary Stroke Program, Hotchkiss Brain Institute, Department of Clinical Neurosciences and Radiology, University of Calgary (P.M., F.A.-A., Z.A., A.M.D.); and Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.)
| | - Fahad Al-Ajlan
- From the Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Spain (M.M., S.R., N.P.d.l.O., M.H., A.D.); Stroke Unit, Neurology Department, Hospital de Bellvitge, L'Hospitalet de Llobregat (Barcelona), Spain (H.Q., P.C.); Stroke Unit, Neurology Department, Hospital Clínic, Barcelona, Spain (A.R., L.L.); Radiology Department (A.T.) and Stroke Unit, Neurology Department (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Calgary Stroke Program, Hotchkiss Brain Institute, Department of Clinical Neurosciences and Radiology, University of Calgary (P.M., F.A.-A., Z.A., A.M.D.); and Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.)
| | - María Hernández
- From the Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Spain (M.M., S.R., N.P.d.l.O., M.H., A.D.); Stroke Unit, Neurology Department, Hospital de Bellvitge, L'Hospitalet de Llobregat (Barcelona), Spain (H.Q., P.C.); Stroke Unit, Neurology Department, Hospital Clínic, Barcelona, Spain (A.R., L.L.); Radiology Department (A.T.) and Stroke Unit, Neurology Department (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Calgary Stroke Program, Hotchkiss Brain Institute, Department of Clinical Neurosciences and Radiology, University of Calgary (P.M., F.A.-A., Z.A., A.M.D.); and Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.)
| | - Zarina Assis
- From the Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Spain (M.M., S.R., N.P.d.l.O., M.H., A.D.); Stroke Unit, Neurology Department, Hospital de Bellvitge, L'Hospitalet de Llobregat (Barcelona), Spain (H.Q., P.C.); Stroke Unit, Neurology Department, Hospital Clínic, Barcelona, Spain (A.R., L.L.); Radiology Department (A.T.) and Stroke Unit, Neurology Department (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Calgary Stroke Program, Hotchkiss Brain Institute, Department of Clinical Neurosciences and Radiology, University of Calgary (P.M., F.A.-A., Z.A., A.M.D.); and Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.)
| | - Andrew M Demchuk
- From the Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Spain (M.M., S.R., N.P.d.l.O., M.H., A.D.); Stroke Unit, Neurology Department, Hospital de Bellvitge, L'Hospitalet de Llobregat (Barcelona), Spain (H.Q., P.C.); Stroke Unit, Neurology Department, Hospital Clínic, Barcelona, Spain (A.R., L.L.); Radiology Department (A.T.) and Stroke Unit, Neurology Department (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Calgary Stroke Program, Hotchkiss Brain Institute, Department of Clinical Neurosciences and Radiology, University of Calgary (P.M., F.A.-A., Z.A., A.M.D.); and Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.)
| | - Tudor Jovin
- From the Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Spain (M.M., S.R., N.P.d.l.O., M.H., A.D.); Stroke Unit, Neurology Department, Hospital de Bellvitge, L'Hospitalet de Llobregat (Barcelona), Spain (H.Q., P.C.); Stroke Unit, Neurology Department, Hospital Clínic, Barcelona, Spain (A.R., L.L.); Radiology Department (A.T.) and Stroke Unit, Neurology Department (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Calgary Stroke Program, Hotchkiss Brain Institute, Department of Clinical Neurosciences and Radiology, University of Calgary (P.M., F.A.-A., Z.A., A.M.D.); and Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.)
| | - Antoni Dávalos
- From the Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Spain (M.M., S.R., N.P.d.l.O., M.H., A.D.); Stroke Unit, Neurology Department, Hospital de Bellvitge, L'Hospitalet de Llobregat (Barcelona), Spain (H.Q., P.C.); Stroke Unit, Neurology Department, Hospital Clínic, Barcelona, Spain (A.R., L.L.); Radiology Department (A.T.) and Stroke Unit, Neurology Department (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Calgary Stroke Program, Hotchkiss Brain Institute, Department of Clinical Neurosciences and Radiology, University of Calgary (P.M., F.A.-A., Z.A., A.M.D.); and Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, PA (T.J.)
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