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Rosso C, Belkacem S, Amor-Sahli M, Clarençon F, Leger A, Baronnet F, Dormont D, Alamowitch S, Lehericy S, Samson Y. Persistent perfusion abnormalities at day 1 correspond to different clinical trajectories after stroke. J Neurointerv Surg 2023; 15:e26-e32. [PMID: 35701108 DOI: 10.1136/neurintsurg-2022-018953] [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: 03/24/2022] [Accepted: 06/01/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Perfusion abnormalities after thrombolysis are frequent within and surrounding ischemic lesions, but their relative frequency is not well known. OBJECTIVE To describe the different patterns of perfusion abnormalities observed at 24 hours and compare the characteristics of the patients according to their perfusion pattern. METHODS From our thrombolysis registry, we included 226 consecutive patients with an available arterial spin labeling (ASL) perfusion sequence at day 1. We performed a blinded assessment of the perfusion status (hypoperfusion-h, hyperperfusion-H, or normal-N) in the ischemic lesion and in the surrounding tissue. We compared the time course of clinical recovery, the rate of arterial recanalization, and hemorrhagic transformations in the different perfusion profiles. RESULTS We identified seven different perfusion profiles at day 1. Four of these (h/h, h/H, H/H, and H/N) represented the majority of the population (84.1%). The H/H profile was the most frequent (34.5%) and associated with 3-month good outcome (modified Rankin Scale (mRS): 63.5%). Patients with persistent hypoperfusion within and outside the lesion (h/h, 12.4%) exhibited worse outcomes after treatment (mRS score 0-2: 23.8%) than other patients, were less frequently recanalized (40.7%), and had more parenchymal hematoma (17.8%). The h/H profile had an intermediate clinical trajectory between the h/h profile and the hyperperfused profiles. CONCLUSION ASL hypoperfusion within the infarct and the surrounding tissue was associated with poor outcome. A more comprehensive view of the mechanisms in the hypoperfused surrounding tissue could help to design new therapeutic approaches during and after reperfusion therapies.
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Affiliation(s)
- Charlotte Rosso
- APHP-Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
- Inserm U 1127, CNRS UMR 7225, Sorbonne Université, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
| | - Samia Belkacem
- APHP-Neuroradiology Department, Hôpital Pitié-Salpêtrière, Paris, France
| | - Mélika Amor-Sahli
- APHP-Neuroradiology Department, Hôpital Pitié-Salpêtrière, Paris, France
| | - Frédéric Clarençon
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
- APHP-Interventional Neuroradiology Department, Hôpital Pitié-Salpêtrière, Paris, France
| | - Anne Leger
- APHP-Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
| | - Flore Baronnet
- APHP-Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
| | - Didier Dormont
- Inserm U 1127, CNRS UMR 7225, Sorbonne Université, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
- APHP-Neuroradiology Department, Hôpital Pitié-Salpêtrière, Paris, France
| | - Sonia Alamowitch
- APHP-Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
| | - Stéphane Lehericy
- Inserm U 1127, CNRS UMR 7225, Sorbonne Université, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
- APHP-Neuroradiology Department, Hôpital Pitié-Salpêtrière, Paris, France
| | - Yves Samson
- APHP-Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
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Bouslama M, Baig AA, Raygor KP, Turner RC, Kuo CC, Donnelly BM, Lim J, Monteiro A, Jaikumar V, Lai PMR, Davies JM, Snyder KV, Levy EI, Siddiqui AH. Mechanical thrombectomy in low Alberta Stroke Program Early Computed Tomographic Score: A systematic review and meta-analysis of randomized controlled trials. Interv Neuroradiol 2023:15910199231193464. [PMID: 37574930 DOI: 10.1177/15910199231193464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND Due to their poor natural history and lack in level-I evidence, patients with large vessel occlusion and large core infarcts (Alberta Stroke Program Early Computed Tomographic Score <6) have been excluded from receiving mechanical thrombectomy. This systematic review and meta-analysis seeks to summarize current evidence from published randomized controlled trials to compare the safety and efficacy of mechanical thrombectomy with optimal medical therapy in treating stroke patients with large core infarcts. METHODS We searched PubMed and EMBASE for randomized controlled trials investigating the safety and efficacy of mechanical thrombectomy vs optimal medical therapy in patients presenting with large vessel occlusion and large infarcts. Basic demographic and comorbidities were assessed, and clinical outcomes were compared, including modified Rankin scale 0-3, and 0-2 at 3 months, symptomatic intracranial hemorrhage, decompressive hemicortectomy, and 90-day mortality. RESULTS Three randomized controlled trials totaling 1011 patients (501 and 510 in the medical management and mechanical thrombectomy arm, respectively) were included. Patients undergoing mechanical thrombectomy had significantly higher odds of achieving better functional outcomes at 3 months: Modified Rankin scale 0-2 (OR = 3.05, 95% CI = 2.101-4.4021, p < 0.0001) and modified Rankin scale 0-3 (OR = 2.20, 95% CI = 1.67-2.89, p < 0.0001) as compared to those receiving optimal medical management. There were no differences between groups in 90-day mortality (OR = 0.93, 95% CI = 0.70-1.23, p = 0.60), symptomatic intracranial hemorrhage (OR = 1.89, 95% = CI 0.95-3.77, p = 0.07) or decompressive hemicraniectomy (OR = 1.25, 95% CI = 0.69-2.25, p = 0.46). CONCLUSION Mechanical thrombectomy for patients with large infarcts is associated with improved functional outcomes and a similar safety profile compared to optimal medical management. Ongoing trials will help better refine the target population that benefits the most from treatment.
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Affiliation(s)
- Mehdi Bouslama
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Ammad A Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Kunal P Raygor
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Ryan C Turner
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Brianna M Donnelly
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Jaims Lim
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Vinay Jaikumar
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Pui M R Lai
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
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3
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Sun H, Wu Y, Liu N, Long M, Liu G, Sun PZ, Yin J. Tissue perfusion of the kurtosis/diffusion mismatch differs from the central core and peripheral regions in acute cerebral infarction patients. Acta Radiol 2023; 64:1155-1165. [PMID: 35765208 DOI: 10.1177/02841851221109678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite its wide adoption in stroke imaging, the diffusion-weighted imaging (DWI) lesion is heterogeneous. The emerging diffusion kurtosis imaging (DKI) has been postulated to resolve the graded DWI lesion. PURPOSE To determine the perfusion characteristics of the central infarction core, kurtosis/diffusion mismatch, and peripheral regions. MATERIAL AND METHODS Patients with acute ischemic stroke underwent DWI, DKI, and perfusion-weighted imaging (PWI) scans. The patients were divided into mean kurtosis (MK)/mean diffusivity (MD) match and mismatch groups. Perfusion parameters were measured in the MK/MD lesion and peripheral areas in the MK/MD match group. We also analyzed perfusion status in the MK/MD lesion mismatch area for the mismatch group. RESULTS A total of 40 eligible patients (24 MK/MD match and 16 MK/MD mismatch) were enrolled in the final data analysis. The MTT and TTP progressively decreased, while the cerebral blood flow (CBF) and cerebral blood volume (CBV) increased from the central to peripheral areas. In addition, CBF in the MK/MD mismatch region was significantly higher than that in the central region (P < 0.05), but similar to the peripheral region. Furthermore, CBV in the MK/MD mismatch region did not differ significantly from that of the central region, but both were significantly lower than that of the peripheral area (P < 0.05). CONCLUSION The MK/MD mismatch region had blood flow similar to the peripheral region but with a reduced blood volume, indicating that it was less ischemic from the infarction core, albeit insufficient collateral circulation.
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Affiliation(s)
- Haizhen Sun
- Department of Radiology, Tianjin Medical University Chu Hsien-I Memorial Hospital & Tianjin Institute of Endocrinology, Tianjin, PR China
- NHC Key Laboratory of Hormones and Development (Tianjin Medical University), Tianjin Key Laboratory of Metabolic Diseases, Tianjin, PR China
| | - Yalin Wu
- The First Central Clinical College of Tianjin Medical University, Tianjin, PR China
| | - Na Liu
- The First Central Clinical College of Tianjin Medical University, Tianjin, PR China
| | - Miaomiao Long
- Department of Radiology, 66571Tianjin First Central Hospital, Tianjin Medical Imaging Institution, Tianjin, PR China
| | - Guoping Liu
- Department of Neurology, 66571Tianjin First Central Hospital, Tianjin, PR China
| | - Phillip Zhe Sun
- Yerkes Imaging Center, Yerkes National Primate Research Center, Emory University, Atlanta, GA, USA
- Department of Radiology and Imaging Sciences, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Jianzhong Yin
- Department of Radiology, 66571Tianjin First Central Hospital, Tianjin Medical Imaging Institution, Tianjin, PR China
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4
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Panni P, Lapergue B, Maïer B, Finitsis S, Clarençon F, Richard S, Marnat G, Bourcier R, Sibon I, Dargazanli C, Blanc R, Consoli A, Eugène F, Vannier S, Spelle L, Denier C, Boulanger M, Gauberti M, Saleme S, Macian F, Rosso C, Naggara O, Turc G, Ozkul-Wermester O, Papagiannaki C, Albucher JF, Darcourt J, Le Bras A, Evain S, Wolff V, Pop R, Timsit S, Gentric JC, Bourdain F, Veunac L, Arquizan C, Gory B. Clinical Impact and Predictors of Diffusion Weighted Imaging (DWI) Reversal in Stroke Patients with Diffusion Weighted Imaging Alberta Stroke Program Early CT Score 0-5 Treated by Thrombectomy : Diffusion Weighted Imaging Reversal in Large Volume Stroke. Clin Neuroradiol 2022; 32:939-950. [PMID: 35412044 DOI: 10.1007/s00062-022-01156-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: 01/08/2022] [Accepted: 03/02/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE To determine whether reversal of DWI lesions (DWIr) on the DWI-ASPECTS (diffusion weighted imaging Alberta Stroke Program CT Score) template should serve as a predictor of 90-day clinical outcome in acute ischemic stroke (AIS) patients with pretreatment diffusion-weighted imaging (DWI)-ASPECTS 0-5 treated with thrombectomy, and to determine its predictors in current practice. METHODS We analyzed data of all consecutive patients included in the prospective multicenter national Endovascular Treatment in Ischemic Stroke Registry between 1 January 2015 and 31 December 2020 with a premorbid mRS ≤ 2, who presented with a pretreatment DWI-ASPECTS 0-5 score, underwent thrombectomy and had an available 24 h post-interventional MRI follow-up. Multivariable analyses were performed to evaluate the clinical impact of DWIr on early neurological improvement (ENI), 3‑month modified Rankin scale (mRS) score distribution (shift analysis) and to define independent predictors of DWIr. RESULTS Early neurological improvement was detected in 82/211 (41.7%) of patients while 3‑month functional independence was achieved by 75 (35.5%) patients. The DWI reversal (39/211, 18.9%) resulted an independent predictor of both ENI (aOR 3.6, 95% CI 1.2-7.7; p 0.018) and 3‑month clinical outcome (aOR for mRS shift: 2.2, 95% CI 1-4.6; p 0.030). Only successful recanalization (mTICI 2c-3) independently predicted DWIr in the studied population (aOR 3.3, 95% CI 1.3-7.9; p 0.009). CONCLUSION The DWI reversal occurs in a non-negligible proportion of DWI-ASPECTS 0-5 patients subjected to thrombectomy and significantly influences clinical outcome. The mTICI 2c-3 recanalization emerged as an independent DWIr predictor.
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Affiliation(s)
- Pietro Panni
- Department of Neuroradiology, Division of Interventional Neuroradiology, Department of Neurosurgery, San Raffaele University Hospital, Milan, Italy.
| | - Bertrand Lapergue
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - Benjamin Maïer
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Stephanos Finitsis
- AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Sébastien Richard
- CHRU-Nancy, Department of Neurology, Stroke Unit, Université de Lorraine, 54000, Nancy, France.,CIC-P 1433, INSERM U1116, CHRU-Nancy, 54000, Nancy, France
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Romain Bourcier
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Igor Sibon
- Neurology, University Hospital of Bordeaux, Bordeaux, France
| | - Cyril Dargazanli
- Department of Interventional Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | - Raphaël Blanc
- Department of Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Arturo Consoli
- Diagnostic and Interventional Neuroradiology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - François Eugène
- Department of Neuroradiology, University Hospital of Rennes, Rennes, France
| | | | | | | | | | | | | | | | - Charlotte Rosso
- Department of Neurology, CHU Pitié-Salpétrière, Paris, France
| | | | - Guillaume Turc
- Department of Neurology, Hôpital Saint-Anne, Paris, France
| | | | | | | | | | - Anthony Le Bras
- Department of Neuroradiology, CHBA Bretagne Atlantique, Vannes, France
| | - Sarah Evain
- Neurology, CHBA Bretagne Atlantique, Vannes, France
| | - Valérie Wolff
- Department of Neurology, CHU Strasbourg, Strasbourg, France
| | - Raoul Pop
- Neuroradiology, CHU Strasbourg, Strasbourg, France
| | - Serge Timsit
- Department of Neurology, CHU Brest, Brest, France
| | | | | | | | | | - Benjamin Gory
- CHRU-Nancy, Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, 54000, Nancy, France.,IADI, INSERM U1254, Université de Lorraine, 54000, Nancy, France
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Cheung J, Doerr M, Hu R, Sun PZ. Refined Ischemic Penumbra Imaging with Tissue pH and Diffusion Kurtosis Magnetic Resonance Imaging. Transl Stroke Res 2021; 12:742-753. [PMID: 33159656 PMCID: PMC8102648 DOI: 10.1007/s12975-020-00868-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 10/14/2020] [Accepted: 10/18/2020] [Indexed: 12/19/2022]
Abstract
Imaging has played a vital role in our mechanistic understanding of acute ischemia and the management of acute stroke patients. The most recent DAWN and DEFUSE-3 trials showed that endovascular therapy could be extended to a selected group of late-presenting stroke patients with the aid of imaging. Although perfusion and diffusion MRI have been commonly used in stroke imaging, the approximation of their mismatch as the penumbra is oversimplified, particularly in the era of endovascular therapy. Briefly, the hypoperfusion lesion includes the benign oligemia that does not proceed to infarction. Also, with prompt and effective reperfusion therapy, a portion of the diffusion lesion is potentially reversible. Therefore, advanced imaging that provides improved ischemic tissue characterization may enable new experimental stroke therapeutics and eventually further individualize stroke treatment upon translation to the clinical setting. Specifically, pH imaging captures tissue of altered metabolic state that demarcates the hypoperfused lesion into ischemic penumbra and benign oligemia, which remains promising to define the ischemic penumbra's outer boundary. On the other hand, diffusion kurtosis imaging (DKI) differentiates the most severely damaged and irreversibly injured diffusion lesion from the portion of diffusion lesion that is potentially reversible, refining the inner boundary of the penumbra. Altogether, the development of advanced imaging has the potential to not only transform the experimental stroke research but also aid clinical translation and patient management.
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Affiliation(s)
- Jesse Cheung
- Emory College of Arts and Sciences, Emory University, Atlanta, GA, 30329, USA
- Yerkes Imaging Center, Yerkes National Primate Research Center, Emory University, Atlanta, GA, 30329, USA
| | - Madeline Doerr
- Yerkes Imaging Center, Yerkes National Primate Research Center, Emory University, Atlanta, GA, 30329, USA
- Dartmouth College, Hanover, NH, 03755, USA
| | - Ranliang Hu
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton RD NE, Atlanta, GA, 30322, USA
| | - Phillip Zhe Sun
- Yerkes Imaging Center, Yerkes National Primate Research Center, Emory University, Atlanta, GA, 30329, USA.
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton RD NE, Atlanta, GA, 30322, USA.
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6
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Seners P, Oppenheim C, Turc G, Albucher JF, Guenego A, Raposo N, Christensen S, Calvière L, Viguier A, Darcourt J, Januel AC, Mlynash M, Sommet A, Thalamas C, Sibon I, Rousseau V, Tourdias T, Menegon P, Bonneville F, Mazighi M, Charron S, Legrand L, Cognard C, Albers GW, Baron JC, Olivot JM. Perfusion Imaging and Clinical Outcome in Acute Ischemic Stroke with Large Core. Ann Neurol 2021; 90:417-427. [PMID: 34216396 DOI: 10.1002/ana.26152] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/28/2021] [Accepted: 06/28/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Mechanical thrombectomy (MT) is not recommended for acute stroke with large vessel occlusion (LVO) and a large volume of irreversibly injured tissue ("core"). Perfusion imaging may identify a subset of patients with large core who benefit from MT. METHODS We compared two cohorts of LVO-related patients with large core (>50 ml on diffusion-weighted-imaging or CT-perfusion using RAPID), available perfusion imaging, and treated within 6 hours from onset by either MT + Best Medical Management (BMM) in one prospective study, or BMM alone in the pre-MT era from a prospective registry. Primary outcome was 90-day modified Rankin Scale ≤2. We searched for an interaction between treatment group and amount of penumbra as estimated by the mismatch ratio (MMRatio = critical hypoperfusion/core volume). RESULTS Overall, 107 patients were included (56 MT + BMM and 51 BMM): Mean age was 68 ± 15 years, median core volume 99 ml (IQR: 72-131) and MMRatio 1.4 (IQR: 1.0-1.9). Baseline clinical and radiological variables were similar between the two groups, except for a higher intravenous thrombolysis rate in the BMM group. The MMRatio strongly modified the clinical outcome following MT (pinteraction < 0.001 for continuous MMRatio); MT was associated with a higher rate of good outcome in patients with, but not in those without, MMRatio>1.2 (adjusted OR [95% CI] = 6.8 [1.7-27.0] vs 0.7 [0.1-6.2], respectively). Similar findings were present for MMRatio ≥1.8 in the subgroup with core ≥70 ml. Parenchymal hemorrhage on follow-up imaging was more frequent in the MT + BMM group regardless of the MMRatio. INTERPRETATION Perfusion imaging may help select which patients with large core should be considered for MT. Randomized studies are warranted. ANN NEUROL 2021.
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Affiliation(s)
- Pierre Seners
- Neurology Department, GHU Paris Psychiatrie et Neurosciences, Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
- Neurology Department, Hôpital Fondation A. de Rothschild, Paris, France
| | - Catherine Oppenheim
- Radiology Department, GHU Paris Psychiatrie et Neurosciences, Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
| | - Guillaume Turc
- Neurology Department, GHU Paris Psychiatrie et Neurosciences, Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
| | - Jean-François Albucher
- Acute Stroke Unit, Hôpital Pierre-Paul Riquet, Centre Hospitalier Universitaire de Toulouse and Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Adrien Guenego
- Department of Neuroradiology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Nicolas Raposo
- Acute Stroke Unit, Hôpital Pierre-Paul Riquet, Centre Hospitalier Universitaire de Toulouse and Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | | | - Lionel Calvière
- Acute Stroke Unit, Hôpital Pierre-Paul Riquet, Centre Hospitalier Universitaire de Toulouse and Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Alain Viguier
- Acute Stroke Unit, Hôpital Pierre-Paul Riquet, Centre Hospitalier Universitaire de Toulouse and Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Jean Darcourt
- Department of Neuroradiology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Anne-Christine Januel
- Department of Neuroradiology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | | | - Agnes Sommet
- Clinical Investigation Center, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Claire Thalamas
- Clinical Investigation Center, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Igor Sibon
- Unité Neurovasculaire, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Vanessa Rousseau
- Clinical Investigation Center, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Thomas Tourdias
- Department of Neuroradiology, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Patrice Menegon
- Department of Neuroradiology, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Fabrice Bonneville
- Department of Neuroradiology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Hôpital Fondation A. de Rothschild, Paris, France
| | - Sylvain Charron
- Radiology Department, GHU Paris Psychiatrie et Neurosciences, Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
| | - Laurence Legrand
- Radiology Department, GHU Paris Psychiatrie et Neurosciences, Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
| | - Christophe Cognard
- Department of Neuroradiology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | | | - Jean-Claude Baron
- Neurology Department, GHU Paris Psychiatrie et Neurosciences, Institut de Psychiatrie et Neurosciences de Paris (IPNP), INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
| | - Jean-Marc Olivot
- Acute Stroke Unit, Hôpital Pierre-Paul Riquet, Centre Hospitalier Universitaire de Toulouse and Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
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Nagaraja N. Diffusion weighted imaging in acute ischemic stroke: A review of its interpretation pitfalls and advanced diffusion imaging application. J Neurol Sci 2021; 425:117435. [PMID: 33836457 DOI: 10.1016/j.jns.2021.117435] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 03/08/2021] [Accepted: 04/02/2021] [Indexed: 12/28/2022]
Abstract
Diffusion weighted imaging (DWI) is a widely used imaging technique to evaluate patients with stroke. It can detect brain ischemia within minutes of stroke onset. However, DWI has few potential pitfalls that should be recognized during interpretation. DWI lesion could be reversible in the early hours of stroke and the entire lesion may not represent ischemic core. False negative DWI could lead to diagnosis of DWI negative stroke or to a missed stroke diagnosis. Ischemic stroke mimics can occur on DWI with non-cerebrovascular neurological conditions. In this article, the history of DWI, its clinical applications, and potential pitfalls for use in acute ischemic stroke are reviewed. Advanced diffusion imaging techniques with reference to Diffusion Kurtosis Imaging and Diffusion Tensor Imaging that has been studied to evaluate ischemic core are discussed.
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Affiliation(s)
- Nandakumar Nagaraja
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.
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8
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Candelario-Jalil E, Paul S. Impact of aging and comorbidities on ischemic stroke outcomes in preclinical animal models: A translational perspective. Exp Neurol 2021; 335:113494. [PMID: 33035516 PMCID: PMC7874968 DOI: 10.1016/j.expneurol.2020.113494] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/25/2020] [Accepted: 10/02/2020] [Indexed: 12/16/2022]
Abstract
Ischemic stroke is a highly complex and devastating neurological disease. The sudden loss of blood flow to a brain region due to an ischemic insult leads to severe damage to that area resulting in the formation of an infarcted tissue, also known as the ischemic core. This is surrounded by the peri-infarct region or penumbra that denotes the functionally impaired but potentially salvageable tissue. Thus, the penumbral tissue is the main target for the development of neuroprotective strategies to minimize the extent of ischemic brain damage by timely therapeutic intervention. Given the limitations of reperfusion therapies with recombinant tissue plasminogen activator or mechanical thrombectomy, there is high enthusiasm to combine reperfusion therapy with neuroprotective strategies to further reduce the progression of ischemic brain injury. Till date, a large number of candidate neuroprotective drugs have been identified as potential therapies based on highly promising results from studies in rodent ischemic stroke models. However, none of these interventions have shown therapeutic benefits in stroke patients in clinical trials. In this review article, we discussed the urgent need to utilize preclinical models of ischemic stroke that more accurately mimic the clinical conditions in stroke patients by incorporating aged animals and animal stroke models with comorbidities. We also outlined the recent findings that highlight the significant differences in stroke outcome between young and aged animals, and how major comorbid conditions such as hypertension, diabetes, obesity and hyperlipidemia dramatically increase the vulnerability of the brain to ischemic damage that eventually results in worse functional outcomes. It is evident from these earlier studies that including animal models of aging and comorbidities during the early stages of drug development could facilitate the identification of neuroprotective strategies with high likelihood of success in stroke clinical trials.
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Affiliation(s)
- Eduardo Candelario-Jalil
- Department of Neuroscience, McKnight Brain Institute, University of Florida, Gainesville, FL 32610, USA.
| | - Surojit Paul
- Department of Neurology, University of New Mexico Health Sciences Center, Albuquerque, NM 87131, USA
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9
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Yoshimoto T, Inoue M, Tanaka K, Kanemaru K, Koge J, Shiozawa M, Kamogawa N, Kimura S, Chiba T, Satow T, Takahashi JC, Toyoda K, Koga M, Ihara M. Identifying large ischemic core volume ranges in acute stroke that can benefit from mechanical thrombectomy. J Neurointerv Surg 2020; 13:1081-1087. [PMID: 33323502 PMCID: PMC8606466 DOI: 10.1136/neurintsurg-2020-016934] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/19/2020] [Accepted: 11/24/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND We aimed to identify the large ischemic core (LIC) volume ranges in acute ischemic stroke patients that can benefit from mechanical thrombectomy (MT). METHODS Consecutive patients within 24 hours of onset of anterior circulation ischemic stroke with large vessel occlusion and ischemic core volumes of 70-300 mL were included from our single-center prospective database from March 2014 to December 2019. Subjects were divided into three groups by baseline ischemic core volume (A: 70-100 mL; B: 101-130 mL; C: >130 mL). We compared modified Rankin Scale (mRS) score 0-2 at 3 months and parenchymal hematoma between patients receiving MT and standard medical treatment (SMT), and determined clinically treatable core volume ranges for MT. RESULTS Of 157 patients (86 women; median age, 81 years; median ischemic core volume, 123 mL), 49 patients underwent MT. In Group A (n=52), MT patients (n=31) showed a higher proportion of mRS 0-2 at 3 months (52% vs 5%, P<0.05) versus SMT, respectively. Group B (n=36) MT patients (n=14) also had a higher proportion of mRS 0-2 at 3 months (29% vs 9%, P=0.13) versus SMT, respectively. In Group C (n=69), only four patients received MT. The 95% confidence intervals for the probability of mRS 0-2 at 3 months in patients with MT (n=49) versus SMT (n=108) intersected at 120-130 mL. CONCLUSIONS Ischemic core volumes between 70 and 100 mL may benefit from MT. The treatable upper core limit is approximately 120 mL in selected patients with LIC of 70-300 mL.
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Affiliation(s)
- Takeshi Yoshimoto
- Neurology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Manabu Inoue
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan .,Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kanta Tanaka
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kodai Kanemaru
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Junpei Koge
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masayuki Shiozawa
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Naruhiko Kamogawa
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Shunsuke Kimura
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Tetsuya Chiba
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Tetsu Satow
- Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Jun C Takahashi
- Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kazunori Toyoda
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masatoshi Koga
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masafumi Ihara
- Neurology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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10
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Lakomkin N, Pan J, Stein L, Malkani B, Dhamoon M, Mocco J. Diffusion MRI Reversibility in Ischemic Stroke Following Thrombolysis: A Meta-Analysis. J Neuroimaging 2020; 30:471-476. [PMID: 32436311 DOI: 10.1111/jon.12703] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/02/2020] [Accepted: 03/05/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Diffusion-weighted magnetic resonance imaging (DWI) detects early infarction in acute stroke. With the substantial progress in stroke therapies, the frequency of posttreatment DWI reversibility in modern stroke cohorts is currently unknown. The purpose of this study was to perform a systematic literature review examining the relationship between characteristics of patients with ischemic stroke and DWI reversibility following treatment with lytic therapy. METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, yielding a total of 422 unique articles. Studies that were nonclinical or did not report data pertaining to DWI reversibility in the context of an acute stroke series were excluded. Characteristics regarding presentation, diagnosis, intervention, and the timing of DWI reversibility were collected for each study. RESULTS After full-text review, 10 studies were identified as meeting inclusion criteria. The number of patients with DWI reversal ranged from .9% to 50%, whereas the extent of reversal ranged from 1.8% to 72.7%. Studies reporting on younger patients describe greater rates of reversibility following stroke treatment. CONCLUSIONS These data suggest that early DWI signal may not represent the definitive DWI burden in recanalized populations. However, substantial heterogeneity exists regarding the rate of DWI reversal following recanalization. Additional studies are needed to elucidate the relationship among time to treatment, early reversal rates, and clinical outcomes. Physicians should use caution when basing clinical decisions on DWI lesion volumes, as these likely change to some degree with recanalization.
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Affiliation(s)
- Nikita Lakomkin
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jonathan Pan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Laura Stein
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Brijesh Malkani
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mandip Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
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11
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Tonetti DA, Desai SM, Hudson J, Gross BA, Jha RM, Molyneaux BJ, Jankowitz BT, Jovin TG, Jadhav AP. Large Infarct Volume Post Thrombectomy: Characteristics, Outcomes, and Predictors. World Neurosurg 2020; 139:e748-e753. [PMID: 32353539 DOI: 10.1016/j.wneu.2020.04.139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/15/2020] [Accepted: 04/17/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Despite increasing interest in endovascular therapy (EVT) for large-core strokes, little is known about the predictors of good outcome in these patients. The aim of this study was to analyze patients with large-core strokes post-EVT and to define the predictors of favorable outcome in this population. METHODS A retrospective analysis of prospectively collected data on anterior circulation strokes undergoing EVT between January 2015 and February 2018 was performed. Patients with good baseline functional status who underwent EVT for occlusion of an anterior circulation artery and achieved successful recanalization (modified Treatment in Cerebral Ischemia score ≥2b) but had large follow-up infarct volume (FIV ≥70 cm3) were included in the study. Demographic characteristics, clinical and radiologic data, treatment and postprocedural outcomes were extracted and analyzed. The primary outcome was 90-day modified Rankin Scale (mRS) score, stratified by favorable (mRS 0-3) versus unfavorable (mRS 4-6). RESULTS Of 355 patients meeting inclusion criteria, 85 (24%) had large FIV on follow-up imaging after EVT and constituted the study cohort. No patients achieved mRS score 0-2 at hospital discharge; 32% had 90-day mRS score 0-3. On multivariate logistic regression analysis, lower FIV (OR, -0.96 [0.95-0.99]; P = 0.007), male sex (OR, -1.29 [1.07-12.3]; P = 0.026), and intravenous tissue plasminogen activator use (OR, 3.6 [2.01-8.9]; P = 0.003) were independent predictors of favorable outcome. Independent predictors of mortality on multivariate analysis were higher FIV (OR, -1.01 [1.007-1.02]; P = 0.001) and female sex (OR, 4.08 [1.25-13.3]; P = 0.02). CONCLUSIONS For patients with large-core strokes (≥70 cm3) after EVT, approximately one third have favorable outcome at 90 days. Independent predictors of favorable 90-day outcomes include male sex, intravenous tissue plasminogen activator use, and lower FIV.
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Affiliation(s)
- Daniel A Tonetti
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; The Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Shashvat M Desai
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; The Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Joseph Hudson
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; The Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ruchira M Jha
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; The Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Bradley J Molyneaux
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; The Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Brian T Jankowitz
- Cooper Neurological Institute, Cooper University Medical Center, Camden, New Jersey, USA
| | - Tudor G Jovin
- Cooper Neurological Institute, Cooper University Medical Center, Camden, New Jersey, USA
| | - Ashutosh P Jadhav
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; The Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
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12
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Nagaraja N, Forder JR, Warach S, Merino JG. Reversible diffusion-weighted imaging lesions in acute ischemic stroke: A systematic review. Neurology 2020; 94:571-587. [PMID: 32132175 DOI: 10.1212/wnl.0000000000009173] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 01/27/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To systematically review the literature for reversible diffusion-weighted imaging (DWIR) lesions and to describe its prevalence, predictors, and clinical significance. METHODS Studies were included if the first DWI MRI was performed within 24 hours of stroke onset and follow-up DWI or fluid-attenuated inversion recovery (FLAIR)/T2 was performed within 7 or 90 days, respectively, to measure DWIR. We abstracted clinical, imaging, and outcomes data. RESULTS Twenty-three studies met the study criteria. The prevalence of DWIR was 26.5% in DWI-based studies and 6% in FLAIR/T2-based studies. DWIR was associated with recanalization or reperfusion of the ischemic tissue with or without the use of tissue plasminogen activator (t-PA) or endovascular therapy, earlier treatment with t-PA, shorter time to endovascular therapy after MRI, and absent or less severe perfusion deficit within the DWI lesion. DWIR was associated with early neurologic improvement in 5 of 6 studies (defined as improvement in the NIH Stroke Scale (NIHSS) score by 4 or 8 points from baseline or NIHSS score 0 to 2 at 24 hours after treatment or at discharge or median NIHSS score at 7 days) and long-term outcome in 6 of 7 studies (defined as NIHSS score ≤1, improvement in the NIHSS score ≥8 points, or modified Rankin Scale score up to ≤2 at 30 or 90 days) likely due to reperfusion. CONCLUSIONS DWIR is seen in up to a quarter of patients with acute ischemic stroke, and it is associated with good clinical outcome following reperfusion. Our findings highlight the pitfalls of DWI to define ischemic core in the early hours of stroke.
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Affiliation(s)
- Nandakumar Nagaraja
- From the Department of Neurology (N.N.), University of Florida College of Medicine, Gainesville; Department of Radiology and Biomedical Engineering (J.R.F.), University of Florida, Gainesville; Dell Medical School (S.W.), University of Texas at Austin; and Department of Neurology (J.G.M.), Georgetown University School of Medicine, Washington, DC.
| | - John R Forder
- From the Department of Neurology (N.N.), University of Florida College of Medicine, Gainesville; Department of Radiology and Biomedical Engineering (J.R.F.), University of Florida, Gainesville; Dell Medical School (S.W.), University of Texas at Austin; and Department of Neurology (J.G.M.), Georgetown University School of Medicine, Washington, DC
| | - Steven Warach
- From the Department of Neurology (N.N.), University of Florida College of Medicine, Gainesville; Department of Radiology and Biomedical Engineering (J.R.F.), University of Florida, Gainesville; Dell Medical School (S.W.), University of Texas at Austin; and Department of Neurology (J.G.M.), Georgetown University School of Medicine, Washington, DC
| | - Jośe G Merino
- From the Department of Neurology (N.N.), University of Florida College of Medicine, Gainesville; Department of Radiology and Biomedical Engineering (J.R.F.), University of Florida, Gainesville; Dell Medical School (S.W.), University of Texas at Austin; and Department of Neurology (J.G.M.), Georgetown University School of Medicine, Washington, DC
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13
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Parthasarathy R, Gupta V. Mechanical Thrombectomy: Answering Unanswered. Ann Indian Acad Neurol 2020; 23:13-19. [PMID: 32055116 PMCID: PMC7001454 DOI: 10.4103/aian.aian_359_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The stroke physician community witnessed a major “breakthrough” in acute stroke therapeutics when the results of the first of the many positive trials, “MR CLEAN,” were published showing a significant absolute benefit in favor of mechanical thrombectomy in patients with large vessel occlusion (LVO). Thereafter, the investigators of ESCAPE, SWIFT PRIME, REVASCAT, THRACE, and PISTE concluded the same. Based on the initial studies, the American Stroke Association amended the 2013 guidelines in 2015 to include mechanical thrombectomy as the standard of care in patients with LVO presenting within six hours. In the past year, the horizon was further expanded when two major landmark trials, DAWN and DEFUSE 3, established the benefit of mechanical thrombectomy in the delayed window period in a select group of patients. It further led to the inclusion of the delayed window period treatment strategies in the 2018 guidelines. However, there are many unanswered questions in scenarios like small deficit with LVO, borderline large core, wake-up stroke (WUS), tandem occlusion, imaging of choice, conscious sedation (CS) versus general anesthesia (GA), and choice of technique. In our review, we aim to answer these questions along with a schematic representation of current techniques used in stroke thrombectomy.
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Affiliation(s)
- Rajsrinivas Parthasarathy
- Department of Stroke and Neurointerventional Surgery, Artemis Agrim Institute of Neuroscience, Gurgaon, India
| | - Vipul Gupta
- Department of Stroke and Neurointerventional Surgery, Artemis Agrim Institute of Neuroscience, Gurgaon, India
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14
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Boss SM, Moustafa RR, Moustafa MA, El Sadek A, Mostafa MM, Aref HM. Lesion homogeneity on diffusion-weighted imaging is a marker of outcome in acute ischemic stroke. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2019. [DOI: 10.1186/s41983-019-0101-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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15
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Karwacki GM, Vögele S, Blackham KA. Dose reduction in perfusion CT in stroke patients by lowering scan frequency does not affect automatically calculated infarct core volumes. J Neuroradiol 2019; 46:351-358. [PMID: 31034899 DOI: 10.1016/j.neurad.2019.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 04/04/2019] [Accepted: 04/09/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND PURPOSE CT Perfusion technique (CTP) is a quantitative, easily performed, accepted and reliable method for detection of ischemic brain changes. Based on calculated parameters, the size of ischemic penumbra and irreversibly damaged infarct core can be determined which helps guide treatment decisions. However, due to the dynamic nature of the CTP study, it is dose intensive. This study determines the consequences of retrospectively reducing the number of scans in the dynamic acquisition by half on the volume of the automatically calculated infarct core (non-viable tissue) and penumbra (tissue at risk) volumes. Our hypothesis was that equivalent volumetric information could be obtained at a substantial dose savings. MATERIALS AND METHODS Fifty one consecutive patients with occlusion of M1 and/or M2 segment of the middle cerebral artery and ischemic stroke proven by follow-up MRI were included. CTP scans were first analyzed in a standard fashion and automatically generated volumes measured in milliliters were recorded in a database. A second analysis was conducted after removing every second data acquisition from the sequential CTP scans. Automatic volume measurements were repeated, recorded and compared to the initial values obtained using the full dataset. RESULTS The two CTP protocols were statistically equivalent pertaining to automatic infarct core volume calculation but a case-by-case analysis revealed substantial overestimation in some cases. CONCLUSION Reduction of radiation exposure in CTP without objective loss of accuracy of automatically calculated infarct core volume is feasible but might lead to clinically relevant infarct core overestimation in individual cases.
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Affiliation(s)
- Grzegorz Marek Karwacki
- University Hospital Basel, University of Basel, clinic of radiology and nuclear medicine, Basel, Switzerland.
| | - Stephan Vögele
- University Hospital Basel, University of Basel, clinic of radiology and nuclear medicine, Basel, Switzerland
| | - Kristine Ann Blackham
- University Hospital Basel, University of Basel, clinic of radiology and nuclear medicine, Basel, Switzerland
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16
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Chen Z, Zhang R, Zhou Y, Gong X, Zhang M, Shi F, Yu X, Lou M. Patients With Ischemic Core ≥70 ml Within 6 h of Symptom Onset May Still Benefit From Endovascular Treatment. Front Neurol 2018; 9:933. [PMID: 30455665 PMCID: PMC6230959 DOI: 10.3389/fneur.2018.00933] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 10/15/2018] [Indexed: 01/01/2023] Open
Abstract
Background: Large core is associated with poor outcome in acute ischemic stroke (AIS) patients. It is unclear whether endovascular treatment (EVT) could bring benefits to patients with core volume ≥70 ml before treatment. We aimed to compare the impact of EVT with intravenous thrombolysis (IVT) on the outcome in patients with core volume ≥70 ml. Methods: We included consecutive anterior circulation AIS patients who underwent MR or CT perfusion within 6 h post stroke onset, which revealed a core ≥70 ml before reperfusion therapy. Good outcome was defined by modified Rankin Scale of 0 to 2 at 90-day. Reperfusion was defined as a reduction in hypoperfusion volume of ≥70% between baseline and 24 h. Results: One hundred four patients were included. Among them, 76 received IVT only, and 28 received EVT. After adjusting for age, NIHSS score, baseline core volume and onset to imaging time, patients in EVT group were more likely to achieve good outcome compared to IVT patients (OR, 3.875; 95% Cl 1.068-14.055, p = 0.039). More patients in EVT group achieved recanalization (84.0 vs. 58.5%, p = 0.027) and reperfusion (66.7 vs. 33.3%, p = 0.010) than in IVT group. Reperfusion also independently predicted good outcome (OR, 7.718; 95% Cl 1.713-34.772, p = 0.008). All patients with good outcome achieved recanalization at 24 h. Conclusions: Our data indicated that patients with core volume ≥70 ml might still benefit from EVT, which was related to its high reperfusion rate.
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Affiliation(s)
- Zhicai Chen
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Ruiting Zhang
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Ying Zhou
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Xiaoxian Gong
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Meixia Zhang
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Feina Shi
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Xinfeng Yu
- Department of Radiology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Min Lou
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
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17
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Mehrkhani F, Berkhemer OA, Majoie CBLM, Mansouri M, Karimi Z, Lev MH, Yoo AJ. Combined Evaluation of Noncontrast CT ASPECTS and CT Angiography Collaterals Improves Detection of Large Infarcts in Proximal Artery Occlusive Stroke. J Neuroimaging 2018; 28:524-529. [PMID: 29749671 DOI: 10.1111/jon.12522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 04/23/2018] [Accepted: 04/24/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND AND PURPOSE Imaging may identify patients with very large infarcts who are unlikely to benefit from intra-arterial therapy. Although computed tomography (CT) is widely used, it suffers from poor sensitivity. We sought to evaluate whether combined evaluation of noncontrast CT (NCCT) and CT angiography (CTA) collaterals would improve the detection of large infarcts. METHODS All patients with anterior circulation proximal artery occlusion and baseline CT, CTA, and magnetic resonance imaging (MRI) performed were identified. NCCT ASPECTS, CTA collateral score (CS), and diffusion-weighted imaging (DWI) lesion volume were determined. Receiver-operating characteristic analyses were performed to test the discrimination of NCCT ASPECTS 0-4, CTA malignant collaterals (CS = 0: absent collaterals in >50% of M2 territory), and the combination for DWI volume > 100 mL. RESULTS Among 54 patients, mean age was 67 years; median NIHSS was 14. Occlusion locations were ICA terminus (18 [33%]), MCA M1 (20 [37%]), and M2 (16 [30%]). Median NCCT ASPECTS was 8; 8 (15%) had ASPECTS 0-4. Median CTA CS was 2; 9 (17%) were categorized as malignant. Median DWI lesion volume was 25 mL; 12 (22%) had lesions >100 mL. Individually, the CTA malignant collateral profile (98%) and NCCT ASPECTS 0-4 (100%) demonstrated high specificity for DWI lesion volume >100 mL, but had suboptimal sensitivity (both 67%). In the combined approach (CTA CS = 0 and/or NCCT ASPECTS ≤4), the sensitivity improved significantly to 92%, while maintaining high specificity (98%). CONCLUSIONS Combined evaluation of NCCT ASPECTS and CTA collaterals identifies patients with infarcts >100 mL with high accuracy, and can improve patient selection using current CT techniques.
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Affiliation(s)
- Farhad Mehrkhani
- Department of Radiology, Case Western Reserve University, Cleveland
| | - Olvert A Berkhemer
- Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands
| | | | | | - Zahra Karimi
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston
| | - Michael H Lev
- Department of Radiology, Massachusetts General Hospital, Boston
| | - Albert J Yoo
- Division of Neurointervention, Texas Stroke Institute, Dallas, TX
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18
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Nah HW, Kim DH, Kang M, Choi JH, Park HS, Cha JK. Thrombolysis in Large Diffusion-Weighted Imaging Lesions: Lower Chance but Still a Chance. J Stroke Cerebrovasc Dis 2018; 27:1511-1516. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.12.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 12/16/2017] [Accepted: 12/24/2017] [Indexed: 01/15/2023] Open
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19
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Oppenheim C, Bracard S, Guillemin F. Response by Oppenheim et al to Letter Regarding Article, "Outcome After Reperfusion Therapies in Patients With Large Baseline Diffusion-Weighted Imaging Stroke Lesions: A THRACE Trial (Mechanical Thrombectomy After Intravenous Alteplase Versus Alteplase Alone After Stroke) Subgroup Analysis". Stroke 2018; 49:e229-e230. [PMID: 29686022 DOI: 10.1161/strokeaha.118.021278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Catherine Oppenheim
- Department of Neuroradiology, INSERM U894, Sainte-Anne Hospital, Université Paris-Descartes, France
| | - Serge Bracard
- Department of Neuroradiology, INSERM U947, Université de Lorraine, CHRU-Nancy, France
| | - Francis Guillemin
- Department of Clinical Epidemiology, INSERM CIC1433, Université de Lorraine, Nancy, France
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20
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Abstract
This review summarizes the current state of knowledge regarding the use of imaging to guide stroke treatment. Brain imaging plays a central role in the diagnosis of stroke and identification of the mechanism of stroke, which is relevant to acute treatment, prognosis, and secondary prevention. The chief potential modalities are computed tomography (CT) and magnetic resonance imaging (MRI). Currently, most imaging occurs in hospital but mobile stroke units have expanded CT brain imaging into the prehospital field. The proven therapies for ischemic stroke are based on achieving reperfusion and the DAWN and DEFUSE 3 trials have now firmly established a need for imaging selection based on estimated ischemic core volume to guide reperfusion decisions in patients beyond 6 h of stroke onset. However, data also indicate that estimated ischemic core volume, in conjunction with patient factors and expected time delay to reperfusion, forms one of the most useful prognostic assessments that could alter decision-making for patients within 6 h. Current trials are also investigating agents that aim to achieve neuroprotection, reduction in edema or prevention of hemorrhagic transformation. Imaging may play a role in identifying patients likely to benefit from this next generation of interventions for stroke patients.
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Affiliation(s)
- Bruce Cv Campbell
- 1 Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Mark W Parsons
- 1 Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia.,2 Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
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21
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Gautheron V, Xie Y, Tisserand M, Raoult H, Soize S, Naggara O, Bourcier R, Richard S, Guillemin F, Bracard S, Oppenheim C. Outcome After Reperfusion Therapies in Patients With Large Baseline Diffusion-Weighted Imaging Stroke Lesions. Stroke 2018; 49:750-753. [DOI: 10.1161/strokeaha.117.020244] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 12/20/2017] [Accepted: 01/03/2018] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Stroke patients with large diffusion-weighted imaging (DWI) volumes are often excluded from reperfusion because of reckoned futility. In those with DWI
volume
>70 mL, included in the THRACE trial (Mechanical Thrombectomy After Intravenous Alteplase Versus Alteplase Alone After Stroke), we report the associations between baseline parameters and outcome.
Methods—
We examined 304 patients with anterior circulation stroke and pretreatment magnetic resonance imaging. Variables were extracted from the THRACE database, and DWI volumes were measured semiautomatically.
Results—
Among 53 patients with DWI
volume
>70 mL, 12 had favorable outcome (modified Rankin Scale score, ≤2) at 3 months; they had less coronary disease (0/12 versus 12/38;
P
=0.046) and less history of smoking (1/10 versus 12/31;
P
=0.013) than patients with modified Rankin Scale score >2. None of the 8 patients >75 years of age reached modified Rankin Scale score ≤2. Favorable outcome occurred in 12 of 37 M1-occluded patients but in 0 of 16 internal carotid-T/L–occluded patients (
P
=0.010). Favorable outcome was more frequent (6/13) when DWI lesion was limited to the superficial middle cerebral artery territory than when it extended to the deep middle cerebral artery territory (6/40;
P
=0.050).
Conclusions—
Stroke patients with DWI lesion >70 mL may benefit from reperfusion therapy, especially those with isolated M1 occlusion or ischemia restricted to the superficial middle cerebral artery territory. The benefit of treatment seems questionable for patients with carotid occlusion or lesion extending to the deep middle cerebral artery territory.
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Affiliation(s)
- Vincent Gautheron
- From the Department of Neuroradiology, INSERM U894, Sainte-Anne Hospital, Université Paris Descartes, France (V.G., O.N., C.O.); Department of Neuroradiology, INSERM U947 (Y.X., S.B.), Department of Neurology (S.R.), and INSERM U1116, CIC-P1433 (S.R., F.G.), Lorraine University, Nancy, France; Department of Neuroradiology, Foch Hospital, Suresnes, France (M.T.); Department of Neuroradiology, CHU Rennes, France (H.R.); Department of Neuroradiology, CHU de Reims, France (S.R.); and Department of
| | - Yu Xie
- From the Department of Neuroradiology, INSERM U894, Sainte-Anne Hospital, Université Paris Descartes, France (V.G., O.N., C.O.); Department of Neuroradiology, INSERM U947 (Y.X., S.B.), Department of Neurology (S.R.), and INSERM U1116, CIC-P1433 (S.R., F.G.), Lorraine University, Nancy, France; Department of Neuroradiology, Foch Hospital, Suresnes, France (M.T.); Department of Neuroradiology, CHU Rennes, France (H.R.); Department of Neuroradiology, CHU de Reims, France (S.R.); and Department of
| | - Marie Tisserand
- From the Department of Neuroradiology, INSERM U894, Sainte-Anne Hospital, Université Paris Descartes, France (V.G., O.N., C.O.); Department of Neuroradiology, INSERM U947 (Y.X., S.B.), Department of Neurology (S.R.), and INSERM U1116, CIC-P1433 (S.R., F.G.), Lorraine University, Nancy, France; Department of Neuroradiology, Foch Hospital, Suresnes, France (M.T.); Department of Neuroradiology, CHU Rennes, France (H.R.); Department of Neuroradiology, CHU de Reims, France (S.R.); and Department of
| | - Hélène Raoult
- From the Department of Neuroradiology, INSERM U894, Sainte-Anne Hospital, Université Paris Descartes, France (V.G., O.N., C.O.); Department of Neuroradiology, INSERM U947 (Y.X., S.B.), Department of Neurology (S.R.), and INSERM U1116, CIC-P1433 (S.R., F.G.), Lorraine University, Nancy, France; Department of Neuroradiology, Foch Hospital, Suresnes, France (M.T.); Department of Neuroradiology, CHU Rennes, France (H.R.); Department of Neuroradiology, CHU de Reims, France (S.R.); and Department of
| | - Sébastien Soize
- From the Department of Neuroradiology, INSERM U894, Sainte-Anne Hospital, Université Paris Descartes, France (V.G., O.N., C.O.); Department of Neuroradiology, INSERM U947 (Y.X., S.B.), Department of Neurology (S.R.), and INSERM U1116, CIC-P1433 (S.R., F.G.), Lorraine University, Nancy, France; Department of Neuroradiology, Foch Hospital, Suresnes, France (M.T.); Department of Neuroradiology, CHU Rennes, France (H.R.); Department of Neuroradiology, CHU de Reims, France (S.R.); and Department of
| | - Olivier Naggara
- From the Department of Neuroradiology, INSERM U894, Sainte-Anne Hospital, Université Paris Descartes, France (V.G., O.N., C.O.); Department of Neuroradiology, INSERM U947 (Y.X., S.B.), Department of Neurology (S.R.), and INSERM U1116, CIC-P1433 (S.R., F.G.), Lorraine University, Nancy, France; Department of Neuroradiology, Foch Hospital, Suresnes, France (M.T.); Department of Neuroradiology, CHU Rennes, France (H.R.); Department of Neuroradiology, CHU de Reims, France (S.R.); and Department of
| | - Romain Bourcier
- From the Department of Neuroradiology, INSERM U894, Sainte-Anne Hospital, Université Paris Descartes, France (V.G., O.N., C.O.); Department of Neuroradiology, INSERM U947 (Y.X., S.B.), Department of Neurology (S.R.), and INSERM U1116, CIC-P1433 (S.R., F.G.), Lorraine University, Nancy, France; Department of Neuroradiology, Foch Hospital, Suresnes, France (M.T.); Department of Neuroradiology, CHU Rennes, France (H.R.); Department of Neuroradiology, CHU de Reims, France (S.R.); and Department of
| | - Sébastien Richard
- From the Department of Neuroradiology, INSERM U894, Sainte-Anne Hospital, Université Paris Descartes, France (V.G., O.N., C.O.); Department of Neuroradiology, INSERM U947 (Y.X., S.B.), Department of Neurology (S.R.), and INSERM U1116, CIC-P1433 (S.R., F.G.), Lorraine University, Nancy, France; Department of Neuroradiology, Foch Hospital, Suresnes, France (M.T.); Department of Neuroradiology, CHU Rennes, France (H.R.); Department of Neuroradiology, CHU de Reims, France (S.R.); and Department of
| | - Francis Guillemin
- From the Department of Neuroradiology, INSERM U894, Sainte-Anne Hospital, Université Paris Descartes, France (V.G., O.N., C.O.); Department of Neuroradiology, INSERM U947 (Y.X., S.B.), Department of Neurology (S.R.), and INSERM U1116, CIC-P1433 (S.R., F.G.), Lorraine University, Nancy, France; Department of Neuroradiology, Foch Hospital, Suresnes, France (M.T.); Department of Neuroradiology, CHU Rennes, France (H.R.); Department of Neuroradiology, CHU de Reims, France (S.R.); and Department of
| | - Serge Bracard
- From the Department of Neuroradiology, INSERM U894, Sainte-Anne Hospital, Université Paris Descartes, France (V.G., O.N., C.O.); Department of Neuroradiology, INSERM U947 (Y.X., S.B.), Department of Neurology (S.R.), and INSERM U1116, CIC-P1433 (S.R., F.G.), Lorraine University, Nancy, France; Department of Neuroradiology, Foch Hospital, Suresnes, France (M.T.); Department of Neuroradiology, CHU Rennes, France (H.R.); Department of Neuroradiology, CHU de Reims, France (S.R.); and Department of
| | - Catherine Oppenheim
- From the Department of Neuroradiology, INSERM U894, Sainte-Anne Hospital, Université Paris Descartes, France (V.G., O.N., C.O.); Department of Neuroradiology, INSERM U947 (Y.X., S.B.), Department of Neurology (S.R.), and INSERM U1116, CIC-P1433 (S.R., F.G.), Lorraine University, Nancy, France; Department of Neuroradiology, Foch Hospital, Suresnes, France (M.T.); Department of Neuroradiology, CHU Rennes, France (H.R.); Department of Neuroradiology, CHU de Reims, France (S.R.); and Department of
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22
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Bache KG, Hov MR, Larsen K, Solyga VM, Lund CG. Prehospital Advanced Diagnostics and Treatment of Acute Stroke: Protocol for a Controlled Intervention Study. JMIR Res Protoc 2018; 7:e53. [PMID: 29490898 PMCID: PMC6283254 DOI: 10.2196/resprot.8110] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 08/07/2017] [Accepted: 08/09/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Acute ischemic stroke (AIS) is a medical emergency. The outcome is closely linked to the time elapsing from symptom onset to treatment, and seemingly small delays can mean the difference between full recovery and physical and cognitive dysfunction. Recanalization to allow blood to reenter the affected area is most efficient immediately after symptoms occur, and intravenous thrombolysis must be initiated no later than 4.5 hours after the symptom onset. A liable diagnosis is mandatory to administer the appropriate treatment. Prehospital diagnosis and, in cases where contraindications are ruled out, prehospital initiation of intravenous thrombolysis have been shown to significantly decrease the time from alarm to the treatment. OBJECTIVE The objective of this paper is to investigate the effectiveness of prehospital thrombolysis as measured by (1) time spent from symptom onset to treatment and (2) the number of patients treated within 4.5 hours. In addition, we want to conduct explorative studies. These will include (1) the use of biomarkers for diagnostic and prognostic use where we will collect blood samples from various time points, including the hyperacute phase and (2) the study of magnetic resonance imaging (MRI) images at day 1 to determine the infarct volume and if the time to thrombolysis has an influence on this. METHODS This is a prospective controlled intervention study. The intervention will involve a computed tomography (CT) and thrombolysis in a physician-manned ambulance called a mobile stroke unit (MSU). The control will be the conventional pathway where the patient is transported to the hospital for CT, and thrombolysis as per current procedure. RESULTS Patient inclusion has started and a total of 37 patients are enrolled (control and intervention combined). The estimated time to completed inclusion is 36 months, starting from May 2017. The results of this study will be analyzed and published at the end of the trial. CONCLUSIONS This trial aims to document the feasibility of saving time for all stroke patients by providing prehospital diagnostics and treatment, as well as transport to appropriate level of care, in a safe environment provided by anesthesiologists trained in prehospital critical care. TRIAL REGISTRATION ClinicalTrials.gov NCT03158259; https://clinicaltrials.gov/show/NCT03158259 (Archived by WebCite at http://www.webcitation.org/6wxNEUMUD).
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Affiliation(s)
- Kristi G Bache
- Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway.,Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Maren Ranhoff Hov
- Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Karianne Larsen
- Research and Development, The Norwegian Air Ambulance Foundation, Drøbak, Norway.,Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
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23
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Olivot J. Which imaging before reperfusion strategy? Rev Neurol (Paris) 2017; 173:584-589. [DOI: 10.1016/j.neurol.2017.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 08/23/2017] [Accepted: 09/01/2017] [Indexed: 11/16/2022]
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24
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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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25
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Manceau PF, Soize S, Gawlitza M, Fabre G, Bakchine S, Durot C, Serre I, Metaxas GE, Pierot L. Is there a benefit of mechanical thrombectomy in patients with large stroke (DWI-ASPECTS ≤ 5)? Eur J Neurol 2017; 25:105-110. [DOI: 10.1111/ene.13460] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 09/06/2017] [Indexed: 12/17/2022]
Affiliation(s)
- P. -F. Manceau
- Department of Neuroradiology; CHU Reims; Hôpital Maison Blanche; Université Reims-Champagne Ardenne; Reims France
| | - S. Soize
- Department of Neuroradiology; CHU Reims; Hôpital Maison Blanche; Université Reims-Champagne Ardenne; Reims France
| | - M. Gawlitza
- Department of Neuroradiology; CHU Reims; Hôpital Maison Blanche; Université Reims-Champagne Ardenne; Reims France
| | - G. Fabre
- Department of Neuroradiology; CHU Reims; Hôpital Maison Blanche; Université Reims-Champagne Ardenne; Reims France
| | - S. Bakchine
- Department of Neurology; CHU Reims; Hôpital Maison Blanche; Université Reims-Champagne Ardenne; Reims France
| | - C. Durot
- Department of Neuroradiology; CHU Reims; Hôpital Maison Blanche; Université Reims-Champagne Ardenne; Reims France
| | - I. Serre
- Department of Neurology; CHU Reims; Hôpital Maison Blanche; Université Reims-Champagne Ardenne; Reims France
| | - G. -E. Metaxas
- Department of Neuroradiology; CHU Reims; Hôpital Maison Blanche; Université Reims-Champagne Ardenne; Reims France
| | - L. Pierot
- Department of Neuroradiology; CHU Reims; Hôpital Maison Blanche; Université Reims-Champagne Ardenne; Reims France
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26
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Regenhardt RW, Das AS, Stapleton CJ, Chandra RV, Rabinov JD, Patel AB, Hirsch JA, Leslie-Mazwi TM. Blood Pressure and Penumbral Sustenance in Stroke from Large Vessel Occlusion. Front Neurol 2017; 8:317. [PMID: 28717354 PMCID: PMC5494536 DOI: 10.3389/fneur.2017.00317] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 06/16/2017] [Indexed: 12/11/2022] Open
Abstract
The global burden of stroke remains high, and of the various subtypes of stroke, large vessel occlusions (LVOs) account for the largest proportion of stroke-related death and disability. Several randomized controlled trials in 2015 changed the landscape of stroke care worldwide, with endovascular thrombectomy (ET) now the standard of care for all eligible patients. With the proven success of this therapy, there is a renewed focus on penumbral sustenance. In this review, we describe the ischemic penumbra, collateral circulation, autoregulation, and imaging assessment of the penumbra. Blood pressure goals in acute stroke remain controversial, and we review the current data and suggest an approach for induced hypertension in the acute treatment of patients with LVOs. Finally, in addition to reperfusion and enhanced perfusion, efforts focused on developing therapeutic targets that afford neuroprotection and augment neural repair will gain increasing importance. ET has revolutionized stroke care, and future emphasis will be placed on promoting penumbral sustenance, which will increase patient eligibility for this highly effective therapy and reduce overall stroke-related death and disability.
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Affiliation(s)
- Robert W. Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Alvin S. Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Christopher J. Stapleton
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Ronil V. Chandra
- Interventional Neuroradiology, Monash Imaging, Monash Health, Monash University, Melbourne, VIC, Australia
| | - James D. Rabinov
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Aman B. Patel
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Joshua A. Hirsch
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Thabele M. Leslie-Mazwi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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27
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Desilles JP, Consoli A, Redjem H, Coskun O, Ciccio G, Smajda S, Labreuche J, Preda C, Ruiz Guerrero C, Decroix JP, Rodesch G, Mazighi M, Blanc R, Piotin M, Lapergue B, Wang A, Evrard S, Tchikviladzé M, Bourdain F, Gonzalez-Valcarcel J, Di Maria F, Pico F, Rakotoharinandrasana H, Tassan P, Poll R, Corabianu O, de Broucker T, Smadja D, Alamowitch S, Obadia M, Ille O, Manchon E, Garcia PY. Successful Reperfusion With Mechanical Thrombectomy Is Associated With Reduced Disability and Mortality in Patients With Pretreatment Diffusion-Weighted Imaging–Alberta Stroke Program Early Computed Tomography Score ≤6. Stroke 2017; 48:963-969. [DOI: 10.1161/strokeaha.116.015202] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 12/10/2016] [Accepted: 12/29/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
In acute ischemic stroke patients, diffusion-weighted imaging (DWI)–Alberta Stroke Program Early Computed Tomography Score (ASPECTS) is correlated with infarct volume and is an independent factor of functional outcome. Patients with pretreatment DWI-ASPECTS ≤6 were excluded or under-represented in the recent randomized mechanical thrombectomy trials. Our aim was to assess the impact of reperfusion in pretreatment DWI-ASPECTS ≤6 patients treated with mechanical thrombectomy.
Methods—
We analyzed data collected between January 2012 and August 2015 in a bicentric prospective clinical registry of consecutive acute ischemic stroke patients treated with mechanical thrombectomy. Every patient with a documented internal carotid artery or middle cerebral artery occlusion with pretreatment DWI-ASPECTS ≤6 was eligible for this study. The primary end point was a favorable outcome defined by a modified Rankin Scale score ≤2 at 90 days.
Results—
Two hundred and eighteen patients with a DWI-ASPECTS ≤6 were included. Among them, 145 (66%) patients had successful reperfusion at the end of mechanical thrombectomy. Reperfused patients had an increased rate of favorable outcome (38.7% versus 17.4%;
P
=0.002) and a decreased rate of mortality at 3 months (22.5% versus 39.1%;
P
=0.013) compared with nonreperfused patients. The symptomatic intracranial hemorrhage rate was not different between the 2 groups (13.0% versus 14.1%;
P
=0.83). However, in patients with DWI-ASPECTS <5, favorable outcome was low (13.0% versus 9.5%;
P
=0.68) with a high mortality rate (45.7% versus 57.1%;
P
=0.38) with or without successful reperfusion.
Conclusions—
Successful reperfusion is associated with reduced mortality and disability in patients with a pretreatment DWI-ASPECTS ≤6. Further data from randomized studies are needed, particularly in patients with DWI-ASPECTS <5.
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Affiliation(s)
- Jean-Philippe Desilles
- From the Department of Interventional Neuroradiology, Fondation Rothschild, Paris, France (J.-P. Desilles, H.R., G.C., S.S., C.R.G., M.M., R.B., M.P.); Department of Neurology, Division of Neurology, Stroke Center (J.-P. Decroix, B.L.) and Department of Interventional Neuroradiology (A.C., O.C., G.R.), Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France; Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM)
| | - Arturo Consoli
- From the Department of Interventional Neuroradiology, Fondation Rothschild, Paris, France (J.-P. Desilles, H.R., G.C., S.S., C.R.G., M.M., R.B., M.P.); Department of Neurology, Division of Neurology, Stroke Center (J.-P. Decroix, B.L.) and Department of Interventional Neuroradiology (A.C., O.C., G.R.), Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France; Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM)
| | - Hocine Redjem
- From the Department of Interventional Neuroradiology, Fondation Rothschild, Paris, France (J.-P. Desilles, H.R., G.C., S.S., C.R.G., M.M., R.B., M.P.); Department of Neurology, Division of Neurology, Stroke Center (J.-P. Decroix, B.L.) and Department of Interventional Neuroradiology (A.C., O.C., G.R.), Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France; Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM)
| | - Oguzhan Coskun
- From the Department of Interventional Neuroradiology, Fondation Rothschild, Paris, France (J.-P. Desilles, H.R., G.C., S.S., C.R.G., M.M., R.B., M.P.); Department of Neurology, Division of Neurology, Stroke Center (J.-P. Decroix, B.L.) and Department of Interventional Neuroradiology (A.C., O.C., G.R.), Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France; Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM)
| | - Gabriele Ciccio
- From the Department of Interventional Neuroradiology, Fondation Rothschild, Paris, France (J.-P. Desilles, H.R., G.C., S.S., C.R.G., M.M., R.B., M.P.); Department of Neurology, Division of Neurology, Stroke Center (J.-P. Decroix, B.L.) and Department of Interventional Neuroradiology (A.C., O.C., G.R.), Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France; Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM)
| | - Stanislas Smajda
- From the Department of Interventional Neuroradiology, Fondation Rothschild, Paris, France (J.-P. Desilles, H.R., G.C., S.S., C.R.G., M.M., R.B., M.P.); Department of Neurology, Division of Neurology, Stroke Center (J.-P. Decroix, B.L.) and Department of Interventional Neuroradiology (A.C., O.C., G.R.), Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France; Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM)
| | - Julien Labreuche
- From the Department of Interventional Neuroradiology, Fondation Rothschild, Paris, France (J.-P. Desilles, H.R., G.C., S.S., C.R.G., M.M., R.B., M.P.); Department of Neurology, Division of Neurology, Stroke Center (J.-P. Decroix, B.L.) and Department of Interventional Neuroradiology (A.C., O.C., G.R.), Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France; Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM)
| | - Cristian Preda
- From the Department of Interventional Neuroradiology, Fondation Rothschild, Paris, France (J.-P. Desilles, H.R., G.C., S.S., C.R.G., M.M., R.B., M.P.); Department of Neurology, Division of Neurology, Stroke Center (J.-P. Decroix, B.L.) and Department of Interventional Neuroradiology (A.C., O.C., G.R.), Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France; Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM)
| | - Clara Ruiz Guerrero
- From the Department of Interventional Neuroradiology, Fondation Rothschild, Paris, France (J.-P. Desilles, H.R., G.C., S.S., C.R.G., M.M., R.B., M.P.); Department of Neurology, Division of Neurology, Stroke Center (J.-P. Decroix, B.L.) and Department of Interventional Neuroradiology (A.C., O.C., G.R.), Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France; Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM)
| | - Jean-Pierre Decroix
- From the Department of Interventional Neuroradiology, Fondation Rothschild, Paris, France (J.-P. Desilles, H.R., G.C., S.S., C.R.G., M.M., R.B., M.P.); Department of Neurology, Division of Neurology, Stroke Center (J.-P. Decroix, B.L.) and Department of Interventional Neuroradiology (A.C., O.C., G.R.), Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France; Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM)
| | - Georges Rodesch
- From the Department of Interventional Neuroradiology, Fondation Rothschild, Paris, France (J.-P. Desilles, H.R., G.C., S.S., C.R.G., M.M., R.B., M.P.); Department of Neurology, Division of Neurology, Stroke Center (J.-P. Decroix, B.L.) and Department of Interventional Neuroradiology (A.C., O.C., G.R.), Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France; Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM)
| | - Mikael Mazighi
- From the Department of Interventional Neuroradiology, Fondation Rothschild, Paris, France (J.-P. Desilles, H.R., G.C., S.S., C.R.G., M.M., R.B., M.P.); Department of Neurology, Division of Neurology, Stroke Center (J.-P. Decroix, B.L.) and Department of Interventional Neuroradiology (A.C., O.C., G.R.), Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France; Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM)
| | - Raphaël Blanc
- From the Department of Interventional Neuroradiology, Fondation Rothschild, Paris, France (J.-P. Desilles, H.R., G.C., S.S., C.R.G., M.M., R.B., M.P.); Department of Neurology, Division of Neurology, Stroke Center (J.-P. Decroix, B.L.) and Department of Interventional Neuroradiology (A.C., O.C., G.R.), Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France; Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM)
| | - Michel Piotin
- From the Department of Interventional Neuroradiology, Fondation Rothschild, Paris, France (J.-P. Desilles, H.R., G.C., S.S., C.R.G., M.M., R.B., M.P.); Department of Neurology, Division of Neurology, Stroke Center (J.-P. Decroix, B.L.) and Department of Interventional Neuroradiology (A.C., O.C., G.R.), Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France; Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM)
| | - Bertrand Lapergue
- From the Department of Interventional Neuroradiology, Fondation Rothschild, Paris, France (J.-P. Desilles, H.R., G.C., S.S., C.R.G., M.M., R.B., M.P.); Department of Neurology, Division of Neurology, Stroke Center (J.-P. Decroix, B.L.) and Department of Interventional Neuroradiology (A.C., O.C., G.R.), Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France; Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM)
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Bateman M, Slater LA, Leslie-Mazwi T, Simonsen CZ, Stuckey S, Chandra RV. Diffusion and Perfusion MR Imaging in Acute Stroke: Clinical Utility and Potential Limitations for Treatment Selection. Top Magn Reson Imaging 2017; 26:77-82. [PMID: 28277459 DOI: 10.1097/rmr.0000000000000124] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Magnetic resonance (MR) diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) offer unique insight into acute ischemic stroke pathophysiology. These techniques may offer the ability to apply pathophysiology to accurately individualize acute stroke reperfusion treatment, including extending the opportunity of reperfusion treatment to well beyond the current time-based treatment windows.This review examines the use of DWI and PWI in the major stroke trials, their current clinical utility, and potential limitations for reperfusion treatment selection. DWI and PWI continue to be investigated in ongoing randomized controlled trials, and continued research into these techniques will help achieve the goal of tissue-based decision making and individualized acute stroke treatment.
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Affiliation(s)
- Mathew Bateman
- *Neuroradiology Service, Monash Imaging, Monash Health †School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia ‡NeuroEndovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA §Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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29
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Lassalle L, Turc G, Tisserand M, Charron S, Roca P, Lion S, Legrand L, Edjlali M, Naggara O, Meder JF, Mas JL, Baron JC, Oppenheim C. ASPECTS (Alberta Stroke Program Early CT Score) Assessment of the Perfusion-Diffusion Mismatch. Stroke 2016; 47:2553-8. [PMID: 27625381 DOI: 10.1161/strokeaha.116.013676] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 08/05/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Rapid and reliable assessment of the perfusion-weighted imaging (PWI)/diffusion-weighted imaging (DWI) mismatch is required to promote its wider application in both acute stroke clinical routine and trials. We tested whether an evaluation based on the Alberta Stroke Program Early CT Score (ASPECTS) reliably identifies the PWI/DWI mismatch. METHODS A total of 232 consecutive patients with acute middle cerebral artery stroke who underwent pretreatment magnetic resonance imaging (PWI and DWI) were retrospectively evaluated. PWI-ASPECTS and DWI-ASPECTS were determined blind from manually segmented PWI and DWI volumes. Mismatch-ASPECTS was defined as the difference between PWI-ASPECTS and DWI-ASPECTS (a high score indicates a large mismatch). We determined the mismatch-ASPECTS cutoff that best identified the volumetric mismatch, defined as VolumeTmax>6s/VolumeDWI≥1.8, a volume difference≥15 mL, and a VolumeDWI<70 mL. RESULTS Inter-reader agreement was almost perfect for PWI-ASPECTS (κ=0.95 [95% confidence interval, 0.90-1]), and DWI-ASPECTS (κ=0.96 [95% confidence interval, 0.91-1]). There were strong negative correlations between volumetric and ASPECTS-based assessments of DWI lesions (ρ=-0.84, P<0.01) and PWI lesions (ρ=-0.90, P<0.01). Receiver operating characteristic curve analysis showed that a mismatch-ASPECTS ≥2 best identified a volumetric mismatch, with a sensitivity of 0.93 (95% confidence interval, 0.89-0.98) and a specificity of 0.82 (95% confidence interval, 0.74-0.89). CONCLUSIONS The mismatch-ASPECTS method can detect a true mismatch in patients with acute middle cerebral artery stroke. It could be used for rapid screening of patients with eligible mismatch, in centers not equipped with ultrafast postprocessing software.
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Affiliation(s)
- Louis Lassalle
- From the Departments of Radiology (L. Lassalle, M.T., S.C., P.R., S.L., L. Legrand, M.E., O.N., J.-F.M., C.O.), and Neurology (G.T., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France
| | - Guillaume Turc
- From the Departments of Radiology (L. Lassalle, M.T., S.C., P.R., S.L., L. Legrand, M.E., O.N., J.-F.M., C.O.), and Neurology (G.T., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France
| | - Marie Tisserand
- From the Departments of Radiology (L. Lassalle, M.T., S.C., P.R., S.L., L. Legrand, M.E., O.N., J.-F.M., C.O.), and Neurology (G.T., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France
| | - Sylvain Charron
- From the Departments of Radiology (L. Lassalle, M.T., S.C., P.R., S.L., L. Legrand, M.E., O.N., J.-F.M., C.O.), and Neurology (G.T., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France
| | - Pauline Roca
- From the Departments of Radiology (L. Lassalle, M.T., S.C., P.R., S.L., L. Legrand, M.E., O.N., J.-F.M., C.O.), and Neurology (G.T., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France
| | - Stephanie Lion
- From the Departments of Radiology (L. Lassalle, M.T., S.C., P.R., S.L., L. Legrand, M.E., O.N., J.-F.M., C.O.), and Neurology (G.T., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France
| | - Laurence Legrand
- From the Departments of Radiology (L. Lassalle, M.T., S.C., P.R., S.L., L. Legrand, M.E., O.N., J.-F.M., C.O.), and Neurology (G.T., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France
| | - Myriam Edjlali
- From the Departments of Radiology (L. Lassalle, M.T., S.C., P.R., S.L., L. Legrand, M.E., O.N., J.-F.M., C.O.), and Neurology (G.T., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France
| | - Olivier Naggara
- From the Departments of Radiology (L. Lassalle, M.T., S.C., P.R., S.L., L. Legrand, M.E., O.N., J.-F.M., C.O.), and Neurology (G.T., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France
| | - Jean-François Meder
- From the Departments of Radiology (L. Lassalle, M.T., S.C., P.R., S.L., L. Legrand, M.E., O.N., J.-F.M., C.O.), and Neurology (G.T., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France
| | - Jean-Louis Mas
- From the Departments of Radiology (L. Lassalle, M.T., S.C., P.R., S.L., L. Legrand, M.E., O.N., J.-F.M., C.O.), and Neurology (G.T., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France
| | - Jean-Claude Baron
- From the Departments of Radiology (L. Lassalle, M.T., S.C., P.R., S.L., L. Legrand, M.E., O.N., J.-F.M., C.O.), and Neurology (G.T., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France
| | - Catherine Oppenheim
- From the Departments of Radiology (L. Lassalle, M.T., S.C., P.R., S.L., L. Legrand, M.E., O.N., J.-F.M., C.O.), and Neurology (G.T., J.-L.M., J.-C.B.), Université Paris Descartes Sorbonne Paris Cité, Centre de Psychiatrie et Neurosciences, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France.
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30
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Olivot JM, Sissani L, Meseguer E, Inoue M, Labreuche J, Mlynash M, Amarenco P, Mazighi M. Impact of Initial Diffusion-Weighted Imaging Lesion Growth Rate on the Success of Endovascular Reperfusion Therapy. Stroke 2016; 47:2305-10. [DOI: 10.1161/strokeaha.116.013916] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 07/11/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Initial diffusion-weighted imaging lesion growth rate (IGR) assessed by diffusion-weighted imaging lesion volume divided by the delay from onset to magnetic resonance imaging offers an estimate of early brain infarction progression. We investigated the impact of IGR on the rate of favorable outcome according to the occurrence of a successful endovascular revascularization within 6 hours after onset in patients experiencing an acute brain infarction complicating internal carotid artery terminus/middle cerebral artery M1 occlusion.
Methods—
The primary study end point was a favorable outcome defined by a modified Rankin Scale score of ≤2, 90 days after onset. A Thrombolysis in Cerebral Infarction score 2b/3 defined a successful recanalization.
Results—
A total of 166 patients were included. Median IGR was 7 mL/h (interquartile range, 2–26). Sixty-eight patients (41%) experienced a favorable outcome. After adjustment on age, systolic blood pressure, vessel site occlusion, National Institutes of Health Stroke Scale, and antithrombotic medication, increase in IGR was associated with a decreased occurrence of favorable outcome with an odds ratio per SD increase of 0.60 (95% confidence interval, 0.38–0.94;
P
=0.03). A successful recanalization was achieved among 56% of the patients after a median delay of 251 minutes (interquartile range, 211–291 minutes). Increasing IGR was associated with a decreased favorable outcome only when a successful recanalization was not achieved (adjusted odds ratio, 0.32; 95% confidence interval, 0.12–0.85;
P
=0.02).
Conclusions—
Proximal internal carotid artery/M1 occlusion did result into a wide range of IGR within 6 hours after onset. Increasing IGR was associated with a lower rate of favorable outcome after endovascular treatment overall and when a successful recanalization was not achieved.
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Affiliation(s)
- Jean-Marc Olivot
- From the Acute Stroke Unit, Toulouse University Hospital, Toulouse Neuro Imaging Center (UMR 1214), Toulouse University Hospital, France (J.-M.O.); UMR 1148 et Centre d’Accueil et de Traitement de l’Attaque Cérébrale, CHU Bichat, Paris, France (L.S., E.M., P.A., M.M.); NCVC Stroke Center, National Cerebral and Cardiovascular Center, Fujishirodai 5-7-1, Suita, Osaka 565-8565, Japan (M.I.); and Department of Biostatistics, Université de Lille, CHU Lille, EA 2694 - Santé Publique Épidémiologie et
| | - Leila Sissani
- From the Acute Stroke Unit, Toulouse University Hospital, Toulouse Neuro Imaging Center (UMR 1214), Toulouse University Hospital, France (J.-M.O.); UMR 1148 et Centre d’Accueil et de Traitement de l’Attaque Cérébrale, CHU Bichat, Paris, France (L.S., E.M., P.A., M.M.); NCVC Stroke Center, National Cerebral and Cardiovascular Center, Fujishirodai 5-7-1, Suita, Osaka 565-8565, Japan (M.I.); and Department of Biostatistics, Université de Lille, CHU Lille, EA 2694 - Santé Publique Épidémiologie et
| | - Elena Meseguer
- From the Acute Stroke Unit, Toulouse University Hospital, Toulouse Neuro Imaging Center (UMR 1214), Toulouse University Hospital, France (J.-M.O.); UMR 1148 et Centre d’Accueil et de Traitement de l’Attaque Cérébrale, CHU Bichat, Paris, France (L.S., E.M., P.A., M.M.); NCVC Stroke Center, National Cerebral and Cardiovascular Center, Fujishirodai 5-7-1, Suita, Osaka 565-8565, Japan (M.I.); and Department of Biostatistics, Université de Lille, CHU Lille, EA 2694 - Santé Publique Épidémiologie et
| | - Manabu Inoue
- From the Acute Stroke Unit, Toulouse University Hospital, Toulouse Neuro Imaging Center (UMR 1214), Toulouse University Hospital, France (J.-M.O.); UMR 1148 et Centre d’Accueil et de Traitement de l’Attaque Cérébrale, CHU Bichat, Paris, France (L.S., E.M., P.A., M.M.); NCVC Stroke Center, National Cerebral and Cardiovascular Center, Fujishirodai 5-7-1, Suita, Osaka 565-8565, Japan (M.I.); and Department of Biostatistics, Université de Lille, CHU Lille, EA 2694 - Santé Publique Épidémiologie et
| | - Julien Labreuche
- From the Acute Stroke Unit, Toulouse University Hospital, Toulouse Neuro Imaging Center (UMR 1214), Toulouse University Hospital, France (J.-M.O.); UMR 1148 et Centre d’Accueil et de Traitement de l’Attaque Cérébrale, CHU Bichat, Paris, France (L.S., E.M., P.A., M.M.); NCVC Stroke Center, National Cerebral and Cardiovascular Center, Fujishirodai 5-7-1, Suita, Osaka 565-8565, Japan (M.I.); and Department of Biostatistics, Université de Lille, CHU Lille, EA 2694 - Santé Publique Épidémiologie et
| | - Michael Mlynash
- From the Acute Stroke Unit, Toulouse University Hospital, Toulouse Neuro Imaging Center (UMR 1214), Toulouse University Hospital, France (J.-M.O.); UMR 1148 et Centre d’Accueil et de Traitement de l’Attaque Cérébrale, CHU Bichat, Paris, France (L.S., E.M., P.A., M.M.); NCVC Stroke Center, National Cerebral and Cardiovascular Center, Fujishirodai 5-7-1, Suita, Osaka 565-8565, Japan (M.I.); and Department of Biostatistics, Université de Lille, CHU Lille, EA 2694 - Santé Publique Épidémiologie et
| | - Pierre Amarenco
- From the Acute Stroke Unit, Toulouse University Hospital, Toulouse Neuro Imaging Center (UMR 1214), Toulouse University Hospital, France (J.-M.O.); UMR 1148 et Centre d’Accueil et de Traitement de l’Attaque Cérébrale, CHU Bichat, Paris, France (L.S., E.M., P.A., M.M.); NCVC Stroke Center, National Cerebral and Cardiovascular Center, Fujishirodai 5-7-1, Suita, Osaka 565-8565, Japan (M.I.); and Department of Biostatistics, Université de Lille, CHU Lille, EA 2694 - Santé Publique Épidémiologie et
| | - Mikael Mazighi
- From the Acute Stroke Unit, Toulouse University Hospital, Toulouse Neuro Imaging Center (UMR 1214), Toulouse University Hospital, France (J.-M.O.); UMR 1148 et Centre d’Accueil et de Traitement de l’Attaque Cérébrale, CHU Bichat, Paris, France (L.S., E.M., P.A., M.M.); NCVC Stroke Center, National Cerebral and Cardiovascular Center, Fujishirodai 5-7-1, Suita, Osaka 565-8565, Japan (M.I.); and Department of Biostatistics, Université de Lille, CHU Lille, EA 2694 - Santé Publique Épidémiologie et
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