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Han N, Zhang X, Zhang Y, Liu Y, Ma H, Ge H, Wang Y, Li S, Yan X, Li T, Wu Y, Ma J, Shi W, Zhang G, Tian Y, Chang M. Endovascular thrombectomy versus medical management on outcomes with infarct volumes more than 70 mL. Ann Clin Transl Neurol 2024; 11:2040-2048. [PMID: 38858521 PMCID: PMC11330213 DOI: 10.1002/acn3.52124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 05/06/2024] [Accepted: 05/27/2024] [Indexed: 06/12/2024] Open
Abstract
OBJECTIVE Endovascular thrombectomy (EVT) in patients with large infarct volume remains controversial. The aim of this study is to compare clinical outcomes between EVT and medical management in acute large vessel occlusion with infarct volumes larger than 70 mL on diffusion-weighted magnetic resonance imaging (DWI). METHODS A prospective observational cohort study was conducted, including patients with anterior cerebral circulation occlusion due to ischemic stroke with infarct volumes larger than 70 mL within 24 h of onset between July 2018 and June 2023. Eligible patients were divided into two groups: the EVT group and the medical management (non-EVT) group. The main outcomes were functional independence and mortality at 90 days. To assess clinical endpoints, we selected variables including age, NIHSS score, infarct volume, and occlusion location for 1:1 propensity score (PS) matching and PS adjustment using inverse probability of treatment weighting (IPTW). RESULTS Among the 131 identified patients (mean [SD] age, 69.9 [13.7] years; 58 female), the median infarct volume was 123.6 mL. Of these patients, 75 (57.3%) underwent EVT. After PS adjustment, EVT was not associated with functional independence (10.9% vs. 10.9%; p = 1.000) or mortality (43.5% vs. 47.8%; p = 0.675). Additionally, after PS adjustment using IPTW, EVT was also not associated with a functional independence (15.8% vs. 13.7%; p = 0.767) or mortality (46.8% vs. 44.0%; p = 0.762). CONCLUSION This study provides real-world evidence regarding infarct volumes larger than 70 mL, indicating that EVT does not provide benefits compared to medical management alone when considering age, NIHSS score, infarct volume, and occlusion location.
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Affiliation(s)
- Nannan Han
- Department of NeurologyThe Affiliated Hospital of Northwest UniversityXi'anChina
| | - Xiaobo Zhang
- The College of Life SciencesNorthwest UniversityXi'anChina
| | - Yu Zhang
- The College of Life SciencesNorthwest UniversityXi'anChina
| | - Yu Liu
- School of Information Science and TechnologyNorthwest UniversityXi'anChina
| | - Haojun Ma
- Department of NeurologyThe Affiliated Hospital of Northwest UniversityXi'anChina
| | - Hanming Ge
- Department of NeurologyThe Affiliated Hospital of Northwest UniversityXi'anChina
| | - Yanfei Wang
- Department of NeurologyThe Affiliated Hospital of Northwest UniversityXi'anChina
| | - Shilin Li
- Department of NeurologyThe Affiliated Hospital of Northwest UniversityXi'anChina
| | - Xudong Yan
- Department of NeurologyThe Affiliated Hospital of Northwest UniversityXi'anChina
| | - Tengfei Li
- Department of NeurologyThe Affiliated Hospital of Northwest UniversityXi'anChina
| | - Yulun Wu
- Department of NeurologyThe Affiliated Hospital of Northwest UniversityXi'anChina
| | - Juan Ma
- Department of NeurologyThe Affiliated Hospital of Northwest UniversityXi'anChina
| | - Wenzhen Shi
- Xi'an Key Laboratory of Cardiovascular and Cerebrovascular DiseasesThe Affiliated Hospital of Northwest UniversityXi'anChina
- Clinical Medical Research CenterThe Affiliated Hospital of Northwest UniversityXi'anChina
| | - Gejuan Zhang
- Department of NeurologyThe Affiliated Hospital of Northwest UniversityXi'anChina
| | - Ye Tian
- Department of NeurologyThe Affiliated Hospital of Northwest UniversityXi'anChina
- Xi'an Key Laboratory of Cardiovascular and Cerebrovascular DiseasesThe Affiliated Hospital of Northwest UniversityXi'anChina
- Clinical Medical Research CenterThe Affiliated Hospital of Northwest UniversityXi'anChina
| | - Mingze Chang
- Department of NeurologyThe Affiliated Hospital of Northwest UniversityXi'anChina
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Tanaka K, Kaveeta C, Pensato U, Zhang J, Bala F, Alhabli I, Horn M, Ademola A, Almekhlafi M, Ganesh A, Buck B, Tkach A, Catanese L, Dowlatshahi D, Shankar J, Poppe AY, Shamy M, Qiu W, Swartz RH, Hill MD, Sajobi TT, Menon BK, Demchuk AM, Singh N. Combining Early Ischemic Change and Collateral Extent for Functional Outcomes After Endovascular Therapy: An Analysis From AcT Trial. Stroke 2024; 55:1758-1766. [PMID: 38785076 DOI: 10.1161/strokeaha.123.046056] [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: 12/10/2023] [Accepted: 04/12/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Early ischemic change and collateral extent are colinear with ischemic core volume (ICV). We investigated the relationship between a combined score using the Alberta Stroke Program Early Computed Tomography Score and multiphase computed tomography angiography (mCTA) collateral extent, named mCTA-ACE score, on functional outcomes in endovascular therapy-treated patients. METHODS We performed a post hoc analysis of a subset of endovascular therapy-treated patients from the Alteplase Compared to Tenecteplase trial which was conducted between December 2019 and January 2022 at 22 centers across Canada. Ten-point mCTA collateral corresponding to M2 to M6 regions of the Alberta Stroke Program Early Computed Tomography Score grid was evaluated as 0 (poor), 1 (moderate), or 2 (normal) and additively combined with the 10-point Alberta Stroke Program Early Computed Tomography Score to produce a 20-point mCTA-ACE score. We investigated the association of mCTA-ACE score with modified Rankin Scale score ≤2 and return to prestroke level of function at 90 to 120 days using mixed-effects logistic regression. In the subset of patients who underwent baseline computed tomography perfusion imaging, we compared the mCTA-ACE score and ICV for outcome prediction. RESULTS Among 1577 intention-to-treat population in the trial, 368 (23%; 179 men; median age, 73 years) were included, with Alberta Stroke Program Early Computed Tomography Score, mCTA collateral, and combination of both (mCTA-ACE score: median [interquartile range], 8 [7-10], 9 [8-10], and 17 [16-19], respectively). The probability of modified Rankin Scale score ≤2 and return to prestroke level of function increased for each 1-point increase in mCTA-ACE score (odds ratio, 1.16 [95% CI, 1.06-1.28] and 1.22 [95% CI, 1.06-1.40], respectively). Among 173 patients in whom computed tomography perfusion data was assessable, the mCTA-ACE score was inversely correlated with ICV (ρ=-0.46; P<0.01). The mCTA-ACE score was comparable to ICV to predict a modified Rankin Scale score ≤2 and return to prestroke level of function (C statistics 0.71 versus 0.69 and 0.68 versus 0.64, respectively). CONCLUSIONS The mCTA-ACE score had a significant positive association with functional outcomes after endovascular therapy and had a similar predictive performance as ICV.
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Affiliation(s)
- Koji Tanaka
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Chitapa Kaveeta
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand (C.K.)
| | - Umberto Pensato
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Biomedical Sciences, Humanitas University, Milan, Italy (U.P.)
- IRCCS Humanitas Research Hospital, Milan, Italy (U.P.)
| | - Jianhai Zhang
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Fouzi Bala
- Department of Radiology (F.B., I.A., M.A., M.D.H., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, France (F.B.)
| | - Ibrahim Alhabli
- Department of Radiology (F.B., I.A., M.A., M.D.H., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - MacKenzie Horn
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Ayoola Ademola
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences (A.A., M.A., A.G., M.D.H., T.T.S., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (F.B., I.A., M.A., M.D.H., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute (M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Aravind Ganesh
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (F.B., I.A., M.A., M.D.H., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences (A.A., M.A., A.G., M.D.H., T.T.S., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute (M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Brian Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada (B.B.)
| | - Aleksander Tkach
- Department of Neurosciences, Kelowna General Hospital, BC, Canada (A.T.)
| | - Luciana Catanese
- Department of Medicine, McMaster University, Hamilton, ON, Canada (L.C.)
| | - Dar Dowlatshahi
- Department of Medicine and Ottawa Hospital Research Institute, University of Ottawa, ON, Canada (D.D., M.S.)
| | - Jai Shankar
- Department of Radiology, Health Sciences Center (J.S.), University of Manitoba, Winnipeg, Canada
| | - Alexandre Y Poppe
- Department of Clinical Neurosciences, Université de Montréal, QC, Canada (A.Y.P.)
| | - Michel Shamy
- Department of Medicine and Ottawa Hospital Research Institute, University of Ottawa, ON, Canada (D.D., M.S.)
| | - Wu Qiu
- Department of Biomedical Engineering, Huazhong University of Science and Technology, Wuhan, China (W.Q.)
| | - Richard H Swartz
- Department of Medicine, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (R.H.S.)
| | - Michael D Hill
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (F.B., I.A., M.A., M.D.H., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences (A.A., M.A., A.G., M.D.H., T.T.S., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute (M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Medicine (M.D.H.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Tolulope T Sajobi
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences (A.A., M.A., A.G., M.D.H., T.T.S., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute (M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (F.B., I.A., M.A., M.D.H., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences (A.A., M.A., A.G., M.D.H., T.T.S., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute (M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute (M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Nishita Singh
- Department of Clinical Neurosciences (K.T., C.K., U.P., J.Z., M.H., A.A., M.A., A.G., M.D.H., T.T.S., B.K.M., A.M.D., N.S.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Internal Medicine, Rady Faculty of Health Sciences (N.S.), University of Manitoba, Winnipeg, Canada
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Lin CH, Ovbiagele B, Liebeskind DS, Saver JL, Lee M. Brain imaging prior to thrombectomy in the late window of large vessel occlusion ischemic stroke: a systematic review and meta-analysis. Neuroradiology 2024; 66:809-816. [PMID: 38427071 DOI: 10.1007/s00234-024-03324-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 02/24/2024] [Indexed: 03/02/2024]
Abstract
PURPOSE Optimal imaging modalities to select patients for endovascular thrombectomy (EVT) in the late window of acute ischemic stroke due to large vessel occlusions (AIS-LVO) are not known. We conducted a systematic review comparing outcomes of patients selected by non-contrast computed tomography (NCCT)/CT angiography (CTA) vs. those selected by CT perfusion (CTP) or magnetic resonance imaging (MRI) for EVT in these patients. METHODS We searched PUBMED, EMBASE, and the Cochrane Library from January 1, 2000, to July 15, 2023, to identify studies comparing outcomes of patients selected for EVT by NCCT/CTA vs. CTP or MRI in the late time window for AIS-LVO. Primary outcome was independence (mRS 0-2) at 90 days or discharge. Secondary outcomes were symptomatic intracranial hemorrhage (sICH) and mortality. We pooled data across studies based on an inverse variance method. RESULTS Six cohort studies with 4208 patients were included. Pooled results showed no significant difference in the rate of independence at 90 days or discharge (RR 0.96, 95% CI 0.88-1.03) and sICH (RR 1.26, 0.85-1.86) between patients selected by NCCT/CTA vs. CTP or MRI for EVT in the late window of AIS-LVO. However, patients selected by NCCT/CTA vs. CTP or MRI for EVT were associated with a higher risk of mortality (RR 1.21, 1.06-1.39). CONCLUSION For AIS-LVO in the late window, patients selected by NCCT/CTA compared with those selected by CTP or MRI for EVT might have a comparable rate of functional independence and sICH. Baseline NCCT/CTA may triage AIS-LVO in the late window.
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Affiliation(s)
- Chun-Hsien Lin
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - David S Liebeskind
- Comprehensive Stroke Center and Department of Neurology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jeffrey L Saver
- Comprehensive Stroke Center and Department of Neurology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Meng Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Puzi, Taiwan.
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Aboul-Nour H, Dolia J, Tarek MA, Grossberg JA, Pabaney A, Damiani M, Al-Bayati AR, Nogueira RG, Haussen DC. Competitive leptomeningeal flow impact on thrombectomy reperfusion grade rating. J Neurointerv Surg 2024:jnis-2023-021268. [PMID: 38302419 DOI: 10.1136/jnis-2023-021268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 01/22/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Competitive leptomeningeal flow (CLF) can be observed immediately after mechanical thrombectomy (MT) reperfusion with retrograde contrast clearing of the distal leptomeningeal branches from non-contrast opacified flow through different vascular territories. We aim to evaluate the frequency of the CLF phenomenon, to determine if it has an association with the degree of leptomeningeal collateral status, and to understand the potentia impact it may have on the final expanded Treatment in Cerebral Ischemia (eTICI) score rating. METHODS Retrospective analysis of a prospective MT database spanning November 2020 to December 2021. Consecutive cases of intracranial internal carotid (i-ICA) or middle cerebral artery (MCA) M1 occlusions were included. CLF was defined by the observation of retrograde clearing of distal MCA branches that were previously opacified by antegrade reperfusion. The clearance of the distal branches is presumed to occur due to CLF via non-contrast opacified posterior cerebral artery or anterior cerebral artery flow. The washout was considered CLF if it cleared abruptly with or without forward reconstitution of antegrade opacification. RESULTS A total of 125 patients met the inclusion criteria. The median age was 64 years (IQR 52.5-75) and 64 (51%) were men. The baseline median National Institutes of Health Stroke Scale score was 17 (IQR 12-22) and the Alberta Stroke Program Early CT Score was 9 (IQR 8-10). Median last known well time to puncture was 7 hours (IQR 4-13.1) and 30.4% received tissue plasminogen activator. Final eTICI 2c-3 was achieved in 80%. CLF was present in 32 (25.6%) patients, who had comparable baseline characteristics to patients without CLF. Twelve (37.5%) patients had regional CLF and 20 (62.5%) had focal CLF. The CLF arm had better leptomeningeal single-phase CTA collaterals than the non-CLF arm (P=0.01). The inter-rater agreement for the eTICI score was moderate when CLF was present and strong in its absence (Krippendorf's alpha=0.65 and 0.81, respectively). There was minimal agreement (Kappa=0.3) for the presence versus absence of CLF between the two operators, possibly related to reader experience. CONCLUSION CLF was observed in 32% of patients, was associated with better collateral flow, and impacted the reported procedural eTICI rating.
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Affiliation(s)
- Hassan Aboul-Nour
- Departments of Neurology and Neurosurgery, University of Kentucky College of Medicine, Lexington, KY, USA
- Department of Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Jaydevsinh Dolia
- Department of Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Mohamed A Tarek
- Department of Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Jonathan A Grossberg
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Aqueel Pabaney
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Mateus Damiani
- Department of Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | | | - Raul G Nogueira
- Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
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Xu Q, Chen Y, Zheng X, Jiang Y, Xu C, Gao Q, Shi F, Zhang J. Clinical efficacy and safety of endovascular treatment for patients with wake-up stroke with large vessel occlusion guided by NCCT-ASPECTS. Interv Neuroradiol 2023:15910199231217145. [PMID: 38055995 DOI: 10.1177/15910199231217145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023] Open
Abstract
OBJECTIVE To evaluate the clinical efficacy and safety of 6 to 24 h endovascular therapy (EVT) in patients with wake-up stroke (WUS) with acute large vessel occlusion (LVO) of the anterior circulation guided by noncontrast computed tomography-Alberta stroke program early CT score (NCCT-ASPECTS). METHODS Fifty-three patients with WUS with acute LVO of the anterior circulation who were treated at the Sir Run Run Shaw Hospital of Zhejiang Medical College from January 2018 to March 2021 were retrospectively analyzed. The patients were divided into NCCT-ASPECTS or CT perfusion groups. Baseline data, perioperative data, and 90-d prognostic information were compared between the two groups. Multivariable logistic regression analysis was used to determine the independent factors influencing outcomes. RESULTS There were no significant differences in the good prognosis, symptomatic intracranial hemorrhage, and mortality rates between the two groups (P > 0.05). Multivariate logistic regression analysis showed that the puncture-recanalization time was an independent factor for good prognosis. CONCLUSION Based on NCCT-ASPECTS guidance, EVT in patients with WUS for acute LVO of the anterior circulation within 6 to 24 h may be safe and effective.
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Affiliation(s)
- Qinglin Xu
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yigang Chen
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xu Zheng
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yun Jiang
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chuan Xu
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qingqing Gao
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Feina Shi
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jinhua Zhang
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Fainardi E, Busto G, Morotti A. Automated advanced imaging in acute ischemic stroke. Certainties and uncertainties. Eur J Radiol Open 2023; 11:100524. [PMID: 37771657 PMCID: PMC10523426 DOI: 10.1016/j.ejro.2023.100524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/12/2023] [Accepted: 09/13/2023] [Indexed: 09/30/2023] Open
Abstract
The purpose of this is study was to review pearls and pitfalls of advanced imaging, such as computed tomography perfusion and diffusion-weighed imaging and perfusion-weighted imaging in the selection of acute ischemic stroke (AIS) patients suitable for endovascular treatment (EVT) in the late time window (6-24 h from symptom onset). Advanced imaging can quantify infarct core and ischemic penumbra using specific threshold values and provides optimal selection parameters, collectively called target mismatch. More precisely, target mismatch criteria consist of core volume and/or penumbra volume and mismatch ratio (the ratio between total hypoperfusion and core volumes) with precise cut-off values. The parameters of target mismatch are automatically calculated with dedicated software packages that allow a quick and standardized interpretation of advanced imaging. However, this approach has several limitations leading to a misclassification of core and penumbra volumes. In fact, automatic software platforms are affected by technical artifacts and are not interchangeable due to a remarkable vendor-dependent variability, resulting in different estimate of target mismatch parameters. In addition, advanced imaging is not completely accurate in detecting infarct core, that can be under- or overestimated. Finally, the selection of candidates for EVT remains currently suboptimal due to the high rates of futile reperfusion and overselection caused by the use of very stringent inclusion criteria. For these reasons, some investigators recently proposed to replace advanced with conventional imaging in the selection for EVT, after the demonstration that non-contrast CT ASPECTS and computed tomography angiography collateral evaluation are not inferior to advanced images in predicting outcome in AIS patients treated with EVT. However, other authors confirmed that CTP and PWI/DWI postprocessed images are superior to conventional imaging in establishing the eligibility of patients for EVT. Therefore, the routine application of automatic assessment of advanced imaging remains a matter of debate. Recent findings suggest that the combination of conventional and advanced imaging might improving our selection criteria.
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Affiliation(s)
- Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Italy
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Giorgio Busto
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Andrea Morotti
- Department of Neurological and Vision Sciences, Neurology Unit, ASST Spedali Civili, Brescia, Italy
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7
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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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Doheim MF, Hagrass AI, Elrefaey M, Al-Bayati AR, Bhatt NR, Lang M, Starr M, Rocha M, Gross B, Nogueira RG. From therapeutic nihilism to armamentarium: A meta-analysis of randomized clinical trials assessing safety and efficacy of endovascular therapy for acute large ischemic strokes. Interv Neuroradiol 2023:15910199231170681. [PMID: 37082795 DOI: 10.1177/15910199231170681] [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: 04/22/2023] Open
Abstract
BACKGROUND Three recent randomized clinical trials (RCTs) investigated the potential benefit of endovascular therapy (EVT) in acute ischemic stroke patients presenting with large infarcts. We aimed to confirm the safety and efficacy of EVT in patients presenting with large infarcts and provide more precise estimations of the treatment effects using study-level meta-analysis. METHODS Comprehensive search of MEDLINE database through PubMed till February 2023 was performed including RCTs only. The data were then extracted from the selected studies and pooled as risk ratio (RR) with 95% confidence interval (95% CI). RESULTS There were a total of 1005 patients across the three qualifying RCTs. Regarding the functional outcomes assessed by modified Rankin Scale (mRS) score, the analyzed data demonstrated statistically significant differences in favor of thrombectomy for both independent ambulatory status (mRS 0-3: RR = 1.78, 95% CI [1.28, 2.48], p = 0.0006) and functional independence (mRS 0-2: RR = 2.54, 95% CI [1.85, 3.48], p < 0.001). The analyzed data did not demonstrate any statistically significant differences between EVT and medical management alone in terms of 90-day mortality (RR = 0.95, 95% CI [0.78, 1.16], p = 0.61), symptomatic intracranial hemorrhage (RR = 1.83, 95% CI [0.95, 3.55], p = 0.07), and need for hemicraniectomy (RR = 1.22, 95% CI [0.43, 3.41], p = 0.71). CONCLUSION This study confirms the benefit of EVT on functional outcomes of patients presenting with large ischemic infarcts without significant differences in the rates of symptomatic intracranial hemorrhage, hemicraniectomy, or 90-day mortality.
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Affiliation(s)
- Mohamed F Doheim
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Mohamed Elrefaey
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Alhamza R Al-Bayati
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nirav R Bhatt
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael Lang
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurosurgery, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Matthew Starr
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Marcelo Rocha
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Bradley Gross
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurosurgery, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Raul G Nogueira
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Ebrahimzadeh SA, Du E, Ivanovic V, Bhadelia RA, Hacein-Bey L, Selim M, Chang YM. Comparing the benefit of ASPECTS on maximum intensity projection images of computed tomography angiography to source images and noncontract computed tomography in predicting infarct volume and collaterals extent. J Stroke Cerebrovasc Dis 2023; 32:107091. [PMID: 37068326 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/18/2023] [Accepted: 03/20/2023] [Indexed: 04/19/2023] Open
Abstract
INTRODUCTION In acute ischemic strokes (AIS), the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) and CT perfusion (CTP) are commonly used to determine mechanical thrombectomy eligibility. Prior work suggests that CTA source image (CTA-SI) ASPECTS (CTAasp) and a newly described CTA maximum intensity projection (CTA-MIP) ASPECTS (MIPasp) better predict the final infarct core. Our goal was to compare MIPasp to CTAasp and non-contrast CT ASPECTS (NCCTasp) for predicting ischemic core and collaterals established by CTP. METHODS AND MATERIALS A single institution, retrospective database for AIS due to internal carotid artery (ICA) or proximal middle cerebral artery (MCA) occlusions between January 2016 and February 2021 was reviewed. We rated ASPECTS on NCCT, CTA-SI, and CTA-MIP at baseline, then used the automated RAPID software to measure CTP ischemic core volume. The accuracy of each ASPECTS in predicting ischemic core volume (ICV) >70 cc and Hypoperfusion intensity ratio (HIR) >0.4 was compared using the receiver operating characteristic (ROC) curve. RESULTS 122/319 patients fulfilled the inclusion criteria. Area under the curve (AUC) for MIPasp was significantly higher than NCCTasp and CTAasp for predicting ICV >70 cc (0.95 vs. 0.89 and 0.95 vs. 0.92, P =0.03 and P = 0.04). For predicting HIR >0.4, AUC for MIPasp was significantly higher than NCCTasp and CTAasp (0.85 vs. 0.72 and 0.85 vs. 0.81, P < 0.001 and P < 0.01). CONCLUSION The predictive accuracy of detecting ischemic stroke with ICV >70cc and HIR >0.4 can be significantly improved using the MIPasp instead of CTAasp or NCCTasp.
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Affiliation(s)
- Seyed Amir Ebrahimzadeh
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, WCB90, 330 Brookline Ave, Boston, MA 02215, USA.
| | - Elizabeth Du
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, WCB90, 330 Brookline Ave, Boston, MA 02215, USA
| | - Vladimir Ivanovic
- Department of Radiology, Section of Neuroradiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rafeeque A Bhadelia
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, WCB90, 330 Brookline Ave, Boston, MA 02215, USA
| | - Lotfi Hacein-Bey
- Department of Radiology, University of California Davis Medical School of Medicine, Sacramento, CA, USA
| | - Magdy Selim
- Department of Neurology, Division of Cerebrovascular Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Yu-Ming Chang
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, WCB90, 330 Brookline Ave, Boston, MA 02215, USA
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10
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Imaging mismatch between Alberta Stroke Program Early CT Score and perfusion imaging may be a good variable for endovascular treatment. Eur Radiol 2023; 33:2629-2637. [PMID: 36502458 DOI: 10.1007/s00330-022-09273-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/18/2022] [Accepted: 10/25/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Some patients with acute large vessel occlusion (LVO) presented imaging mismatch, low Alberta Stroke Program Early CT Score (ASPECTS) with small ischemic core, or high ASPECTS with large ischemic core. The study was designed to explore whether patients with imaging mismatch could benefit from endovascular treatment (EVT). METHODS We retrospectively reviewed patients with LVO treated with EVT in our center from March 2018 to Jul 2020. Patients were divided into three groups, imaging mismatch, small ischemic core, and large ischemic core groups. Pooled analyses based on stroke onset to treatment time were done. Multivariate regression analysis was performed to explore the factors for good outcomes. RESULTS Sixty-eight of 419 patients with LVO presented with imaging mismatch, and 35 of those (51%) achieved good outcomes after EVT at 90-day. No significant differences were noted in good outcomes and symptomatic intracranial hemorrhage (sICH) between patients with imaging mismatch and small ischemic core. Compared with large ischemic core, patients with imaging mismatch presented lower risk of sICH (95% confidence interval (CI) 0.04-0.75, p = 0.011) within 6 h and higher proportion of good outcomes (95% CI 0.37-0.82, p = 0.002) at 6 to 24 h. Baseline NIHSS (odds ratio (OR) = 0.91, 95% CI 0.88-0.95)), ASPECTS (OR = 1.14, 95% CI 1.01-1.29), ischemic core (OR = 0.99, 95% CI 0.98-1.00), and sICH (OR = 61.61, 95% CI 8.09-461.32) were associated with good outcomes. CONCLUSIONS Patients with imaging mismatch treated within 24 h could benefit from EVT and without increasing the risk of sICH. KEY POINTS • Patients with imaging mismatch between ASPECTS and ischemic core could achieve good outcomes after endovascular treatment. • Compared with large ischemic core, patients with imaging mismatch presented lower risk of symptomatic hemorrhage within 6 h and higher proportion of good outcomes within 6-24 h. • Baseline NIHSS score, ASPECTS, ischemic core, and symptomatic intracranial hemorrhage were associated with good outcomes.
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11
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Hashimoto H, Maruo T, Kimoto Y, Nakamura M, Fujinaga T, Nakamura H, Ushio Y. The association between diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomography Score and the outcome following mechanical thrombectomy of anterior circulation occlusion. INTERDISCIPLINARY NEUROSURGERY 2023. [DOI: 10.1016/j.inat.2023.101758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
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Neurological Functional Independence After Endovascular Thrombectomy and Different Imaging Modalities for Large Infarct Core Assessment : A Systematic Review and Meta-analysis. Clin Neuroradiol 2023; 33:21-29. [PMID: 35920865 DOI: 10.1007/s00062-022-01202-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 07/10/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE To investigate the rate of neurological functional independence (NFI) at 90 days in patients with large infarct core (LIC), which was evaluated by different imaging modalities before endovascular thrombectomy (EVT). METHODS PubMed and EMBASE were searched for original studies on clinical functional outcomes at 90 days in LIC patients who received EVT treatment from inception to 28 September 2021. The pooled NFI rates were calculated using random effects model according to different imaging modalities and criteria. RESULTS We included 34 studies enrolling 2997 LIC patients. The NFI rates were 23% (95% confidence interval, CI 15-32%) and 24% (95% CI 10-38%) when LIC was defined as core volume ≥50 ml and ≥ 70 ml separately on computed tomography perfusion, 36% (95% CI 23-48%) and 21% (95% CI 17-25%) when LIC was defined as core volume ≥ 50 ml and ≥ 70 ml separately on magnetic resonance diffusion-weighted imaging (DWI), 28% (95% CI 24-32%) and 37% (95% CI 21-53%) when LIC was defined as DWI-ASPECTS ≤ 5 and ≤ 6 separately, 23% (95% CI 19-27%) and 32% (95% CI 18-46%) when LIC was defined as NCCT-ASPECTS ≤ 5 and ≤ 6 separately. CONCLUSION Similar NFI rates could be obtained after EVT in LIC patients if proper LIC criteria were select according to the imaging modality.
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Gu Y, Hang Y, Jia Z, Zhao L, Shi H, Cao Y, Liu S. Predictive value of computed tomography perfusion for acute ischemic stroke patients with ASPECTS < 6 in an early time window. Clin Neurol Neurosurg 2023; 225:107605. [PMID: 36701939 DOI: 10.1016/j.clineuro.2023.107605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The standard for computed tomography perfusion (CTP) assessment has not been well established in early acute ischemic stroke (AIS). We aimed to examine the prognostic factors for good outcomes in patients who received CTP, with an Alberta Stroke Program Early CT Score (ASPECTS) < 6 after endovascular thrombectomy (EVT) in the early time window (0-6 h). METHODS We retrospectively reviewed 59 patients who met the criteria from October 2019 to April 2021. Based on the modified Rankin Score (mRS) at 90 days, the patients were divided into a good outcome group (mRS 0-2) and a poor outcome group (mRS 3-6). Baseline and procedural characteristics were collected for unilateral and multivariate regression analyses to explore the influencing factors for good outcomes. RESULTS Of the 59 patients included, good outcomes were observed in 21 (35.6%). Multivariate logistic regression analysis showed that smaller ischemic core volume (odds ratio [OR]: 0.950; 95% CI: 0.908-0.994; P = 0.026), lower National Institutes of Health Stroke Scale (NIHSS) score (OR: 0.750; 95% CI: 0.593-0.949; P = 0.017) and shorter stroke onset to reperfusion time (ORT) (OR: 0.981; 95% CI: 0.966-0.996; P = 0.016) were independent predictors for good outcomes at 90 days. CONCLUSION Smaller ischemic core volume based on CTP, lower NIHSS score and shorter ORT were significant independent predictors of good outcomes in patients with ASPECTS < 6 in the early time window after EVT.
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Affiliation(s)
- Yiming Gu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China; Department of Intervention Radiology, Suzhou Municipal Hospital Affiliated to Nanjing Medical University, 242 Guangji Road, Gusu District, Suzhou 215008, China.
| | - Yu Hang
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China.
| | - Zhenyu Jia
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China.
| | - Linbo Zhao
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China.
| | - Haibin Shi
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China.
| | - Yuezhou Cao
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China.
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China.
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Shulman JG, Abdalkader M. Imaging of Central Nervous System Ischemia. Continuum (Minneap Minn) 2023; 29:54-72. [PMID: 36795873 DOI: 10.1212/con.0000000000001185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
OBJECTIVE This article describes imaging modalities used in the evaluation of patients presenting with symptoms of acute ischemic stroke. LATEST DEVELOPMENTS The year 2015 marked the beginning of a new era in acute stroke care with the widespread adoption of mechanical thrombectomy. Subsequent randomized controlled trials in 2017 and 2018 brought the stroke community even further into this new territory with the expansion of the eligibility window for thrombectomy using imaging-based patient selection, which led to an increase in the use of perfusion imaging. Now, after several years of routine use, the debate is ongoing as to when this additional imaging is truly required and when it results in unnecessary delays in time-sensitive stroke care. At this time, more than ever, a robust understanding of neuroimaging techniques, applications, and interpretation is essential for the practicing neurologist. ESSENTIAL POINTS CT-based imaging is the first step in most centers for the evaluation of patients presenting with symptoms of acute stroke because of its wide availability, speed, and safety. Noncontrast head CT alone is sufficient for IV thrombolysis decision making. CT angiography is very sensitive for the detection of large-vessel occlusion and can be used reliably to make this determination. Advanced imaging including multiphase CT angiography, CT perfusion, MRI, and MR perfusion can provide additional information useful for therapeutic decision making in specific clinical scenarios. In all cases, it is essential that neuroimaging be performed and interpreted rapidly to allow for timely reperfusion therapy.
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Giancardo L, Niktabe A, Ocasio L, Abdelkhaleq R, Salazar-Marioni S, Sheth SA. Segmentation of acute stroke infarct core using image-level labels on CT-angiography. Neuroimage Clin 2023; 37:103362. [PMID: 36893661 PMCID: PMC10011814 DOI: 10.1016/j.nicl.2023.103362] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 02/22/2023] [Accepted: 02/24/2023] [Indexed: 03/02/2023]
Abstract
Acute ischemic stroke is a leading cause of death and disability in the world. Treatment decisions, especially around emergent revascularization procedures, rely heavily on size and location of the infarct core. Currently, accurate assessment of this measure is challenging. While MRI-DWI is considered the gold standard, its availability is limited for most patients suffering from stroke. Another well-studied imaging modality is CT-Perfusion (CTP) which is much more common than MRI-DWI in acute stroke care, but not as precise as MRI-DWI, and it is still unavailable in many stroke hospitals. A method to determine infarct core using CT-Angiography (CTA), a much more available imaging modality albeit with significantly less contrast in stroke core area than CTP or MRI-DWI, would enable significantly better treatment decisions for stroke patients throughout the world. Existing deep-learning-based approaches for stroke core estimation have to face the trade-off between voxel-level segmentation / image-level labels and the difficulty of obtaining large enough samples of high-quality DWI images. The former occurs when algorithms can either output voxel-level labeling which is more informative but requires a significant effort by annotators, or image-level labels that allow for much simpler labeling of the images but results in less informative and interpretable output; the latter is a common issue that forces training either on small training sets using DWI as the target or larger, but noisier, dataset using CT-Perfusion (CTP) as the target. In this work, we present a deep learning approach including a new weighted gradient-based approach to obtain stroke core segmentation with image-level labeling, specifically the size of the acute stroke core volume. Additionally, this strategy allows us to train using labels derived from CTP estimations. We find that the proposed approach outperforms segmentation approaches trained on voxel-level data and the CTP estimation themselves.
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Affiliation(s)
- Luca Giancardo
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX 77030 USA.
| | - Arash Niktabe
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030 USA
| | - Laura Ocasio
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX 77030 USA
| | - Rania Abdelkhaleq
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030 USA
| | - Sergio Salazar-Marioni
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030 USA
| | - Sunil A Sheth
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030 USA
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Chen J, Zhang J, Zhu X, Zhang X, Jiang B, Liu Q, Wei ZZ. Selection of patients with acute vertebrobasilar artery occlusion for endovascular treatment by magnetic resonance imaging. Front Neurol 2023; 14:1084819. [PMID: 36891472 PMCID: PMC9986452 DOI: 10.3389/fneur.2023.1084819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/19/2023] [Indexed: 02/22/2023] Open
Abstract
Background and purpose The best method for selecting patients with acute vertebrobasilar artery occlusion (VBAO) who would benefit from endovascular treatment (EVT) is still the key question. This study aimed to assess the efficacy of magnetic resonance imaging (MRI) for selecting patients with acute VBAO for EVT. Materials and methods A total of 14 patients with suspected acute VBAO on MR angiography (MRA) in the EVT database (from April 2016 to August 2019) were enrolled. Acute Stroke Prognosis Early Computed Tomography Score (ASPECTS) and pons-midbrain index were assessed on diffusion-weighted imaging (DWI). EVT included a stent retriever and a rescue treatment (angioplasty and/or stenting). The proportion of successful reperfusion and favorable functional outcomes (modified Rankin Scale ≤ 3) at 90 days was documented. Results A total of 11 patients were included in the final analysis. The median DWI-ASPECTS and pons-midbrain index were 7 and 2, respectively. Underlying stenosis was detected in 10 of 11 (90.9%) patients. Balloon angioplasty and/or stenting were used as rescue therapy for five patients and two patients, respectively. A total of nine patients (81.8%) achieved successful reperfusion (mTICI, 2b, or 3). The 90-day mRS score of 0-3 was achieved in six (54.5%) patients. The mortality rate within 90 days was 18.2% (two of 11 patients). Conclusion DWI plus MRA could help select the patients with acute VBAO for EVT by assessing ASPECTS and the pons-midbrain index. Patients could achieve good reperfusion and favorable functional outcomes.
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Affiliation(s)
- Jun Chen
- Department of Geriatrics, The Affiliated Hospital of Chengde Medical University, Chengde, Hebei, China
| | - Jiwei Zhang
- Department of Neurosurgery, The Affiliated Hospital of Chengde Medical University, Chengde, Hebei, China
| | - Xianjin Zhu
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Xuebin Zhang
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Bin Jiang
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Qi Liu
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zheng Z Wei
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Porto GBF, Chen CJ, Al Kasab S, Essibayi MA, Almallouhi E, Hubbard Z, Chalhoub R, Alawieh A, Maier I, Psychogios MN, Wolfe SQ, Jabbour P, Rai A, Starke RM, Shaban A, Arthur A, Kim JT, Yoshimura S, Grossberg J, Kan P, Fragata I, Polifka A, Osbun J, Mascitelli J, Levitt MR, Williamson R, Romano DG, Crosa R, Gory B, Mokin M, Limaye KS, Casagrande W, Moss M, Grandhi R, Yoo A, Spiotta AM, Park MS. Association of Noncontrast Computed Tomography and Perfusion Modalities With Outcomes in Patients Undergoing Late-Window Stroke Thrombectomy. JAMA Netw Open 2022; 5:e2241291. [PMID: 36367728 PMCID: PMC9652750 DOI: 10.1001/jamanetworkopen.2022.41291] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
IMPORTANCE There is substantial controversy with regards to the adequacy and use of noncontrast head computed tomography (NCCT) for late-window acute ischemic stroke in selecting candidates for mechanical thrombectomy. OBJECTIVE To assess clinical outcomes of patients with acute ischemic stroke presenting in the late window who underwent mechanical thrombectomy stratified by NCCT admission in comparison with selection by CT perfusion (CTP) and diffusion-weighted imaging (DWI). DESIGN, SETTING, AND PARTICIPANTS In this multicenter retrospective cohort study, prospectively maintained Stroke Thrombectomy and Aneurysm (STAR) database was used by selecting patients within the late window of acute ischemic stroke and emergent large vessel occlusion from 2013 to 2021. Patients were selected by NCCT, CTP, and DWI. Admission Alberta Stroke Program Early CT Score (ASPECTS) as well as confounding variables were adjusted. Follow-up duration was 90 days. Data were analyzed from November 2021 to March 2022. EXPOSURES Selection by NCCT, CTP, or DWI. MAIN OUTCOMES AND MEASURES Primary outcome was functional independence (modified Rankin scale 0-2) at 90 days. RESULTS Among 3356 patients, 733 underwent late-window mechanical thrombectomy. The median (IQR) age was 69 (58-80) years, 392 (53.5%) were female, and 449 (65.1%) were White. A total of 419 were selected with NCCT, 280 with CTP, and 34 with DWI. Mean (IQR) admission ASPECTS were comparable among groups (NCCT, 8 [7-9]; CTP, 8 [7-9]; DWI 8, [7-9]; P = .37). There was no difference in the 90-day rate of functional independence (aOR, 1.00; 95% CI, 0.59-1.71; P = .99) after adjusting for confounders. Symptomatic intracerebral hemorrhage (NCCT, 34 [8.6%]; CTP, 37 [13.5%]; DWI, 3 [9.1%]; P = .12) and mortality (NCCT, 78 [27.4%]; CTP, 38 [21.1%]; DWI, 7 [29.2%]; P = .29) were similar among groups. CONCLUSIONS AND RELEVANCE In this cohort study, comparable outcomes were observed in patients in the late window irrespective of neuroimaging selection criteria. Admission NCCT scan may triage emergent large vessel occlusion in the late window.
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Affiliation(s)
| | - Ching-Jen Chen
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Sami Al Kasab
- Department of Neurosurgery, Medical University of South Carolina, Charleston
| | | | - Eyad Almallouhi
- Department of Neurosurgery, Medical University of South Carolina, Charleston
| | - Zachary Hubbard
- Department of Neurosurgery, Medical University of South Carolina, Charleston
| | - Reda Chalhoub
- Department of Neurosurgery, Medical University of South Carolina, Charleston
| | - Ali Alawieh
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Ilko Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Stacey Q. Wolfe
- Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ansaar Rai
- Department of Radiology, West Virginia University, Morgantown
| | - Robert M. Starke
- Department of Neurosurgery, University of Miami Health System, Miami, Florida
| | - Amir Shaban
- Department of Neurology, University of Iowa, Iowa City
| | - Adam Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Science Center, Memphis
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | | | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston
| | - Isabel Fragata
- Neuroradiology Department, Hospital São José Centro Hospitalar, Lisboa, Portugal
| | - Adam Polifka
- Department of Neurosurgery, University of Florida, Gainesville
| | - Joshua Osbun
- Department of Neurological Surgery, Washington University in St Louis, St Louis, Missouri
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio
| | | | - Richard Williamson
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Daniele G. Romano
- Department of Radiology, A.O.U.S. Giovanni di Dio e Ruggi d’Aragona, Salerno, Italy
| | - Roberto Crosa
- Department of Neurosurgery, Endovascular Neurological Center, Montevideo, Uruguay
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hospitalier Régional Universitaire de Nancy, Nancy, France
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa
| | | | - Walter Casagrande
- Department of Cerebrovascular and Endovascular Neurosurgery, Hospital Juan Fernandez, Buenos Aires, Argentina
| | - Mark Moss
- Department of Interventional Neuroradiology, Washington Regional Medical Center, Fayetteville, Arkansas
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City
| | - Albert Yoo
- Department of Neurosurgery, Texas Stroke Institute, Plano
| | | | - Min S. Park
- Department of Neurosurgery, University of Virginia Health, Charlottesville
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18
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Katyal A, Bhaskar SMM. Value of pre-intervention computed tomography perfusion imaging in the assessment of tissue outcome and long-term clinical prognosis in patients with anterior circulation acute ischemic stroke receiving reperfusion therapy: a systematic review. Acta Radiol 2022; 63:1243-1254. [PMID: 34342497 DOI: 10.1177/02841851211035892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Computed tomography perfusion (CTP) imaging has emerged as an important adjunct to the current armamentarium of acute ischemic stroke (AIS) workflow. However, its adoption in routine clinical practice is far from optimal. PURPOSE To investigate the putative association of CTP imaging biomarkers in the assessment of prognosis in acute ischemic stroke. MATERIAL AND METHODS We performed a systematic review of the literature using MEDLINE, EMBASE, and Cochrane Central Register of Clinical Trials focusing on CTP biomarkers, tissue-based and clinical-based patient outcomes. We included randomized controlled trials, prospective cohort studies, and case-controlled studies published from January 2005 to 28 August 2020. Two independent reviewers conducted the study appraisal, data extraction, and quality assessment of the studies. RESULTS A total of 60 full-text studies were included in the final systematic review analysis. Increasing infarct core volume is associated with reduced odds of achieving functional independence (modified Rankin score 0-2) at 90 days and is correlated with the final infarct volume when reperfusion is achieved. CONCLUSION CTP has value in assessing tissue perfusion status in the hyperacute stroke setting and the long-term clinical prognosis of patients with AIS receiving reperfusion therapy. However, the prognostic use of CTP requires optimization and further validation.
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Affiliation(s)
- Anubhav Katyal
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, NSW, Australia.,University of New South Wales (UNSW), South West Sydney Clinical School, Sydney, NSW, Australia
| | - Sonu Menachem Maimonides Bhaskar
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, NSW, Australia.,Liverpool Hospital & South West Sydney Local Health District (SWSLHD), Department of Neurology & Neurophysiology, Sydney, NSW, Australia.,NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW, Australia.,Thrombolysis and Endovascular WorkFLOw Network (TEFLON), Sydney, NSW, Australia
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19
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Clinical and therapeutic variables may influence the association between infarct core predicted by CT perfusion and clinical outcome in acute stroke. Eur Radiol 2022; 32:4510-4520. [PMID: 35182205 DOI: 10.1007/s00330-022-08590-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/07/2021] [Accepted: 01/22/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVES After an acute ischemic stroke, patients with a large CT perfusion (CTP) predicted infarct core (pIC) have poor clinical outcome. However, previous research suggests that this relationship may be relevant for subgroups of patients determined by pretreatment and treatment-related variables while negligible for others. We aimed to identify these variables. METHODS We included a cohort of 828 patients with acute proximal carotid arterial occlusions imaged with a whole-brain CTP within 8 h from stroke onset. pIC was computed on CTP Maps (cerebral blood flow < 30%), and poor clinical outcome was defined as a 90-day modified Rankin Scale score > 2. Potential mediators of the association between pIC and clinical outcome were evaluated through first-order and advanced interaction analyses in the derivation cohort (n = 654) for obtaining a prediction model. The derived model was further validated in an independent cohort (n = 174). RESULTS The volume of pIC was significantly associated with poor clinical outcome (OR = 2.19, 95% CI = 1.73 - 2.78, p < 0.001). The strength of this association depended on baseline National Institute of Health Stroke Scale, glucose levels, the use of thrombectomy, and the interaction of age with thrombectomy. The model combining these variables showed good discrimination for predicting clinical outcome in both the derivation cohort and validation cohorts (area under the receiver operating characteristic curve 0.780 (95% CI = 0.746-0.815) and 0.782 (95% CI = 0.715-0.850), respectively). CONCLUSIONS In patients imaged within 8 h from stroke onset, the association between pIC and clinical outcome is significantly modified by baseline and therapeutic variables. These variables deserve consideration when evaluating the prognostic relevance of pIC. KEY POINTS •The volume of CT perfusion (CTP) predicted infarct core (pIC) is associated with poor clinical outcome in acute ischemic stroke imaged within 8 h of onset. •The relationship between pIC and clinical outcome may be modified by baseline clinical severity, glucose levels, thrombectomy use, and the interaction of age with thrombectomy. •CTP pIC should be evaluated in an individual basis for predicting clinical outcome in patients imaged within 8 h from stroke onset.
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20
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Malikova H, Weichet J. Diagnosis of Ischemic Stroke: As Simple as Possible. Diagnostics (Basel) 2022; 12:diagnostics12061452. [PMID: 35741262 PMCID: PMC9221735 DOI: 10.3390/diagnostics12061452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/06/2022] [Accepted: 06/10/2022] [Indexed: 11/29/2022] Open
Abstract
The absolute majority of strokes in high-income countries, roughly 91%, are of ischemic origin. This review is focused on acute ischemic stroke (AIS) with large vessel occlusion (LVO) in the anterior circulation, which is considered the most devastating subtype of AIS. Moreover, stroke survivors impose substantial direct and indirect costs of care as well as costs due to productivity loss. We review of diagnostic possibilities of individual imaging methods such as computed tomography and magnetic resonance imaging, and discuss their pros and cons in the imaging of AIS. The goals of non-invasive imaging in AIS are as follows: (a) to rule out intracranial hemorrhage and to quickly exclude hemorrhagic stroke and contraindications for intravenous thrombolysis; (b) to identify potential LVO and its localization and to quickly provide guidance for endovascular treatment; (c) to assess/estimate the volume or size of the ischemic core. We suggest fast diagnostic management, which is able to quickly satisfy the above-mentioned diagnostic goals in AIS with LVO.
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Affiliation(s)
- Hana Malikova
- Correspondence: ; Tel.: +420-267-162-400; Fax: +420-267-162-409
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21
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Dhillon PS, Butt W, Podlasek A, McConachie N, Lenthall R, Nair S, Malik L, Booth TC, Bhogal P, Makalanda HLD, Spooner O, Mortimer A, Lamin S, Chavda S, Chew HS, Nader K, Al-Ali S, Butler B, Rajapakse D, Appleton JP, Krishnan K, Sprigg N, Smith A, Lobotesis K, White P, James MA, Bath PM, Dineen RA, England TJ. Perfusion Imaging for Endovascular Thrombectomy in Acute Ischemic Stroke Is Associated With Improved Functional Outcomes in the Early and Late Time Windows. Stroke 2022; 53:2770-2778. [PMID: 35506384 PMCID: PMC9389941 DOI: 10.1161/strokeaha.121.038010] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The impact on clinical outcomes of patient selection using perfusion imaging for endovascular thrombectomy (EVT) in patients with acute ischemic stroke presenting beyond 6 hours from onset remains undetermined in routine clinical practice.
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Affiliation(s)
- Permesh Singh Dhillon
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, United Kingdom. (P.S.D., N.M., R.L., S.N., L.M.).,National Institute for Health and Care Research Nottingham Biomedical Research Centre, University of Nottingham, United Kingdom. (P.S.D., A.P., R.A.D.)
| | - Waleed Butt
- Interventional Neuroradiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, United Kingdom (W.B., S.L., S.C., H.S.C., K.N., S.A.-A., B.B., D.R.)
| | - Anna Podlasek
- National Institute for Health and Care Research Nottingham Biomedical Research Centre, University of Nottingham, United Kingdom. (P.S.D., A.P., R.A.D.)
| | - Norman McConachie
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, United Kingdom. (P.S.D., N.M., R.L., S.N., L.M.)
| | - Robert Lenthall
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, United Kingdom. (P.S.D., N.M., R.L., S.N., L.M.)
| | - Sujit Nair
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, United Kingdom. (P.S.D., N.M., R.L., S.N., L.M.)
| | - Luqman Malik
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, United Kingdom. (P.S.D., N.M., R.L., S.N., L.M.)
| | - Thomas C Booth
- Department of Neuroradiology, King's College Hospital NHS Foundation Trust, London, United Kingdom (T.C.B.).,School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom (T.C.B.)
| | - Pervinder Bhogal
- Interventional Neuroradiology, The Royal London Hospital, Barts Health NHS Trust, United Kingdom. (P.B., H.L.D.M.)
| | | | - Oliver Spooner
- Stroke, The Royal London Hospital, Barts Health NHS Trust, United Kingdom. (O.S.)
| | - Alex Mortimer
- Interventional Neuroradiology, Southmead Hospital, North Bristol NHS Trust, United Kingdom (A.M.)
| | - Saleh Lamin
- Interventional Neuroradiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, United Kingdom (W.B., S.L., S.C., H.S.C., K.N., S.A.-A., B.B., D.R.)
| | - Swarupsinh Chavda
- Interventional Neuroradiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, United Kingdom (W.B., S.L., S.C., H.S.C., K.N., S.A.-A., B.B., D.R.)
| | - Han Seng Chew
- Interventional Neuroradiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, United Kingdom (W.B., S.L., S.C., H.S.C., K.N., S.A.-A., B.B., D.R.)
| | - Kurdow Nader
- Interventional Neuroradiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, United Kingdom (W.B., S.L., S.C., H.S.C., K.N., S.A.-A., B.B., D.R.)
| | - Samer Al-Ali
- Interventional Neuroradiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, United Kingdom (W.B., S.L., S.C., H.S.C., K.N., S.A.-A., B.B., D.R.)
| | - Benjamin Butler
- Interventional Neuroradiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, United Kingdom (W.B., S.L., S.C., H.S.C., K.N., S.A.-A., B.B., D.R.)
| | - Dilina Rajapakse
- Interventional Neuroradiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, United Kingdom (W.B., S.L., S.C., H.S.C., K.N., S.A.-A., B.B., D.R.)
| | - Jason P Appleton
- Stroke, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, United Kingdom (J.P.A.).,Institute of Applied Health Research, College of Dental and Medical Sciences, University of Birmingham, United Kingdom (J.P.A.)
| | - Kailash Krishnan
- Stroke, Queens Medical Centre, Nottingham University Hospitals NHS Trust, United Kingdom. (K.K., N.S., P.M.B.)
| | - Nikola Sprigg
- Stroke, Queens Medical Centre, Nottingham University Hospitals NHS Trust, United Kingdom. (K.K., N.S., P.M.B.).,Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, United Kingdom. (N.S., P.M.B., T.J.E.)
| | - Aubrey Smith
- Interventional Neuroradiology, Hull Royal Infirmary, Hull and East Yorkshire Hospitals NHS Trust, United Kingdom (A.S.)
| | - Kyriakos Lobotesis
- Interventional Neuroradiology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (K.L.)
| | - Phil White
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom (P.W.)
| | - Martin A James
- University of Exeter Medical School, United Kingdom (M.A.J.).,Royal Devon and Exeter NHS Foundation Trust, United Kingdom (M.A.J.).,Sentinel Stroke National Audit Programme, King's College London, United Kingdom (M.A.J.)
| | - Philip M Bath
- Stroke, Queens Medical Centre, Nottingham University Hospitals NHS Trust, United Kingdom. (K.K., N.S., P.M.B.).,Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, United Kingdom. (N.S., P.M.B., T.J.E.)
| | - Robert A Dineen
- National Institute for Health and Care Research Nottingham Biomedical Research Centre, University of Nottingham, United Kingdom. (P.S.D., A.P., R.A.D.).,Radiological Sciences, Mental Health and Clinical Neuroscience, University of Nottingham, United Kingdom. (R.A.D.)
| | - Timothy J England
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, United Kingdom. (N.S., P.M.B., T.J.E.).,Stroke, University Hospitals of Derby and Burton NHS Foundation Trust, United Kingdom (T.J.E.)
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22
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Pellegrino MP, Guerra FBD, Perissinotti IN. Decision-making strategies for reperfusion therapies: navigating through stroke trials gaps. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:60-71. [PMID: 35976313 PMCID: PMC9491414 DOI: 10.1590/0004-282x-anp-2022-s123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
Despite there being a robust amount of literature and numerous randomized clinical trials regarding acute ischemic stroke treatment, the trials have not included some frequent controversial situations for which decision-making strategies are an urgent and unmet need in clinical practice. This article tries to summarize the current evidence about some selected situations (mechanical thrombectomy in low ASPECTS, low NIHSS with proximal occlusion, acute basilar occlusion, distal and medium vessel occlusion, among others), make suggestions on how to approach them in clinical practice and show what to expect in acute stroke research in the near future.
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Affiliation(s)
- Mateus Paquesse Pellegrino
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Radiologia, São Paulo, SP, Brazil
| | | | - Iago Navas Perissinotti
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto Central, Departamento de Neurologia, São Paulo, SP, Brazil
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23
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Yang Y, Cui T, Li Z, Li J, Duan T, Yuan Z, Wang C, Wan J, Li C, Zhang S, Li L, Hu F, Wu B. Benefits of Endovascular Treatment in Late Window for Acute Ischemic Stroke Selected without CT Perfusion: A Real-World Study. Clin Interv Aging 2022; 17:577-587. [PMID: 35497054 PMCID: PMC9041145 DOI: 10.2147/cia.s362119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/12/2022] [Indexed: 01/01/2023] Open
Abstract
Objective This study examined the functional outcomes and safety of endovascular treatment (EVT) in acute ischemic stroke (AIS) patients owing to large vessel occlusion of the anterior circulation, presented during a late-time window (6–24 hours after last seen well (LSW)) in a real-world practice. Methods This was a retrospective analysis from a bi-center prospective cohort. According to the stroke treatment, patients with continuous Alberta Stroke Plan Early Aspect score (ASPECTS) ≥6 on non-contrast CT (NCCT) and moderate to good collateral state on CT angiography (CTA) were divided into EVT group and standard medical treatment (SMT) group. The primary outcome was the rate of functional independence (90-day mRS ≤2). Safety outcomes were the occurrence of symptomatic intracranial hemorrhage (sICH) and the 90-day mortality. Results Among the 288 enrolled patients (53.5% male, median age 64 years), there were 167 patients in the EVT group and 121 in the SMT group. After multivariable adjustments for potential confounders, EVT was associated with functional independence (adjusted OR: 3.052; 95% confidence interval (CI): 1.553–5.997; p = 0.001). In the PSM cohort, 44.2% (42/95) of patients in the EVT group versus 18.9% (18/95) in the SMT group achieved functional independence (OR: 3.39, 95% CI: 1.763–6.517), and there was a significant difference favoring EVT over the SMT in the overall distribution of mRS (OR: 2.170, 95% CI: 1.302–3.618) at 90 days. The rate of sICH did not differ between the EVT and SMT groups (10.5% vs 8.4%, p = 0.804) nor did 90-day mortality (18.9% vs 22.1%, p = 0.719). No interaction was found in p-values with statistical significance in subgroup analysis. Conclusion This real-world experience suggests that EVT for late-presenting stroke patients, based on small core on NCCT and moderate to good collaterals on CTA, is associated with better outcomes than SMT alone, with no increase in sICH and 90-day mortality rates.
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Affiliation(s)
- Yuan Yang
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
| | - Ting Cui
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Zuoxiao Li
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
| | - Jinglun Li
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
| | - Ting Duan
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Zhengzhou Yuan
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
| | - Changyi Wang
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Jincheng Wan
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Cao Li
- Department of Radiology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
| | - Shujiang Zhang
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
| | - Ling Li
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
| | - Fayun Hu
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Bo Wu
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
- Correspondence: Bo Wu; Fayun Hu, Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China, Tel +86-18980602142; +86-15902861270, Email ;
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24
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Shchehlov D, Konotopchyk S, Pastushyn O. Clinical protocol of the ischemic stroke patients treatment. UKRAINIAN INTERVENTIONAL NEURORADIOLOGY AND SURGERY 2022. [DOI: 10.26683/2786-4855-2021-3(37)-14-56] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Today in Ukraine there is no single standardized protocol for the treatment of patients in the acute period of ischemic stroke using modern methods of diagnosis and treatment, which include thrombolytic therapy and endovascular treatment. This protocol was created and implemented in Scientific-practical Center of endovascular neuroradiology, NAMS of Ukraine and is based on the latest recommendations of AHA/ASA and ESO, as well as registers of patients with ischemic stroke. The main purpose of this publication is the creation and implementation of «instructions» for the diagnosis and selection of objective tactics for treating patients in the acute period of ischemic stroke.
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25
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Koopman MS, Hoving JW, Kappelhof M, Berkhemer OA, Beenen LFM, van Zwam WH, de Jong HWAM, Dankbaar JW, Dippel DWJ, Coutinho JM, Marquering HA, Emmer BJ, Majoie CBLM. Association of Ischemic Core Imaging Biomarkers With Post-Thrombectomy Clinical Outcomes in the MR CLEAN Registry. Front Neurol 2022; 12:771367. [PMID: 35082746 PMCID: PMC8784730 DOI: 10.3389/fneur.2021.771367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/30/2021] [Indexed: 12/04/2022] Open
Abstract
Background: A considerable proportion of acute ischemic stroke patients treated with endovascular thrombectomy (EVT) are dead or severely disabled at 3 months despite successful reperfusion. Ischemic core imaging biomarkers may help to identify patients who are more likely to have a poor outcome after endovascular thrombectomy (EVT) despite successful reperfusion. We studied the association of CT perfusion-(CTP), CT angiography-(CTA), and non-contrast CT-(NCCT) based imaging markers with poor outcome in patients who underwent EVT in daily clinical practice. Methods: We included EVT-treated patients (July 2016–November 2017) with an anterior circulation occlusion from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry with available baseline CTP, CTA, and NCCT. We used multivariable binary and ordinal logistic regression to analyze the association of CTP ischemic core volume, CTA-Collateral Score (CTA-CS), and Alberta Stroke Program Early CT Score (ASPECTS) with poor outcome (modified Rankin Scale score (mRS) 5-6) and likelihood of having a lower score on the mRS at 90 days. Results: In 201 patients, median core volume was 13 (IQR 5-41) mL. Median ASPECTS was 9 (IQR 8-10). Most patients had grade 2 (83/201; 42%) or grade 3 (28/201; 14%) collaterals. CTP ischemic core volume was associated with poor outcome [aOR per 10 mL 1.02 (95%CI 1.01–1.04)] and lower likelihood of having a lower score on the mRS at 90 days [aOR per 10 mL 0.85 (95% CI 0.78–0.93)]. In multivariable analysis, neither CTA-CS nor ASPECTS were significantly associated with poor outcome or the likelihood of having a lower mRS. Conclusion: In our population of patients treated with EVT in daily clinical practice, CTP ischemic core volume is associated with poor outcome and lower likelihood of shift toward better outcome in contrast to either CTA-CS or ASPECTS.
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Affiliation(s)
- Miou S Koopman
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Jan W Hoving
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Olvert A Berkhemer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Ludo F M Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Wim H van Zwam
- Department of Radiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, Netherlands
| | - Hugo W A M de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Jan Willem Dankbaar
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Henk A Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands.,Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
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Evolution of Hypodensity on Non-Contrast CT in Correlation with Collaterals in Anterior Circulation Stroke with Successful Endovascular Reperfusion. J Clin Med 2022; 11:jcm11020446. [PMID: 35054140 PMCID: PMC8777970 DOI: 10.3390/jcm11020446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 01/07/2022] [Accepted: 01/13/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction: The aim of the study was to assess the impact of collaterals on the evolution of hypodensity on non-contrast CT (NCCT) in anterior circulation stroke with reperfusion by mechanical thrombectomy (MT). Methods: We retrospectively included stroke patients with middle cerebral artery occlusion who were reperfused by MT in early and late time window. Artificial intelligence (AI)-based software was used to calculate of hypodensity volumes at baseline NCCT (V1) and at follow-up NCCT 24 h after MT (V2), along with the difference between the two volumes (V2-V1) and the follow-up (V2)/baseline (V1) volume ratio (V2/V1). The same software was used to classify collateral status by using a 4-point scale where the score of zero indicated no collaterals and the score of three represented contrast filling of all collaterals. The volumetric values were correlated with the collateral scores. Results: Collateral scores had significant negative correlation with V1 (p = 0.035), V2, V2− V1 and V2/V1 (p < 0.001). In cases with collateral score = 3, V2 was significantly smaller or absent compared to V1; in those with collateral score 2, V2 was slightly larger than V1, and in those with scores 1 and 0 V2 was significantly larger than V1. These relationships were observed in both early and late time windows. Conclusions: The collateral status determined the evolution of the baseline hypodensity on NCCT in patients with anterior circulation stroke who had MT reperfusion. Damage can be stable or reversible in patients with good collaterals while in those with poor collaterals tissues that initially appear normal will frequently appear as necrotic after 24 h. With good collaterals, it is stable or can be reversible while with poor collaterals, normal looking tissue frequently appears as necrotic in follow-up exam. Hence, acute hypodensity represents different states of the ischemic brain parenchyma.
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27
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Del Brutto VJ, Rundek T, Sacco RL. Prognosis After Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00017-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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28
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Nguyen TN, Abdalkader M, Nagel S, Qureshi MM, Ribo M, Caparros F, Haussen DC, Mohammad MH, Sheth SA, Ortega-Gutierrez S, Siegler JE, Zaidi S, Olive-Gadea M, Henon H, Möhlenbruch MA, Castonguay AC, Nannoni S, Kaesmacher J, Puri AS, Seker F, Farooqui M, Salazar-Marioni S, Kuhn AL, Kaliaev A, Farzin B, Boisseau W, Masoud HE, Lopez CY, Rana A, Kareem SA, Sathya A, Klein P, Kassem MW, Ringleb PA, Cordonnier C, Gralla J, Fischer U, Michel P, Jovin TG, Raymond J, Zaidat OO, Nogueira RG. Noncontrast Computed Tomography vs Computed Tomography Perfusion or Magnetic Resonance Imaging Selection in Late Presentation of Stroke With Large-Vessel Occlusion. JAMA Neurol 2021; 79:22-31. [PMID: 34747975 PMCID: PMC8576630 DOI: 10.1001/jamaneurol.2021.4082] [Citation(s) in RCA: 116] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Question In patients with proximal anterior circulation occlusion stroke presenting in the extended window, are rates of favorable outcomes at 90 days comparable in the patients selected for thrombectomy with noncontrast computed tomography vs patients selected with computed tomography perfusion or magnetic resonance imaging? Findings In a multicenter cohort of 1604 patients in the extended window with large-vessel occlusion, patients selected by noncontrast computed tomography had comparable clinical and safety outcomes with patients selected by computed tomography perfusion or magnetic resonance imaging. Meaning These findings suggest noncontrast computed tomography alone may be used as an alternative to advanced imaging in selecting patients with late-presenting large-vessel occlusion for mechanical thrombectomy. Importance Advanced imaging for patient selection in mechanical thrombectomy is not widely available. Objective To compare the clinical outcomes of patients selected for mechanical thrombectomy by noncontrast computed tomography (CT) vs those selected by computed tomography perfusion (CTP) or magnetic resonance imaging (MRI) in the extended time window. Design, Setting, and Participants This multinational cohort study included consecutive patients with proximal anterior circulation occlusion stroke presenting within 6 to 24 hours of time last seen well from January 2014 to December 2020. This study was conducted at 15 sites across 5 countries in Europe and North America. The duration of follow-up was 90 days from stroke onset. Exposures Computed tomography with Alberta Stroke Program Early CT Score, CTP, or MRI. Main Outcomes and Measures The primary end point was the distribution of modified Rankin Scale (mRS) scores at 90 days (ordinal shift). Secondary outcomes included the rates of 90-day functional independence (mRS scores of 0-2), symptomatic intracranial hemorrhage, and 90-day mortality. Results Of 2304 patients screened for eligibility, 1604 patients were included, with a median (IQR) age of 70 (59-80) years; 848 (52.9%) were women. A total of 534 patients were selected to undergo mechanical thrombectomy by CT, 752 by CTP, and 318 by MRI. After adjustment of confounders, there was no difference in 90-day ordinal mRS shift between patients selected by CT vs CTP (adjusted odds ratio [aOR], 0.95 [95% CI, 0.77-1.17]; P = .64) or CT vs MRI (aOR, 0.95 [95% CI, 0.8-1.13]; P = .55). The rates of 90-day functional independence (mRS scores 0-2 vs 3-6) were similar between patients selected by CT vs CTP (aOR, 0.90 [95% CI, 0.7-1.16]; P = .42) but lower in patients selected by MRI than CT (aOR, 0.79 [95% CI, 0.64-0.98]; P = .03). Successful reperfusion was more common in the CT and CTP groups compared with the MRI group (474 [88.9%] and 670 [89.5%] vs 250 [78.9%]; P < .001). No significant differences in symptomatic intracranial hemorrhage (CT, 42 [8.1%]; CTP, 43 [5.8%]; MRI, 15 [4.7%]; P = .11) or 90-day mortality (CT, 125 [23.4%]; CTP, 159 [21.1%]; MRI, 62 [19.5%]; P = .38) were observed. Conclusions and Relevance In patients undergoing proximal anterior circulation mechanical thrombectomy in the extended time window, there were no significant differences in the clinical outcomes of patients selected with noncontrast CT compared with those selected with CTP or MRI. These findings have the potential to widen the indication for treating patients in the extended window using a simpler and more widespread noncontrast CT–only paradigm.
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Affiliation(s)
- Thanh N Nguyen
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts.,Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Muhammad M Qureshi
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.,Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Marc Ribo
- Stroke Unit, Department of Neurology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Francois Caparros
- University Lille, Inserm, Centre Hospitalier Universitaire de Lille, U1172, LilNCog-Lille Neuroscience & Cognition, Lille, France
| | - Diogo C Haussen
- Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - Mahmoud H Mohammad
- Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - Sunil A Sheth
- Department of Neurology, McGovern Medical School at UTHealth, Houston, Texas
| | | | - James E Siegler
- Department of Neurology, Cooper University Hospital, Camden, New Jersey
| | - Syed Zaidi
- Department of Neurology, University of Toledo, Toledo, Ohio
| | - Marta Olive-Gadea
- Stroke Unit, Department of Neurology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Hilde Henon
- University Lille, Inserm, Centre Hospitalier Universitaire de Lille, U1172, LilNCog-Lille Neuroscience & Cognition, Lille, France
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Stefania Nannoni
- Stroke Center, Neurology Service, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, Bern, Switzerland.,Institute of Diagnostic, Interventional and Pediatric Radiology, University Hospital Bern, Inselspital, Bern, Switzerland
| | - Ajit S Puri
- Neurointerventional Radiology, Department of Radiology, University of Massachusetts, Worcester, Massachusetts
| | - Fatih Seker
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | | | - Anna L Kuhn
- Neurointerventional Radiology, Department of Radiology, University of Massachusetts, Worcester, Massachusetts
| | - Artem Kaliaev
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Behzad Farzin
- Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - William Boisseau
- Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - Hesham E Masoud
- Department of Neurology, SUNY Upstate Medical University Hospital, Syracuse, New York
| | - Carlos Ynigo Lopez
- Department of Neurology, SUNY Upstate Medical University Hospital, Syracuse, New York
| | - Ameena Rana
- Department of Neurology, Cooper University Hospital, Camden, New Jersey
| | - Samer Abdul Kareem
- Neuroscience and Stroke Program, Bon Secours Mercy Health St Vincent Hospital, Toledo, Ohio
| | - Anvitha Sathya
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Piers Klein
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Mohammad W Kassem
- Neuroscience and Stroke Program, Bon Secours Mercy Health St Vincent Hospital, Toledo, Ohio
| | - Peter A Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Charlotte Cordonnier
- University Lille, Inserm, Centre Hospitalier Universitaire de Lille, U1172, LilNCog-Lille Neuroscience & Cognition, Lille, France
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland.,Department of Neurology, University Hospital Basel, University of Basel, Switzerland
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Tudor G Jovin
- Department of Neurology, Cooper University Hospital, Camden, New Jersey
| | - Jean Raymond
- Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - Osama O Zaidat
- Neuroscience and Stroke Program, Bon Secours Mercy Health St Vincent Hospital, Toledo, Ohio
| | - Raul G Nogueira
- Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
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Bouslama M, Haussen DC, Rodrigues G, Barreira C, Frankel M, Nogueira RG. Novel selection paradigms for endovascular stroke treatment in the extended time window. J Neurol Neurosurg Psychiatry 2021; 92:1152-1157. [PMID: 34117100 DOI: 10.1136/jnnp-2020-325284] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 05/31/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND PURPOSE The optimal selection methodology for stroke thrombectomy beyond 6 hours remains to be established. METHODS Review of a prospectively collected database of thrombectomy patients with anterior circulation strokes, adequate CT perfusion (CTP) maps, National Institute of Health Stroke Scale (NIHSS)≥10 and presenting beyond 6 hours from January 2014 to October 2018. Patients were categorised according to five selection paradigms: DAWN clinical-core mismatch (DAWN-CCM): between age-adjusted NIHSS and CTP core, DEFUSE 3 perfusion imaging mismatch (DEFUSE-3-PIM): between CTP-derived perfusion defect (Tmax >6 s lesion) and ischaemic core volumes and three non-contrast CT Alberta Stroke Program Early CT Score (ASPECTS)-based criteria: age-adjusted clinical-ASPECTS mismatch (aCAM): between age-adjusted NIHSS and ASPECTS, eloquence-adjusted clinical ASPECTS mismatch (eCAM): ASPECTS 6-10 and non-involvement of the right M6 and left M4 areas and standard clinical ASPECTS mismatch (sCAM): ASPECTS 6-10. RESULTS 310 patients underwent analysis. DEFUSE-3-PIM had the highest proportion of qualifying patients followed by sCAM, eCAM, aCAM and DAWN-CCM (93.5%, 92.6%, 90.6%, 90% and 84.5%, respectively). Patients meeting aCAM, eCAM, sCAM and DAWN-CCM criteria had higher rates of 90-day good outcome compared with their non-qualifying counterparts(43.2% vs 12%,p=0.002; 42.4% vs 17.4%, p=0.02; 42.4% vs 11.2%, p=0.009; and 43.7% vs 20.5%, p=0.007, respectively). There was no difference between patients meeting DEFUSE-3-PIM criteria versus not(40.8% vs 31.3%,p=0.45). In multivariate analysis, all selection modalities except for DEFUSE-3-PIM were independently associated with 90-day good outcome. CONCLUSIONS ASPECTS-based selection paradigms for late presenting and wake-up strokes ET have comparable proportions of qualifying patients and similar 90-day functional outcomes as DAWN-CCM and DEFUSE-3-PIM. They also might lead to better outcome discrimination. These could represent a potential alternative for centres where access to advanced imaging is limited.
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Affiliation(s)
- Mehdi Bouslama
- Neurology, Emory University, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
| | - Diogo C Haussen
- Neurology, Emory University, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
| | - Gabriel Rodrigues
- Neurology, Emory University, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
| | - Clara Barreira
- Neurology, Emory University, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
| | - Michael Frankel
- Neurology, Emory University, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
| | - Raul G Nogueira
- Neurology, Emory University, Atlanta, Georgia, USA .,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
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30
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Kerleroux B, Janot K, Hak JF, Kaesmacher J, Hassen WB, Benzakoun J, Oppenheim C, Herbreteau D, Ifergan H, Bricout N, Henon H, Yoshimoto T, Inoue M, Consoli A, Costalat V, Naggara O, Lapergue B, Cagnazzo F, Boulouis G. Mechanical Thrombectomy in Patients with a Large Ischemic Volume at Presentation: Systematic Review and Meta-Analysis. J Stroke 2021; 23:358-366. [PMID: 34649380 PMCID: PMC8521249 DOI: 10.5853/jos.2021.00724] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 07/12/2021] [Indexed: 12/25/2022] Open
Abstract
The benefits of mechanical thrombectomy (MT) for patients with acute ischemic stroke (AIS) and a large ischemic core (LIC) at presentation are uncertain. We aimed to obtain up-to-date aggregate estimates of the outcomes following MT in patients with volumetrically assessed LIC. We conducted a Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA)-conformed, PROSPERO-registered, systematic review and meta-analysis of studies that included patients with AIS and a baseline LIC treated with MT, reported ischemic core volume quantitatively, and included patients with a LIC defined as a core volume ≥50 mL. The search was restricted to studies published between January 2015 and June 2020. Random-effects-meta-analysis was used to assess the effect of MT on 90-day unfavorable outcome (i.e., modified Rankin Scale [mRS] 3–6), mortality, and symptomatic intracranial hemorrhage (sICH) occurrence. Sensitivity analyses were performed for imaging-modality (computed tomography-perfusion or magnetic resonance-diffusion weighted imaging) and LIC-definition (≥50 or ≥70 mL). We analyzed 10 studies (954 patients), including six (682 patients) with a control group, allowing to compare 332 patients with MT to 350 who received best-medical-management alone. Overall, after MT the rate of patients with mRS 3–6 at 90 days was 74% (99% confidence interval [CI], 67 to 84; Z-value=7.04; I2=92.3%) and the rate of 90-day mortality was 36% (99% CI, 33 to 40; Z-value=–7.07; I2=74.5). Receiving MT was associated with a significant decrease in mRS 3–6 odds ratio (OR) 0.19 (99% CI, 0.11 to 0.33; P<0.01; Z-value=–5.92; I2=62.56) and in mortality OR 0.60 (99% CI, 0.34 to 1.06; P=0.02; Z-value=–2.30; I2=58.72). Treatment group did not influence the proportion of patients experiencing sICH, OR 0.96 (99% CI, 0.2 to 1.49; P=0.54; Z-value=–0.63; I2=64.74). Neither imaging modality for core assessment, nor LIC definition influenced the aggregated outcomes. Using aggregate estimates, MT appeared to decrease the risk of unfavorable functional outcome in patients with a LIC assessed volumetrically at baseline.
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Affiliation(s)
- Basile Kerleroux
- Department of Neuroradiology, GHU Paris, Sainte Anne Hospital Pscyhiatry and Neurosciences Institute (IPNP), UMR_S1266, INSERM, University of Paris, Tours, France
| | - Kevin Janot
- Department of Neuroradiology, University Hospital of Tours, Tours, France
| | - Jean François Hak
- Department of Neuroradiology, University Hospital of Marseille La Timone, Marseille, France
| | - Johannes Kaesmacher
- Institute of Diagnostic, Interventional and Pediatric Radiology and Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Wagih Ben Hassen
- Department of Neuroradiology, GHU Paris, Sainte Anne Hospital Pscyhiatry and Neurosciences Institute (IPNP), UMR_S1266, INSERM, University of Paris, Tours, France
| | - Joseph Benzakoun
- Department of Neuroradiology, GHU Paris, Sainte Anne Hospital Pscyhiatry and Neurosciences Institute (IPNP), UMR_S1266, INSERM, University of Paris, Tours, France
| | - Catherine Oppenheim
- Department of Neuroradiology, GHU Paris, Sainte Anne Hospital Pscyhiatry and Neurosciences Institute (IPNP), UMR_S1266, INSERM, University of Paris, Tours, France
| | - Denis Herbreteau
- Department of Neuroradiology, University Hospital of Tours, Tours, France
| | - Heloise Ifergan
- Department of Neuroradiology, University Hospital of Tours, Tours, France
| | - Nicolas Bricout
- Diagnostic and Interventional Neuroradiology, University Hospital of Lille, Lille, France
| | - Hilde Henon
- Neuroradiology Department and Stroke Unit, University Hospital of Lille, Lille, France
| | - Takeshi Yoshimoto
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center, Suita, Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center, Suita, Japan
| | - Arturo Consoli
- Department of Diagnostic and Interventional Neuroradiology, Foch Hospital, Suresnes, France
| | - Vincent Costalat
- Neuroradiology Department, University Hospital of Gui de Chauliac, Montpellier, France
| | - Olivier Naggara
- Department of Neuroradiology, GHU Paris, Sainte Anne Hospital Pscyhiatry and Neurosciences Institute (IPNP), UMR_S1266, INSERM, University of Paris, Tours, France
| | - Bertrand Lapergue
- Department of Interventional Neuroradiology, Foch Hospital, Suresnes, France
| | - Federico Cagnazzo
- Neuroradiology Department, University Hospital of Gui de Chauliac, Montpellier, France
| | - Grégoire Boulouis
- Department of Neuroradiology, GHU Paris, Sainte Anne Hospital Pscyhiatry and Neurosciences Institute (IPNP), UMR_S1266, INSERM, University of Paris, Tours, France.,Department of Neuroradiology, University Hospital of Tours, Tours, France
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31
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Su R, Cornelissen SAP, van der Sluijs M, van Es ACGM, van Zwam WH, Dippel DWJ, Lycklama G, van Doormaal PJ, Niessen WJ, van der Lugt A, van Walsum T. autoTICI: Automatic Brain Tissue Reperfusion Scoring on 2D DSA Images of Acute Ischemic Stroke Patients. IEEE TRANSACTIONS ON MEDICAL IMAGING 2021; 40:2380-2391. [PMID: 33939611 DOI: 10.1109/tmi.2021.3077113] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The Thrombolysis in Cerebral Infarction (TICI) score is an important metric for reperfusion therapy assessment in acute ischemic stroke. It is commonly used as a technical outcome measure after endovascular treatment (EVT). Existing TICI scores are defined in coarse ordinal grades based on visual inspection, leading to inter- and intra-observer variation. In this work, we present autoTICI, an automatic and quantitative TICI scoring method. First, each digital subtraction angiography (DSA) acquisition is separated into four phases (non-contrast, arterial, parenchymal and venous phase) using a multi-path convolutional neural network (CNN), which exploits spatio-temporal features. The network also incorporates sequence level label dependencies in the form of a state-transition matrix. Next, a minimum intensity map (MINIP) is computed using the motion corrected arterial and parenchymal frames. On the MINIP image, vessel, perfusion and background pixels are segmented. Finally, we quantify the autoTICI score as the ratio of reperfused pixels after EVT. On a routinely acquired multi-center dataset, the proposed autoTICI shows good correlation with the extended TICI (eTICI) reference with an average area under the curve (AUC) score of 0.81. The AUC score is 0.90 with respect to the dichotomized eTICI. In terms of clinical outcome prediction, we demonstrate that autoTICI is overall comparable to eTICI.
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Zhang WY, Xiang SF, Yang SJ, Wu YP, Li JT, Liu GK, Li JF, Wang WW. The Application of Computed Tomography Perfusion in the Alberta Stroke Program Early Computed Tomography Score for Endovascular Treatment of Acute Ischemic Stroke in the Anterior Circulation. Int J Gen Med 2021; 14:1865-1871. [PMID: 34040418 PMCID: PMC8139848 DOI: 10.2147/ijgm.s309232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 04/29/2021] [Indexed: 12/17/2022] Open
Abstract
Objective The present study investigated the predictive value of each perfusion parameter of the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) in CT perfusion (CTP) imaging for the prognosis of endovascular treatment at the time of admission in patients with acute ischemic stroke in the anterior circulation. Patients and Methods The imaging data of 62 patients with acute ischemic stroke in the anterior circulation with an onset time of 6 h or less were retrospectively analyzed. All patients underwent the one-stop whole-brain dynamic volume four-dimensional (4D) CT angiography (CTA)-CTP and cranial magnetic resonance imaging (MRI) within seven days after treatment. The patients were divided into better and worse prognosis groups according to their clinical symptoms, combined with an MRI-ASPECTS score of ≤ 6 within seven days after treatment. The observed perfusion parameters included cerebral blood flow (CBF)-ASPECTS, cerebral blood volume (CBV)-ASPECTS, mean transit time (MTT)-ASPECTS, and time to peak (TTP)-ASPECTS. The difference in ASPECTS scores involving the CTP parameter, as well as diagnostic power, was compared between the two groups of patients. Results All CTP-ASPECTS scores negatively correlated with clinical prognosis. The higher the CTP-ASPECTS scores preceding treatment in patients with ischemic stroke in the anterior circulation, the better the prognosis. There were statistically significant differences in the scores of CBF-ASPECTS and CBV-ASPECTS between the two groups (P < 0.05). Receiver operating curve (ROC) analysis showed that the parameter with the largest area under the curve (AUC) was the CBF-ASPECTS score (P = 0.003), with a sensitivity of 90.9%, a specificity of 59.1%, and an AUC of 0.806, which was the most valuable prognostic predictor. Conclusion The CBF-ASPECTS score presented significant value as a primary indicator for predicting the outcome of endovascular treatment in patients with acute ischemic stroke in the anterior circulation, and it had good application prospects in clinical practice.
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Affiliation(s)
- Wei-Yong Zhang
- Department of CT/MRI, Handan Central Hospital, Handan, 056001, People's Republic of China
| | - Shi-Feng Xiang
- Department of CT/MRI, Handan Central Hospital, Handan, 056001, People's Republic of China
| | - Su-Jun Yang
- Department of CT/MRI, Handan Central Hospital, Handan, 056001, People's Republic of China
| | - Yi-Ping Wu
- Department of Neurology, Handan Central Hospital, Handan, 056001, People's Republic of China
| | - Jun-Tao Li
- Department of Neurology, Handan Central Hospital, Handan, 056001, People's Republic of China
| | - Guo-Kun Liu
- Department of CT/MRI, Handan Central Hospital, Handan, 056001, People's Republic of China
| | - Jian-Fei Li
- Department of CT/MRI, Handan Central Hospital, Handan, 056001, People's Republic of China
| | - Wei-Wei Wang
- Department of CT/MRI, Handan Central Hospital, Handan, 056001, People's Republic of China
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Xing PF, Zhang YW, Zhang L, Li ZF, Shen HJ, Zhang YX, Li H, Hua WL, Liu P, Liu P, Yang PF, Hong B, Deng BQ, Liu JM. Higher Baseline Cortical Score Predicts Good Outcome in Patients With Low Alberta Stroke Program Early Computed Tomography Score Treated with Endovascular Treatment. Neurosurgery 2021; 88:612-618. [PMID: 33270112 DOI: 10.1093/neuros/nyaa472] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/12/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with large vessel occlusion and noncontrast computed tomography (CT) Alberta Stroke Program Early CT Score (ASPECTS) <6 may benefit from endovascular treatment (EVT). There is uncertainty about who will benefit from it. OBJECTIVE To explore the predicting factors for good outcome in patients with ASPECTS <6 treated with EVT. METHODS We retrospectively reviewed 60 patients with ASPECTS <6 treated with EVT in our center between March 2018 and June 2019. Patients were divided into 2 groups because of the modified Rankin Score (mRS) at 90 d: good outcome group (mRS 0-2) and poor outcome group (mRS ≥3). Baseline and procedural characteristics were collected for unilateral variate and multivariate regression analyses to explore the influent variates for good outcome. RESULTS Good outcome (mRS 0-2) was achieved in 24 (40%) patients after EVT and mortality was 20% for 90 d. Compared with the poor outcome group, higher baseline cortical ASPECTS (c-ASPECTS), lower intracranial hemorrhage, and malignant brain edema after thrombectomy were noted in the good outcome group (all P < .01). Multivariate logistic regression showed that only baseline c-ASPECTS (≥3) was positive factor for good outcome (odds ratio = 4.29; 95% CI, 1.21-15.20; P = .024). The receiver operating characteristics curve indicated a moderate value of c-ASPECTS for predicting good outcome, with the area under receiver operating characteristics curve 0.70 (95% CI, 0.56-0.83; P = .011). CONCLUSION Higher baseline c-ASPECTS was a predictor for good clinical outcome in patients with ASPECTS <6 treated with EVT, which could be helpful to treatment decision.
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Affiliation(s)
- Peng-Fei Xing
- Department of Neurology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yong-Wei Zhang
- Department of Neurology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Lei Zhang
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zi-Fu Li
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Hong-Jian Shen
- Department of Neurology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yong-Xin Zhang
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - He Li
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Wei-Long Hua
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Pei Liu
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Peng Liu
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Peng-Fei Yang
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Bo Hong
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Ben-Qiang Deng
- Department of Neurology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jian-Min Liu
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
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Nannoni S, Kaesmacher J, Ricciardi F, Strambo D, Dunet V, Hajdu S, Saliou G, Mordasini P, Hakim A, Arnold M, Gralla J, Fischer U, Michel P. ASPECTS-based selection for late endovascular treatment: a retrospective two-site cohort study. Int J Stroke 2021; 17:434-443. [PMID: 33787411 DOI: 10.1177/17474930211009806] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The DAWN trial demonstrated the effectiveness of late endovascular treatment in acute ischemic stroke patients selected on the basis of a clinical-core mismatch. We explored in a real-world sample of endovascular treatment patients if a clinical-ASPECTS (Alberta Stroke Program Early CT Score) mismatch was associated with an outcome benefit after late endovascular treatment. METHODS We retrospectively analyzed all consecutive acute ischemic stroke patients admitted 6-24 h after last proof of good health in two stroke centers, with initial National Institutes of Health Stroke Scale (NIHSS) ≥10 and an internal carotid artery or M1 occlusion. We defined clinical-ASPECTS mismatch as NIHSS ≥ 10 and ASPECTS ≥ 7, or NIHSS ≥ 20 and ASPECTS ≥ 5. We assessed the interaction between the presence of the clinical-ASPECTS mismatch and late endovascular treatment using ordinal shift analysis of the three-month modified Rankin Scale and adjusting for multiple confounders. RESULTS The included 337 patients had a median age of 73 years (IQR = 61-82), admission NIHSS of 18 (15-22), and baseline ASPECTS of 7 (5-9). Out of 196 (58.2%) patients showing clinical-ASPECTS mismatch, 146 (74.5%) underwent late endovascular treatment. Among 141 (41.8%) mismatch negative patients, late endovascular treatment was performed in 72 (51.1%) patients. In the adjusted analysis, late endovascular treatment was significantly associated with a better outcome in the presence of clinical-ASPECTS mismatch (adjusted odd ratio, aOR = 2.83; 95% confidence interval, CI: 1.48-5.58) but not in its absence (aOR = 1.32; 95%CI: 0.61-2.84). The p-value for the interaction term between clinical-ASPECTS mismatch and late endovascular treatment was 0.073. CONCLUSIONS In our retrospective two-site analysis, late endovascular treatment seemed effective in the presence of a clinical-ASPECTS mismatch, but not in its absence. If confirmed in randomized trials, this finding could support the use of an ASPECTS-based selection for late endovascular treatment decisions, obviating the need for advanced imaging.
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Affiliation(s)
- Stefania Nannoni
- Stroke Center, Neurology Service, 30635Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, Bern, Switzerland.,Institute of Diagnostic, Interventional and Pediatric Radiology, University Hospital Bern, Inselspital, Bern, Switzerland
| | - Federico Ricciardi
- Stroke Center, Neurology Service, 30635Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Davide Strambo
- Stroke Center, Neurology Service, 30635Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Vincent Dunet
- Department of Diagnostic and Interventional Radiology, 30635Lausanne University Hospital, and University of Lausanne, Lausanne, Switzerland
| | - Steven Hajdu
- Department of Diagnostic and Interventional Radiology, 30635Lausanne University Hospital, and University of Lausanne, Lausanne, Switzerland
| | - Guillaume Saliou
- Department of Diagnostic and Interventional Radiology, 30635Lausanne University Hospital, and University of Lausanne, Lausanne, Switzerland
| | - Pasquale Mordasini
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, Bern, Switzerland
| | - Arsany Hakim
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Patrik Michel
- Stroke Center, Neurology Service, 30635Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Karhi S, Tähtinen O, Aherto J, Matikka H, Manninen H, Nerg O, Taina M, Jäkälä P, Vanninen R. Effect of different thresholds for CT perfusion volumetric analysis on estimated ischemic core and penumbral volumes. PLoS One 2021; 16:e0249772. [PMID: 33882098 PMCID: PMC8059822 DOI: 10.1371/journal.pone.0249772] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 03/24/2021] [Indexed: 01/08/2023] Open
Abstract
Purpose This single-center study compared three threshold settings for automated analysis of the ischemic core (IC) and penumbral volumes using computed tomographic perfusion, and their accuracy for predicting final infarct volume (FIV) in patients with anterior circulation acute ischemic stroke (AIS). Methods Fifty-two consecutive AIS patients undergoing mechanical thrombectomy (November 2015–March 2018) were included. Perfusion images were retrospectively analyzed using a single CT Neuro perfusion application (syngo.via 4.1, Siemens Healthcare GmbH). Three threshold values (S1–S3) were derived from another commercial package (RAPID; iSchema View) (S1), up-to-date syngo.via default values (S2), and adapted values for syngo.via from a reference study (S3). The results were compared with FIV determined by non-contrast CT. Results The median IC volume (mL) was 24.6 (interquartile range: 13.7–58.1) with S1 and 30.1 (20.1–53.1) with S2/S3. After removing the contralateral hemisphere from the analysis, the median IC volume decreased by 1.33(0–3.14) with S1 versus 9.13 (6.24–14.82) with S2/S3. The median penumbral volume (mL) was 74.52 (49.64–131.91), 77.86 (46.56–99.23), and 173.23 (125.86–200.64) for S1, S2, and S3, respectively. Limiting analysis to the affected hemisphere, the penumbral volume decreased by 1.6 (0.13–9.02), 19.29 (12.59–26.52), and 58.33 mL (45.53–74.84) for S1, S2, and S3, respectively. The correlation between IC and FIV was highest in patients with successful recanalization (n = 34, r = 0.784 for S1; r = 0.797 for S2/S3). Conclusion Optimizing thresholds significantly improves the accuracy of estimated IC and penumbral volumes. Current recommended values produce diversified results. International guidelines based on larger multicenter studies should be established to support the standardization of volumetric analysis in clinical decision-making.
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Affiliation(s)
- Simo Karhi
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- * E-mail:
| | - Olli Tähtinen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Joona Aherto
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Hanna Matikka
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Hannu Manninen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Ossi Nerg
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- Neuro Center, Kuopio University Hospital, Kuopio, Finland
| | - Mikko Taina
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Pekka Jäkälä
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- Neuro Center, Kuopio University Hospital, Kuopio, Finland
| | - Ritva Vanninen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
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Derraz I, Ahmed R, Benali A, Corti L, Cagnazzo F, Dargazanli C, Gascou G, Riquelme C, Lefevre PH, Bonafe A, Arquizan C, Costalat V. FLAIR vascular hyperintensities and functional outcome in nonagenarians with anterior circulation large-vessel ischemic stroke treated with endovascular thrombectomy. Eur Radiol 2021; 31:7406-7416. [PMID: 33851277 DOI: 10.1007/s00330-021-07866-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 03/04/2021] [Accepted: 03/11/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To establish whether imaging assessments of irreversibly injured ischemic core and potentially salvageable penumbral volumes and collateral circulation were associated with functional outcome in nonagenarians (90 years or older) undergoing endovascular thrombectomy (EVT). METHODS Data from a prospectively maintained institutional registry of consecutive stroke patients treated with EVT from January 2012 to December 2018 were retrospectively analyzed. Functional outcome was evaluated with the modified Rankin scale (mRS) at 3 months. mRS score of 0-3 was defined as a good clinical outcome. Ischemic core and penumbral volumes were calculated using the RAPID software. Quantification of collateral circulation was performed using a fluid-attenuated inversion recovery vascular hyperintensity (FVH)-Alberta Stroke Program Early CT Score (ASPECTS) rating system. RESULTS Among 85 patients (age, 92.4 ± 2.6 years; men, 30.6%) treated with EVT, good outcome (mRS 0-3) was achieved in 29 (34.1%) patients and 31 (36.5%) patients died at 90 days. The median estimated ischemic core volume was 15 mL (IQR, 7-27 mL). The median mismatch volume was 83 mL (IQR, 43-120 mL). The median FVH score was 4 (IQR, 3-4). FVH score was independently associated with good functional outcome (adjusted OR = 1.96 [95% CI, 1.16-3.32]; p = 0.01 per 1-point increase) and mortality (adjusted OR = 0.54 [95% CI, 0.34-0.85]; p = 0.007 per 1-point increase). Ischemic core and mismatch volumes were associated with neither good outcome nor mortality. CONCLUSIONS In nonagenarians with anterior circulation large-vessel ischemic stroke, good collaterals as measured by the FVH-ASPECTS rating system are independently associated with improved outcomes and may help select patients for reperfusion therapy in this frail population. KEY POINTS • Endovascular thrombectomy can allow at least 1 in 3 patients older than 90 years of age to achieve good functional outcome (modified Rankin scale of 0-3) at 3 months. • Functional outcome at 3 months is associated with pre-stroke status (number and severity of patients' comorbidities). • A higher FVH score (as reflected by higher FLAIR vascular hyperintensity [FVH]-Alberta Stroke Program Early CT Score [ASPECTS] values) is independently associated with better 3-month functional outcome and mortality in nonagenarians with anterior circulation ischemic stroke.
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Affiliation(s)
- Imad Derraz
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France.
| | - Raed Ahmed
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Amel Benali
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Lucas Corti
- Department of Neurology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Federico Cagnazzo
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Cyril Dargazanli
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Gregory Gascou
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Carlos Riquelme
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Pierre-Henri Lefevre
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Alain Bonafe
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Caroline Arquizan
- Department of Neurology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Vincent Costalat
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
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Bouslama M, Barreira CM, Haussen DC, Rodrigues GM, Pisani L, Frankel MR, Nogueira RG. Endovascular reperfusion outcomes in patients with a stroke and low ASPECTS is highly dependent on baseline infarct volumes. J Neurointerv Surg 2021; 14:117-121. [PMID: 33722970 DOI: 10.1136/neurintsurg-2020-017184] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/12/2021] [Accepted: 02/13/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients with large vessel occlusion stroke (LVOS) and a low Alberta Stroke Program Early CT Score (ASPECTS) are often not offered endovascular therapy (ET) as they are thought to have a poor prognosis. OBJECTIVE To compare the outcomes of patients with low and high ASPECTS undergoing ET based on baseline infarct volumes. METHODS Review of a prospectively collected endovascular database at a tertiary care center between September 2010 and March 2020. All patients with anterior circulation LVOS and interpretable baseline CT perfusion (CTP) were included. Subjects were divided into groups with low ASPECTS (0-5) and high ASPECTS (6-10) and subsequently into limited and large CTP-core volumes (cerebral blood flow 30% >70 cc). The primary outcome measure was the difference in rates of 90-day good outcome as defined by a modified Rankin Scale (mRS) score of 0 to 2 across groups. RESULTS 1248 patients fit the inclusion criteria. 125 patients had low ASPECTS, of whom 16 (12.8%) had a large core (LC), whereas 1123 patients presented with high ASPECTS, including 29 (2.6%) patients with a LC. In the category with a low ASPECTS, there was a trend towards lower rates of functional independence (90-day modified Rankin Scale (mRS) score 0-2) in the LC group (18.8% vs 38.9%, p=0.12), which became significant after adjusting for potential confounders in multivariable analysis (aOR=0.12, 95% CI 0.016 to 0.912, p=0.04). Likewise, LC was associated with significantly lower rates of functional independence (31% vs 51.9%, p=0.03; aOR=0.293, 95% CI 0.095 to 0.909, p=0.04) among patients with high ASPECTS. CONCLUSIONS Outcomes may vary significantly in the same ASPECTS category depending on infarct volume. Patients with ASPECTS ≤5 but baseline infarct volumes ≤70 cc may achieve independence in nearly 40% of the cases and thus should not be excluded from treatment.
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Affiliation(s)
- Mehdi Bouslama
- Department of Neurology, Emory University, Atlanta, Georgia, USA
| | - Clara M Barreira
- Department of Neurology, Neurosurgery and Radiology, Emory University, Atlanta, Georgia, USA
| | - Diogo C Haussen
- Department of Neurology, Neurosurgery and Radiology, Emory University, Atlanta, Georgia, USA
| | | | - Leonardo Pisani
- Department of Radiology, Georgetown University Medical Center, Washington, District of Columbia, USA
| | | | - Raul G Nogueira
- Department of Neurology and Interventional Neuroradiology, Emory University, Atlanta, Georgia, USA
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Yamagami H, Hayakawa M, Inoue M, Iihara K, Ogasawara K, Toyoda K, Hasegawa Y, Ohata K, Shiokawa Y, Nozaki K, Ezura M, Iwama T. Guidelines for Mechanical Thrombectomy in Japan, the Fourth Edition, March 2020: A Guideline from the Japan Stroke Society, the Japan Neurosurgical Society, and the Japanese Society for Neuroendovascular Therapy. Neurol Med Chir (Tokyo) 2021; 61:163-192. [PMID: 33583863 DOI: 10.2176/nmc.nmc.st.2020-0357] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Osaka, Japan
| | - Mikito Hayakawa
- Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Manabu Inoue
- Division of Stroke Care Unit/Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Koji Iihara
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University, Morioka, Iwate, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yasuhiro Hasegawa
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan.,Stroke Center and Department of Neurology, Shin-yurigaoka General Hospital, Kawasaki, Kanagawa, Japan
| | - Kenji Ohata
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Osaka, Japan
| | | | - Kazuhiko Nozaki
- Department of Neurosurgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Masayuki Ezura
- Department of Neurosurgery, National Hospital Organization Sendai Medical Center, Sendai, Miyagi, Japan
| | - Toru Iwama
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Gifu, Japan
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Nannoni S, Ricciardi F, Strambo D, Sirimarco G, Wintermark M, Dunet V, Michel P. Correlation between ASPECTS and Core Volume on CT Perfusion: Impact of Time since Stroke Onset and Presence of Large-Vessel Occlusion. AJNR Am J Neuroradiol 2021; 42:422-428. [PMID: 33509915 DOI: 10.3174/ajnr.a6959] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 10/15/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Both ASPECTS and core volume on CTP are used to estimate infarct volume in acute ischemic stroke. To evaluate the potential role of ASPECTS for acute endovascular treatment decisions, we studied the correlation between ASPECTS and CTP core, depending on the timing and the presence of large-vessel occlusion. MATERIALS AND METHODS We retrospectively reviewed all MCA acute ischemic strokes with standardized reconstructions of CTP maps entered in the Acute STroke Registry and Analysis of Lausanne (ASTRAL) registry. Correlation between ASPECTS and CTP core was determined for early (<6 hours) versus late (6-24 hours) times from stroke onset and in the presence versus absence of large-vessel occlusion. We used correlation coefficients and adjusted multiple linear regression models. RESULTS We included 1046 patients with a median age of 71.4 years (interquartile range, IQR = 59.8-79.4 years), an NIHSS score of 12 (IQR, 6-18), an ASPECTS of 9 (IQR, 7-10), and a CTP core of 13.6 mL (IQR, 0.6-52.8 mL). The overall correlation between ASPECTS and CTP core was moderate (ρ = -0.49, P < .01) but significantly stronger in the late-versus-early window (ρ = -0.56 and ρ = -0.48, respectively; P = .05) and in the presence versus absence of large-vessel occlusion (ρ = -0.40 and ρ = -0.20, respectively; P < .01). In the regression model, the independent association between ASPECTS and CTP core was confirmed and was twice as strong in late-arriving patients with large-vessel occlusion (β = -0.21 per 10 mL; 95% CI, -0.27 to -0.15; P < .01) than in the overall population (β = -0.10; 95% CI, -0.14 to -0.07; P < .01). CONCLUSIONS In a large cohort of patients with acute ischemic stroke, we found a moderate correlation between ASPECTS and CTP core. However, this was stronger in patients with large-vessel occlusion and longer delay from stroke onset. Our results could support the use of ASPECTS as a surrogate marker of CTP core in late-arriving patients with acute ischemic stroke with large-vessel occlusion.
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Affiliation(s)
- S Nannoni
- From the Stroke Center (S.N., D.S., G.S., P.M.), Neurology Service
| | - F Ricciardi
- Department of Statistical Science (F.R.), University College London, London, UK
| | - D Strambo
- From the Stroke Center (S.N., D.S., G.S., P.M.), Neurology Service
| | - G Sirimarco
- From the Stroke Center (S.N., D.S., G.S., P.M.), Neurology Service
| | - M Wintermark
- Department of Radiology (M.W.), Neuroradiology Division, Stanford University and Medical Center, Stanford, California
| | - V Dunet
- Department of Diagnostic and Interventional Radiology (V.D.), Lausanne University Hospital, Lausanne, Switzerland
| | - P Michel
- From the Stroke Center (S.N., D.S., G.S., P.M.), Neurology Service
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Shigeta K, Ota T, Kaneko J, Sato K, Aoki R, Jimbo H, Sato Y, Kuroshima Y, Shiokawa Y, Hirano T. Negative impact of Interhospital Transfer on Clinical Outcomes of Mechanical Thrombectomy for Fast Progressive Stroke. J Stroke Cerebrovasc Dis 2021; 30:105633. [PMID: 33517031 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/04/2020] [Accepted: 01/16/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES The time-dependence of the clinical outcome of mechanical thrombectomy is higher in the "fast progressor" in whom cerebral ischemia progresses rapidly. The impact of time-consuming interhospital transfer (IT) on the clinical outcome of such patients is unknown. The effect on clinical outcomes of IT of fast progressors was investigated. METHODS Among the patients enrolled in the Tokyo/Tama REgistry of Acute endovascular Thrombectomy, fast progressor cerebral ischemia cases were retrospectively investigated. In this study, a fast progressor was defined as a case with an Alberta Stroke Program Early CT Score less than 6 and last known well (LKW) to arterial puncture within 6 h. Patients' background characteristics, treatment progress, and the modified Rankin Scale (mRS) score at 3 months were examined. RESULTS Of a total of 1182 patients, 92 (7.8%) were included, with 76 patients in the direct transfer (DT) group, and 16 patients in the IT group. Median LKW to reperfusion was 190 min and 272 min, respectively (P<.001). The number of patients with mRS scores 0-2 at three months was 22 (28.9%) in the DT group and 1 (6.2%) in the IT group. Interhospital transfer was an independent factor associated with worse outcomes (odds ratio 0.08, 95% confidence interval 0.01-0.87, P=.038). CONCLUSION This study showed that, among fast progressor patients, the IT group had a worse prognosis than the DT group. To provide good clinical outcomes for fast progressor patients, those who are likely to undergo mechanical thrombectomy should be sent directly to a thrombectomy-capable center.
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Affiliation(s)
- Keigo Shigeta
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center, 3256, Midorhicho, Tachikawa, Tokyo 190-0014, Japan.
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, 2-8-29, Musashidai, Fuchu, Tokyo 183-8524, Japan.
| | - Junya Kaneko
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama, Tokyo 206-8512, Japan
| | - Katsuya Sato
- Department of Neurosurgery, Showa General Hospital, 8-1-1 Hanakoganei, Kodaira, Tokyo 187-8510, Japan.
| | - Rie Aoki
- Department of Neurosurgery, Tokai University Hachioji Hospital, 1838 Ishikawamachi, Hachioji, Tokyo 192-0032, Japan.
| | - Hiroyuki Jimbo
- Department of Neurosurgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo 193-0998, Japan.
| | - Yohei Sato
- Department of Neurosurgery, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonancho, Musashino, Tokyo 180-8610, Japan.
| | - Yoshiaki Kuroshima
- Department of Neurosurgery, Hino Municipal Hospital, 4-3-1 Tamadaira, Hino, Tokyo 191-0062, Japan
| | - Yoshiaki Shiokawa
- Department of Neurosurgery, Kyorin University, 6-20-2, Shinkawa, Mitaka, Tokyo 181-8611, Japan.
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, 6-20-2, Shinkawa, Mitaka, Tokyo 181-8611, Japan.
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Voleti S, Vidovich J, Corcoran B, Zhang B, Khandwala V, Mistry EA, Khatri P, Tomsick T, Vagal A. Correlation of Alberta Stroke Program Early Computed Tomography Score With Computed Tomography Perfusion Core in Large Vessel Occlusion in Delayed Time Windows. Stroke 2021; 52:498-504. [PMID: 33406866 DOI: 10.1161/strokeaha.120.030353] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The Alberta Stroke Program Early Computed Tomography (CT) Score (ASPECTS) and CT perfusion (CTP) are commonly used to predict the ischemic core in acute ischemic strokes. CT angiography source images (CTA-SI) can also provide additional information to identify the extent of ischemia. Our objective was to investigate the correlation of noncontrast CT (NCCT) ASPECTS and CTA-SI ASPECTS with CTP core volumes. METHODS We utilized a single institutional, retrospective registry of consecutive patients with acute ischemic stroke with large vessel occlusion between May 2016 and May 2018. We graded ASPECTS both on baseline NCCT and CTA-SI and measured CTP core using automated RAPID software (cerebral blood flow <30%). We used Spearman's correlation coefficients to evaluate the correlation between continuous variables. RESULTS A total of 52 patients fit the inclusion criteria of large vessel occlusion in 6 to 24 hours and baseline imaging work up of NCCT, CTA, and CTP. The median age was 63 (interquartile range=53.5-75) and 38.46% were female. The median NCCT ASPECTS was 7 (interquartile range=6-9), CTA-SI ASPECTS was 5 (interquartile range=4-7), and CTP core was 14.5 mL (interquartile range=0-46 mL). There was a moderate correlation between NCCT ASPECTS and CTP core (rs=-0.55, P<0.0001) and between CTA-SI ASPECTS and CTP core (rs=-0.50, P=0.0002). The optimal NCCT ASPECTS cutoff score to detect CTP core ≤70 mL was ≥6 (sensitivity, 0.84; specificity, 0.57; positive predictive value, 0.93; negative predictive value, 0.36) and the optimal CTA-SI ASPECTS was ≥5 (sensitivity, 0.76; specificity, 0.71; positive predictive value, 0.94; negative predictive value, 0.31). CONCLUSIONS There was a moderate correlation between NCCT and CTA-SI ASPECTS in predicting CTP defined ischemic core in delayed time windows. Further studies are needed to determine if NCCT and CTA imaging could be used for image-based patient selection when CTP imaging is not available.
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Affiliation(s)
- Sriharsha Voleti
- Department of Radiology (S.V., J.V., B.C., V.K., T.T., A.V.), University of Cincinnati Medical Center, OH
| | - Johnathan Vidovich
- Department of Radiology (S.V., J.V., B.C., V.K., T.T., A.V.), University of Cincinnati Medical Center, OH
| | - Brendan Corcoran
- Department of Radiology (S.V., J.V., B.C., V.K., T.T., A.V.), University of Cincinnati Medical Center, OH
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, OH (B.Z.)
| | - Vivek Khandwala
- Department of Radiology (S.V., J.V., B.C., V.K., T.T., A.V.), University of Cincinnati Medical Center, OH
| | - Eva A Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN (E.A.M.)
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati Medical Center, OH
| | - Thomas Tomsick
- Department of Radiology (S.V., J.V., B.C., V.K., T.T., A.V.), University of Cincinnati Medical Center, OH
| | - Achala Vagal
- Department of Radiology (S.V., J.V., B.C., V.K., T.T., A.V.), University of Cincinnati Medical Center, OH
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Copelan AZ, Smith ER, Drocton GT, Narsinh KH, Murph D, Khangura RS, Hartley ZJ, Abla AA, Dillon WP, Dowd CF, Higashida RT, Halbach VV, Hetts SW, Cooke DL, Keenan K, Nelson J, Mccoy D, Ciano M, Amans MR. Recent Administration of Iodinated Contrast Renders Core Infarct Estimation Inaccurate Using RAPID Software. AJNR Am J Neuroradiol 2020; 41:2235-2242. [PMID: 33214184 DOI: 10.3174/ajnr.a6908] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 08/01/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Automated CTP software is increasingly used for extended window emergent large-vessel occlusion to quantify core infarct. We aimed to assess whether RAPID software underestimates core infarct in patients with an extended window recently receiving IV iodinated contrast. MATERIALS AND METHODS We reviewed a prospective, single-center data base of 271 consecutive patients who underwent CTA ± CTP for acute ischemic stroke from May 2018 through January 2019. Patients with emergent large-vessel occlusion confirmed by CTA in the extended window (>6 hours since last known well) and CTP with RAPID postprocessing were included. Two blinded raters independently assessed CT ASPECTS on NCCT performed at the time of CTP. RAPID software used relative cerebral blood flow of <30% as a surrogate for irreversible core infarct. Patients were dichotomized on the basis of receiving recent IV iodinated contrast (<8 hours before CTP) for a separate imaging study. RESULTS The recent IV contrast and contrast-naïve cohorts comprised 23 and 15 patients, respectively. Multivariate linear regression analysis demonstrated that recent IV contrast administration was independently associated with a decrease in the RAPID core infarct estimate (proportional increase = 0.34; 95% CI, 0.12-0.96; P = .04). CONCLUSIONS Patients who received IV iodinated contrast in proximity (<8 hours) to CTA/CTP as part of a separate imaging study had a much higher likelihood of core infarct underestimation with RAPID compared with contrast-naïve patients. Over-reliance on RAPID postprocessing for treatment disposition of patients with extended window emergent large-vessel occlusion should be avoided, particularly with recent IV contrast administration.
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Affiliation(s)
- A Z Copelan
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - E R Smith
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.).,Department of Radiology (E.R.S.), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - G T Drocton
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - K H Narsinh
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - D Murph
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - R S Khangura
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - Z J Hartley
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - A A Abla
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.).,Neurosurgery (A.A.A.), University of California, San Francisco, San Francisco, California
| | - W P Dillon
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - C F Dowd
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - R T Higashida
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - V V Halbach
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - S W Hetts
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - D L Cooke
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - K Keenan
- Department of Neurology (K.K.), University of California Davis, Sacramento, California
| | - J Nelson
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - D Mccoy
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - M Ciano
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
| | - M R Amans
- From the Departments of Diagnostic and Interventional Neuroradiology (A.Z.C., E.R.S., G.T.D., K.H.N., D.M., R.S.K., Z.J.H., A.A.A., W.P.D., C.F.D., R.T.H., V.V.H., S.W.H., D.L.C., J.N., D.M., M.C., M.R.A.)
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McDougall CC, Chan L, Sachan S, Guo J, Sah RG, Menon BK, Demchuk AM, Hill MD, Forkert ND, d'Esterre CD, Barber PA. Dynamic CTA-Derived Perfusion Maps Predict Final Infarct Volume: The Simple Perfusion Reconstruction Algorithm. AJNR Am J Neuroradiol 2020; 41:2034-2040. [PMID: 33004342 DOI: 10.3174/ajnr.a6783] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/07/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Infarct core volume measurement using CTP (CT perfusion) is a mainstay paradigm for stroke treatment decision-making. Yet, there are several downfalls with cine CTP technology that can be overcome by adopting the simple perfusion reconstruction algorithm (SPIRAL) derived from multiphase CTA. We compare SPIRAL with CTP parameters for the prediction of 24-hour infarction. MATERIALS AND METHODS Seventy-two patients had admission NCCT, multiphase CTA, CTP, and 24-hour DWI. All patients had successful/quality reperfusion. Patient-level and cohort-level receiver operator characteristic curves were generated to determine accuracy. A 10-fold cross-validation was performed on the cohort-level data. Infarct core volume was compared for SPIRAL, CTP-time-to-maximum, and final DWI by Bland-Altman analysis. RESULTS When we compared the accuracy in patients with early and late reperfusion for cortical GM and WM, there was no significant difference at the patient level (0.83 versus 0.84, respectively), cohort level (0.82 versus 0.81, respectively), or the cross-validation (0.77 versus 0.74, respectively). In the patient-level receiver operating characteristic analysis, the SPIRAL map had a slightly higher, though nonsignificant (P < .05), average receiver operating characteristic area under the curve (cortical GM/WM, r = 0.82; basal ganglia = 0.79, respectively) than both the CTP-time-to-maximum (cortical GM/WM = 0.82; basal ganglia = 0.78, respectively) and CTP-CBF (cortical GM/WM = 0.74; basal ganglia = 0.78, respectively) parameter maps. The same relationship was observed at the cohort level. The Bland-Altman plot limits of agreement for SPIRAL and time-to-maximum infarct volume were similar compared with 24-hour DWI. CONCLUSIONS We have shown that perfusion maps generated from a temporally sampled helical CTA are an accurate surrogate for infarct core.
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Affiliation(s)
- C C McDougall
- From the Department of Clinical Neurosciences (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d., P.A.B.), Calgary Stroke Program.,Department of Radiology (C.C.M., B.K.M., N.D.F., C.D.d.E., P.A.B.).,Hotchkiss Brain Institute (C.C.M., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E., P.A.B.).,Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.).,Seaman Family Centre (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d.E., P.A.B.), Foothills Medical Centre, Calgary, Alberta, Canada
| | - L Chan
- Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.)
| | - S Sachan
- Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.)
| | - J Guo
- Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.)
| | - R G Sah
- From the Department of Clinical Neurosciences (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d., P.A.B.), Calgary Stroke Program.,Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.).,Seaman Family Centre (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d.E., P.A.B.), Foothills Medical Centre, Calgary, Alberta, Canada
| | - B K Menon
- From the Department of Clinical Neurosciences (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d., P.A.B.), Calgary Stroke Program.,Department of Radiology (C.C.M., B.K.M., N.D.F., C.D.d.E., P.A.B.).,Hotchkiss Brain Institute (C.C.M., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E., P.A.B.).,Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.).,Seaman Family Centre (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d.E., P.A.B.), Foothills Medical Centre, Calgary, Alberta, Canada
| | - A M Demchuk
- From the Department of Clinical Neurosciences (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d., P.A.B.), Calgary Stroke Program.,Hotchkiss Brain Institute (C.C.M., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E., P.A.B.).,Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.).,Seaman Family Centre (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d.E., P.A.B.), Foothills Medical Centre, Calgary, Alberta, Canada
| | - M D Hill
- From the Department of Clinical Neurosciences (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d., P.A.B.), Calgary Stroke Program.,Hotchkiss Brain Institute (C.C.M., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E., P.A.B.).,Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.).,Seaman Family Centre (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d.E., P.A.B.), Foothills Medical Centre, Calgary, Alberta, Canada
| | - N D Forkert
- Department of Radiology (C.C.M., B.K.M., N.D.F., C.D.d.E., P.A.B.).,Hotchkiss Brain Institute (C.C.M., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E., P.A.B.).,Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.).,Alberta Children's Hospital Research Institute (N.D.F.), University of Calgary, Calgary, Alberta, Canada
| | - C D d'Esterre
- From the Department of Clinical Neurosciences (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d., P.A.B.), Calgary Stroke Program.,Department of Radiology (C.C.M., B.K.M., N.D.F., C.D.d.E., P.A.B.).,Hotchkiss Brain Institute (C.C.M., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E., P.A.B.).,Department of Clinical Neurosciences (C.C.M., L.C., S.S., J.G., R.G.S., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E.).,Seaman Family Centre (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d.E., P.A.B.), Foothills Medical Centre, Calgary, Alberta, Canada
| | - P A Barber
- From the Department of Clinical Neurosciences (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d., P.A.B.), Calgary Stroke Program .,Department of Radiology (C.C.M., B.K.M., N.D.F., C.D.d.E., P.A.B.).,Hotchkiss Brain Institute (C.C.M., B.K.M., A.M.D., M.D.H., N.D.F., C.C.d.E., P.A.B.).,Seaman Family Centre (C.C.M., R.G.S., B.K.M., A.M.D., M.D.H., C.D.d.E., P.A.B.), Foothills Medical Centre, Calgary, Alberta, Canada
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Dehkharghani S, Yaghi S, Bowen MT, Pisani L, Scher E, Haussen DC, Nogueira RG. Mild fever as a catalyst for consumption of the ischaemic penumbra despite endovascular reperfusion. Brain Commun 2020; 2:fcaa116. [PMID: 33033801 PMCID: PMC7532660 DOI: 10.1093/braincomms/fcaa116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/18/2020] [Accepted: 06/23/2020] [Indexed: 11/26/2022] Open
Abstract
Cerebrovascular ischaemia is potentiated by hyperthermia, and even mild temperature elevation has proved detrimental to ischaemic brain. Infarction progression following endovascular reperfusion relates to multiple patient-specific and procedural variables; however, the potential influence of mild systemic temperature fluctuations is not fully understood. This study aims to assess the relationship between systemic temperatures in the early aftermath of acute ischaemic stroke and the loss of at-risk penumbral tissues, hypothesizing consumption of the ischaemic penumbra as a function of systemic temperatures, irrespective of reperfusion status. A cross-sectional, retrospective evaluation of a single-institution, prospectively collected endovascular therapy registry was conducted. Patients with anterior circulation, large vessel occlusion acute ischaemic stroke who underwent initial CT perfusion, and in whom at least four-hourly systemic temperatures were recorded beginning from presentation and until the time of final imaging outcome were included. Initial CT perfusion core and penumbra volumes and final MRI infarction volumes were computed. Systemic temperature indices including temperature maxima were recorded, and pre-defined temperature thresholds varying between 37°C and 38°C were examined in unadjusted and adjusted regression models which included glucose, collateral status, reperfusion status, CT perfusion-to-reperfusion delay, general anaesthesia and antipyretic exposure. The primary outcome was the relative consumption of the penumbra, reflecting normalized growth of the at-risk tissue volume ≥10%. The final study population comprised 126 acute ischaemic stroke subjects (mean 63 ± 14.5 years, 63% women). The primary outcome of penumbra consumption ≥10% occurred in 51 (40.1%) subjects. No significant differences in baseline characteristics were present between groups, with the exception of presentation glucose (118 ± 26.6 without versus 143.1 ± 61.6 with penumbra consumption, P = 0.009). Significant differences in the likelihood of penumbra consumption relating to systemic temperature maxima were observed [37°C (interquartile range 36.5 − 37.5°C) without versus 37.5°C (interquartile range 36.8 − 38.2°C) with penumbra consumption, P = 0.001]. An increased likelihood of penumbra consumption was observed for temperature maxima in unadjusted (odds ratio 3.57, 95% confidence interval 1.65 − 7.75; P = 0.001) and adjusted (odds ratio 3.06, 95% confidence interval 1.33 − 7.06; P = 0.009) regression models. Significant differences in median penumbra consumption were present at a pre-defined temperature maxima threshold of 37.5°C [4.8 ml (interquartile range 0 − 11.5 ml) versus 21.1 ml (0 − 44.7 ml) for subjects not reaching or reaching the threshold, respectively, P = 0.007]. Mild fever may promote loss of the ischaemic penumbra irrespective of reperfusion, potentially influencing successful salvage of at-risk tissue volumes following acute ischaemic stroke.
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Affiliation(s)
- Seena Dehkharghani
- Department of Radiology, New York University Langone Health, New York, NY, USA
| | - Shadi Yaghi
- Department of Neurology, New York University Langone Health, New York, NY, USA
| | - Meredith T Bowen
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Leonardo Pisani
- Department of Neurology, Emory University Hospital, Atlanta, GA, USA
| | - Erica Scher
- Department of Neurology, New York University Langone Health, New York, NY, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University Hospital, Atlanta, GA, USA.,Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA 30303, USA
| | - Raul G Nogueira
- Department of Neurology, Emory University Hospital, Atlanta, GA, USA.,Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA 30303, USA
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Laredo C, Renú A, Tudela R, Lopez-Rueda A, Urra X, Llull L, Macías NG, Rudilosso S, Obach V, Amaro S, Chamorro Á. The accuracy of ischemic core perfusion thresholds varies according to time to recanalization in stroke patients treated with mechanical thrombectomy: A comprehensive whole-brain computed tomography perfusion study. J Cereb Blood Flow Metab 2020; 40:966-977. [PMID: 31208242 PMCID: PMC7181085 DOI: 10.1177/0271678x19855885] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Computed tomography perfusion (CTP) allows the estimation of pretreatment ischemic core after acute ischemic stroke. However, CTP-derived ischemic core may overestimate final infarct volume. We aimed to evaluate the accuracy of CTP-derived ischemic core for the prediction of final infarct volume according to time from stroke onset to recanalization in 104 patients achieving complete recanalization after mechanical thrombectomy who had a pretreatment CTP and a 24-h follow-up MRI-DWI. A range of CTP thresholds was explored in perfusion maps at constant increments for ischemic core calculation. Time to recanalization modified significantly the association between ischemic core and DWI lesion in a non-linear fashion (p-interaction = 0.018). Patients with recanalization before 4.5 h had significantly lower intraclass correlation coefficient (ICC) values between CTP-predicted ischemic core and DWI lesion (n = 54; best threshold relative cerebral blood flow (rCBF) < 25%, ICC = 0.673, 95% CI = 0.495-0.797) than those with later recanalization (n = 50; best threshold rCBF < 30%, ICC = 0.887, 95% CI = 0.811-0.935, p = 0.013), as well as poorer spatial lesion agreement. The significance of the associations between CTP-derived ischemic core and clinical outcome at 90 days was lost in patients recanalized before 4.5 h. CTP-derived ischemic core must be interpreted with caution given its dependency on time to recanalization, primarily in patients with higher chances of early recanalization.
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Affiliation(s)
- Carlos Laredo
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Arturo Renú
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Raúl Tudela
- CIBER de Bioingeniería, Biomateriales y Nanomedicina, Group of Biomedical Imaging of the University of Barcelona, Barcelona, Spain
| | | | - Xabier Urra
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Laura Llull
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | | | - Salvatore Rudilosso
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Víctor Obach
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Sergio Amaro
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Ángel Chamorro
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
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Endovascular Thrombectomy for Low ASPECTS Large Vessel Occlusion Ischemic Stroke: A Systematic Review and Meta-Analysis. Can J Neurol Sci 2020; 47:612-619. [DOI: 10.1017/cjn.2020.71] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
ABSTRACT:Background:The current American Heart Association guidelines for acute ischemic stroke reserve Grade 1A recommendation for the use of endovascular thrombectomy (EVT) for patients with an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of ≥6.Objective:We aim to determine the safety and efficacy of EVT for large vessel occlusion ischemic stroke patients with low ASPECTS (5 or less).Methods:Medline, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched for studies appraising the outcomes of EVT for low ASPECTS ischemic stroke. A meta-analysis of proportions compared the clinical outcomes of patients undergoing EVT and those receiving best medical therapy only.Results:Nine studies (1,196 patients) were included. There was a trend (p = 0.11) toward a higher rate of symptomatic intracranial hemorrhage (sICH) in the EVT group (9.2%; 95% CI 6.1–13.6; I2 53.37%) compared to the medical group (5.5%; 95% CI 3.7–8.1; I2 0%). There was no difference (p = 0.41) in the pooled 90-day mortality of EVT patients (30.7%; 95% CI 21.7–41.5; I2 84.23%) and medical patients (36.6%; 95% CI 26.4–48.1; I2 76.2%). EVT patients had better (p = 0.001) 90-day outcomes, with 27.7% (95% CI 21.8–34.5; I2 62.08%) of patients attaining a modified Rankin Scale of 0–2 compared to only 3.7% (95% CI 2.3–5.9; I2 87.21%) in the medical group.Conclusions:This meta-analysis demonstrates a trend in higher sICH among low ASPECTS patients undergoing EVT. Despite this, a significant proportion of this subset of patients still achieved good functional outcomes at 90 days. Randomized trials are necessary to substantiate this result as significant bias is inherent in the observational studies included in this review.
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Liu F, Chen C, Hong L, Shen H, Cao W, Dong Q, Yang X, Guo M, Li Y, Xiao Y, Cheng X, Li G. Lenticulostriate arteries appearance before thrombectomy predicts good outcome in acute middle cerebral artery occlusion. BMC Neurol 2020; 20:139. [PMID: 32299387 PMCID: PMC7161229 DOI: 10.1186/s12883-020-01716-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 04/02/2020] [Indexed: 12/27/2022] Open
Abstract
Background Endovascular therapy is widely used in acute large vessel occlusion. This study investigated whether imaging of lateral lenticulostriate arteries (LSAs) before thrombectomy would potentially be helpful for predicting prognosis of patients with acute M1 segment of middle cerebral artery occlusion (MCAO). Methods 59 consecutive patients with acute M1 segment of MCAO treated with mechanical thrombectomy at two comprehensive stroke centers were analyzed. Patients were categorized into LSA+ (appearing of lateral LSAs) and LSA- (sparing of lateral LSAs) group according to preprocedural digital substraction angiography (DSA). Baseline data and clinical outcomes were compared. A good clinical outcome was defined as a modified Rankin Scale score of 0 to 2 at 3 months. The association between clinical and imaging parameters and functional outcome was evaluated with logistic regression analysis. Results LSA+ was shown in 36 patients (61%). LSA+ group had a significantly higher proportion of good outcome (72.2% vs. 8.7%, OR 27.3,95% CI 5.38–138.4, P < 0.001), lower risk of symptomatic intracranial haemorrhages (sICH) (8.3% vs. 47.8%,OR 0.10,95% CI 0.02–0.42, P = 0.001) and lower mortality in hospital (5.6% vs. 34.8%, OR 0.11,95% CI 0.02–0.58, P < 0.004) compared with LSA- group. Patients in LSA+ group had lower baseline NIHSS score(P < 0.01) and NIHSS score at 14 days(P < 0.01) and smaller infarct core volume (P = 0.016) on computed tomography perfusion imaging (CTP) compared to the LSA- group. Multivariate logistic regression analysis showed that a small infarct core volume (OR 6.74,95% CI 1.148–39.569, P = 0.035) and LSA+(OR 22.114,95% CI 3.339–146.470, P = 0.001) were associated with a good clinical outcome. Conclusions Our data suggest that appearance of lateral LSAs before mechanical thrombectomy would be potentially helpful for predicting favorable prognosis of patients with acute M1 segment of MCAO.
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Affiliation(s)
- Feifeng Liu
- Department of Neurology, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Chen Chen
- Department of Neurology, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Lan Hong
- Department of Neurology, Shanghai huashan hospital, Fudan University, Shanghai, China
| | - Hao Shen
- Department of Neurology, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Wenjie Cao
- Department of Neurology, Shanghai huashan hospital, Fudan University, Shanghai, China
| | - Qiang Dong
- Department of Neurology, Shanghai huashan hospital, Fudan University, Shanghai, China
| | - Xinyi Yang
- Department of Neurology, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Mengruo Guo
- Department of Neurology, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Ying Li
- Department of Neurology, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Yaping Xiao
- Department of Neurology, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Xin Cheng
- Department of Neurology, Shanghai huashan hospital, Fudan University, Shanghai, China
| | - Gang Li
- Department of Neurology, Shanghai East Hospital, Tongji University, Shanghai, China.
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Siegler JE, Olsen A, Rosenberg J, Cristancho D, Pulst-Korenberg J, Raab L, Woo JH, Messé SR. Mismatch between automated CTP and ASPECTS score in patients with anterior large vessel occlusion. Clin Neurol Neurosurg 2020; 194:105797. [PMID: 32222652 DOI: 10.1016/j.clineuro.2020.105797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To evaluate the relationship between delay to computed tomography perfusion and estimated core infarct volumes in patients with large vessel occlusion (LVO). PATIENTS AND METHODS A retrospective registry of consecutive adults >18 years old who underwent CTP in clinical practice for suspected LVO within 24 h of LKN at 3 academic hospitals was queried (06/2017 - 12/2017). CT and CTP findings were compared over time as a continuous variable, and dichotomized by ≤6 h or 6-24 h from LKN. RESULTS Of 410 screened patients, 75 had LVO, of whom 60 (14.6 %) met inclusion criteria (median age 78y [IQR 64-84], 36 were female [60 %]), and 39 (65.0 %) underwent thrombectomy. Thirty (50 %) presented in the extended window (6-24 h) and had lower ASPECTS scores compared to patients in the early window (median 7 vs. 9, p < 0.01). Perfusion core (rCBF <30 %) volumes were similar (median 8 vs. 25, p = 0.10). After adjustment for age, NIHSS, and thrombolysis, there was a trend for lower ASPECTS for every hour after LKN (proportional OR 0.92, 95 %CI 0.84-1.00, p = 0.06), but no change in perfusion core (p = 0.37) or Tmax>6 s volumes (p = 0.29), or mismatch ratios (p = 0.48) after adjusting for age, NIHSS, ASPECTS, and thrombolysis. CONCLUSION As time progresses in anterior LVO, the unenhanced CT is more sensitive than CTP for detecting irreversibly damaged tissue. These results underscore the importance of carefully reviewing the unenhanced and perfusion CT when considering a patient for thrombectomy.
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Affiliation(s)
- James E Siegler
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia PA, 19104, United States.
| | - Andrew Olsen
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia PA, 19104, United States
| | - Jon Rosenberg
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia PA, 19104, United States
| | - Daniel Cristancho
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia PA, 19104, United States
| | - Johannes Pulst-Korenberg
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia PA, 19104, United States
| | - Lindsay Raab
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia PA, 19104, United States
| | - John H Woo
- Department of Radiology, Division of Neuroradiology, Hospital of the University of Pennsylvania, Philadelphia PA, 19104, United States
| | - Steven R Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia PA, 19104, United States
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Ferraz B, Reis R, Rocha ALC, Moreira G, Fonseca L, Parreira T, Azevedo E, Castro P. Prognostic yield of imaging before and after recanalization treatments in ischemic stroke. Acta Neurol Scand 2020; 141:226-235. [PMID: 31858586 DOI: 10.1111/ane.13208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/09/2019] [Accepted: 12/16/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The scores to predict outcome in ischemic stroke were validated prior to the approval of modern revascularization treatments. We evaluated the accuracy of pre and post-treatment models in a recent recanalization therapy cohort and whether radiological and ultrasound findings could improve their accuracy. MATERIAL & METHODS We included 375 anterior circulation ischemic stroke patients treated with intravenous thrombolysis or thrombectomy during 2017 and 2018. We collected demographic, clinical, and imaging data. We built pre and post-treatment logistic regression models to predict independence (modified Rankin Scale 0-2) at 3 months. The models included the Alberta Stroke Program Early CT Score (ASPECTS), infarct volume (ABC/2 method), and the Thrombolysis in Brain Ischemia (TIBI) ultrasonographic grade of recanalization. We compared areas under the receiver operating characteristic curve (AUC). RESULTS Our preintervention model, combining neurological deficit severity, age, and admission glycemia, was not improved by the inclusion of ASPECTS (AUC 0.80 vs 0.79, P = .28). Early neurological recovery at 24-hour significantly increased prognostic performance (AUC = 0.85, P < .01), which did not change by adding final infarct volume or the persistence of arterial occlusion of the affected territory (AUC = 0.86 and 0.85, P > .05). CONCLUSIONS Models that combine simple variables such as neurological deficit severity, age, and admission glycemia were the most useful for predicting functional outcome in ischemic stroke patients submitted to revascularization treatments. Pre and post-treatment imaging findings did not enhance prognostic accuracy when compared to the patient's clinical improvement.
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Affiliation(s)
- Beatriz Ferraz
- Department of Neurology Faculty of Medicine of University of Porto Centro Hospitalar Universitário São João Porto Portugal
| | - Ricardo Reis
- Department of Neurology Faculty of Medicine of University of Porto Centro Hospitalar Universitário São João Porto Portugal
| | - Ana Luísa Carvalho Rocha
- Department of Neurology Faculty of Medicine of University of Porto Centro Hospitalar Universitário São João Porto Portugal
| | - Goreti Moreira
- Department of Internal Medicine and Stroke Unit Centro Hospitalar Universitário São João Porto Portugal
| | - Luísa Fonseca
- Department of Internal Medicine and Stroke Unit Faculty of Medicine Centro Hospitalar Universitário São João Porto Portugal
| | - Tiago Parreira
- Department of Neuroradiology Centro Hospitalar Universitário São João Porto Portugal
| | - Elsa Azevedo
- Department of Neurology Faculty of Medicine of University of Porto Centro Hospitalar Universitário São João Porto Portugal
| | - Pedro Castro
- Department of Neurology and Stroke Unit Faculty of Medicine of University of Porto Centro Hospitalar Universitário São João Porto Portugal
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Non-Contrast CT and CT-Angiogram for Late Window Ischemic Stroke Treatment Selection. Can J Neurol Sci 2020; 47:309-313. [PMID: 31928557 DOI: 10.1017/cjn.2020.15] [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] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The benefit of late window endovascular treatment (EVT) for anterior circulation ischemic stroke has been demonstrated using perfusion-based neuroimaging. We evaluated whether non-contrast CT (NCCT) and CT-angiogram (CTA) alone can select late-presenting patients for EVT. METHODS We performed a retrospective comparison of all patients undergoing EVT at a single comprehensive stroke center from January 2016 to April 2017. Patients planned for EVT were divided into early (<6 hours from onset) and late (≥6 hours from onset or last time seen normal) window groups. Incidence of symptomatic hemorrhagic transformations (sHTs) at 24 hours and 3-month modified Rankin scores (mRSs) were compared. RESULTS During the study period, 204 (82%) patients underwent EVT in the early and 44 (18%) in the late window. Median (interquartile range) NIH Stroke Scale Score was similar between groups (early: 18 [15-23] vs. late: 17 [13-21]), as were median ASPECT scores (early: 9 [8-10] vs. late: 9 [7-9]). In the late window, 42 (95%) strokes were of unknown onset. Similar proportions of sHT occurred at 24 hours (early: 12 [6%] vs. late: 4 [9%], p = 0.43). At 3 months, the proportion of patients achieving functional independence (mRS 0-2) were comparable in the early (80/192 [42%]) and late (16/41 [39%]) windows (p = 0.76). CONCLUSION NCCT- and CTA-based patient selection led to similar functional independence outcomes and low proportions of sHT in the early and late windows. In centers without access to perfusion-based neuroimaging, this pragmatic approach could be safe, particularly for strokes of unknown onset.
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