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Deshpande A, Elliott J, Jiang B, Tahsili-Fahadan P, Kidwell C, Wintermark M, Laksari K. End to end stroke triage using cerebrovascular morphology and machine learning. Front Neurol 2023; 14:1217796. [PMID: 37941573 PMCID: PMC10628321 DOI: 10.3389/fneur.2023.1217796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/20/2023] [Indexed: 11/10/2023] Open
Abstract
Background Rapid and accurate triage of acute ischemic stroke (AIS) is essential for early revascularization and improved patient outcomes. Response to acute reperfusion therapies varies significantly based on patient-specific cerebrovascular anatomy that governs cerebral blood flow. We present an end-to-end machine learning approach for automatic stroke triage. Methods Employing a validated convolutional neural network (CNN) segmentation model for image processing, we extract each patient's cerebrovasculature and its morphological features from baseline non-invasive angiography scans. These features are used to detect occlusion's presence and the site automatically, and for the first time, to estimate collateral circulation without manual intervention. We then use the extracted cerebrovascular features along with commonly used clinical and imaging parameters to predict the 90 days functional outcome for each patient. Results The CNN model achieved a segmentation accuracy of 94% based on the Dice similarity coefficient (DSC). The automatic stroke detection algorithm had a sensitivity and specificity of 92% and 94%, respectively. The models for occlusion site detection and automatic collateral grading reached 96% and 87.2% accuracy, respectively. Incorporating the automatically extracted cerebrovascular features significantly improved the 90 days outcome prediction accuracy from 0.63 to 0.83. Conclusion The fast, automatic, and comprehensive model presented here can improve stroke diagnosis, aid collateral assessment, and enhance prognostication for treatment decisions, using cerebrovascular morphology.
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Affiliation(s)
- Aditi Deshpande
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, United States
- Department of Mechanical Engineering, University of California, Riverside, Riverside, CA, United States
| | - Jordan Elliott
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, United States
| | - Bin Jiang
- Department of Radiology, Stanford University, Stanford, CA, United States
| | - Pouya Tahsili-Fahadan
- Department of Medical Education, University of Virginia, Inova Campus, Falls Church, VA, United States
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Chelsea Kidwell
- Department of Neurology, University of Arizona, Tucson, AZ, United States
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson Center, University of Texas, Houston, TX, United States
| | - Kaveh Laksari
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, United States
- Department of Mechanical Engineering, University of California, Riverside, Riverside, CA, United States
- Department of Aerospace and Mechanical Engineering, University of Arizona, Tucson, AZ, United States
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2
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Deshpande A, Elliott J, Kari N, Jiang B, Michel P, Toosizadeh N, Fahadan PT, Kidwell C, Wintermark M, Laksari K. Novel imaging markers for altered cerebrovascular morphology in aging, stroke, and Alzheimer's disease. J Neuroimaging 2022; 32:956-967. [PMID: 35838658 PMCID: PMC9474631 DOI: 10.1111/jon.13023] [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: 02/08/2022] [Revised: 06/26/2022] [Accepted: 06/29/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE Altered brain vasculature is a key phenomenon in several neurologic disorders. This paper presents a quantitative assessment of the anatomical variations in the Circle of Willis (CoW) and vascular morphology in healthy aging, acute ischemic stroke (AIS) and Alzheimer's Disease (AD). METHODS We used our novel automatic method to segment and extract geometric features of the cerebral vasculature from MR angiography scans of 175 healthy subjects, which were used to create a probabilistic atlas of cerebrovasculature and to study normal aging and intersubject variations in CoW anatomy. Subsequently, we quantified and analyzed vascular alterations in 45AIS and 50 AD patients, two prominent cerebrovascular and neurodegenerative disorders. RESULTS In the sampled cohort, we determined that the CoW is fully formed in only 35% of healthy adults and found significantly (p < .05) increased tortuosity and fractality, with increasing age and also with disease in both AIS and AD. We also found significantly lower vessel length, volume, and number of branches in AIS patients, as expected. The AD cerebral vessels exhibited significantly smaller diameter and more complex branching patterns, compared to age-matched healthy adults. These changes were significantly heightened (p < .05) among healthy, early onset mild AD, and moderate/severe dementia groups. CONCLUSION Although our study does not include longitudinal data due to paucity of such datasets, the specific geometric features and quantitative comparisons demonstrate the potential for using vascular morphology as a noninvasive imaging biomarker for neurologic disorders.
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Affiliation(s)
| | - Jordan Elliott
- Department of Biomedical Engineering, University of Arizona
| | - Nitya Kari
- Department of Biomedical Engineering, University of Arizona
| | - Bin Jiang
- Department of Radiology, Stanford University
| | - Patrik Michel
- Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Nima Toosizadeh
- Department of Biomedical Engineering, University of Arizona
- Arizona Center on Aging, Department of Medicine, University of Arizona
| | - Pouya Tahsili Fahadan
- Neuroscience Intensive Care Unit, Medical Critical Care Service and Department of Medical Education, University of Virginia School of Medicine, Inova Fairfax Medical Campus
- Departments of Neurology, Johns Hopkins University School of Medicine
| | | | | | - Kaveh Laksari
- Department of Biomedical Engineering, University of Arizona
- Department of Aerospace and Mechanical Engineering, University of Arizona
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3
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Zhang K, Ren W, Sun YX, Wang XJ, Li CY, Wang ZL, Li TX, Gao BL. Angiographic Characteristics of Cerebral Perfusion and Hemodynamics of the Bridging Artery After Surgical Treatment of Unilateral Moyamoya Disease. Front Neurosci 2022; 16:922482. [PMID: 35774553 PMCID: PMC9239480 DOI: 10.3389/fnins.2022.922482] [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: 04/18/2022] [Accepted: 05/16/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose To investigate the characteristics of cerebral perfusion and hemodynamics of bypass grafting in the treatment of moyamoya disease (MMD) using the iFlow color-coded flow map in comparison with magnetic resonance imaging–perfusion-weighted imaging (MRI–PWI) and computational fluid dynamic (CFD) analysis. Materials and Methods Patients with MMD treated with bypass grafting who had undergone MRI PWI and digital subtraction angiography for iFlow color-coded map was retrospectively enrolled and CFD was performed for calculating the hemodynamic stresses around the bypass grafting. Results Forty-five patients with unilateral MMD treated with bypass surgery were enrolled. The bypass surgery was successful in all patients, with no severe neurological complications during the periprocedural period. Followed up for 4–12 months (median 5.5), the neurological function was good in all patients. The cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time to peak (TTP) were significantly (p < 0.05) improved in the middle cerebral artery distribution area on the surgical side before and after vascular bypass, and the difference of TTP (s) measured from the proximal bifurcation of common carotid artery to the confluence of sinus was also significant (p < 0.05). A significant (p < 0.05) positive correlation existed in the perfusion parameters between the iFlow blood perfusion and the MRI–PWI perfusion, with r-value for TTP of 0.765 (p < 0.01). The iFlow color-coded blood flow map showed warm color changes on the diseased side, similar to those on the contralateral side. In CFD analysis, the hemodynamic stresses were all improved, in and around the bypass grafting and distal vessels, which were beneficial to blood flow entering distal arterial branches. Conclusion The iFlow color-coded flow map can be used to analyze cerebral perfusion after bypass grafting for MMD, similar to MRI–PWI, and CFD can be used to analyze the hemodynamics after bypass grafting, revealing improved hemodynamics to promote blood flow entering distal arteries.
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Affiliation(s)
- Kun Zhang
- The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Wei Ren
- Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Yu-Xue Sun
- Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Xin-Jun Wang
- The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Xin-Jun Wang,
| | - Chao-Yue Li
- Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Zi-Liang Wang
- Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
- Zi-Liang Wang,
| | - Tian-Xiao Li
- Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Bu-Lang Gao
- Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
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4
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Assessment of Cerebral Collateral Flow With Single-Phase Computed Tomography Angiography–Based Multimodal Scales in Patients With Acute Ischemic Stroke. J Comput Assist Tomogr 2020; 44:708-713. [DOI: 10.1097/rct.0000000000001030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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5
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Liu L, Chen W, Zhou H, Duan W, Li S, Huo X, Xu W, Huang L, Zheng H, Liu J, Liu H, Wei Y, Xu J, Wang Y. Chinese Stroke Association guidelines for clinical management of cerebrovascular disorders: executive summary and 2019 update of clinical management of ischaemic cerebrovascular diseases. Stroke Vasc Neurol 2020; 5:159-176. [PMID: 32561535 PMCID: PMC7337371 DOI: 10.1136/svn-2020-000378] [Citation(s) in RCA: 139] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 12/16/2022] Open
Abstract
Aim Stroke is the leading cause of disability and death in China. Ischaemic stroke accounts for about 60%–80% of all strokes. It is of considerable significance to carry out multidimensional management of ischaemic cerebrovascular diseases. This evidence-based guideline aims to provide the latest detailed and comprehensive recommendations on the diagnosis, treatment and secondary prevention of ischaemic cerebrovascular diseases. Methods We had performed comprehensive searches of MEDLINE (via PubMed) (before 30 June 2019), and integrated the relevant information into charts and distributed to the writing group. Writing group members discussed and determined the recommendations through teleconference. We used the level of evidence grading algorithm of Chinese Stroke Association to grade each recommendation. The draft was reviewed by the Guideline Writing Committee of Chinese Stroke Association Stroke and finalised. This guideline is fully updated every 3 years. Results This evidence-based guideline is based on the treatment, care and prevention of ischaemic cerebrovascular diseases, which emphasises on pathogenesis evaluation, intravenous thrombolysis, endovascular therapy, antiplatelet therapy, prevention and treatment of complications, and risk factor management. Conclusions This updated guideline presents a framework for the management of ischaemic cerebrovascular diseases. Timely first-aid measures, professional care in the acute stage, and proactive secondary prevention will be helpful to patients.
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Affiliation(s)
- Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Weiqi Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hongyu Zhou
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wanying Duan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shujuan Li
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xiaochuan Huo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Weihai Xu
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China
| | - Li'an Huang
- Department of Neurology, Guangzhou Overseas Chinese Hospital, The First Affiliated Hospital of JINAN University, Guangzhou, China
| | - Huaguang Zheng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jingyi Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hui Liu
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yufei Wei
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jie Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Jadhav AP, Aghaebrahim A, Jankowitz BT, Haussen DC, Budzik RF, Bonafe A, Bhuva P, Yavagal DR, Hanel RA, Hassan AE, Ribo M, Cognard C, Sila CA, Zhang Y, Smith WS, Saver JL, Liebeskind DS, Nogueira RG, Jovin TG. Benefit of Endovascular Thrombectomy by Mode of Onset. Stroke 2019; 50:3141-3146. [DOI: 10.1161/strokeaha.119.025795] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
It is unknown whether the benefit of thrombectomy in late presenting acute stroke patients with imaging evidence of clinical-infarct mismatch is different in patients presenting with wake-up stroke compared with those presenting with witnessed onset or unwitnessed onset.
Methods—
Prespecified secondary analysis was performed from DAWN (Diffusion Weighted Imaging [DWI] or Computerized Tomography Perfusion [CTP] Assessment With Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention), a multicenter, prospective, randomized clinical trial with blinded end point assessment comparing thrombectomy with the Trevo device against standard medical therapy in patients with acute stroke and clinical-infarct mismatch presenting 6 to 24 hour after the time last seen well. For the purposes of this study, the primary outcome was the proportion of modified Rankin Scale score 0 to 2 at 90 days. Univariable analysis and multivariable logistic regression was used to assess the relationship between outcome and mode of onset.
Results—
All 206 enrolled patients were included in the study. Mode of onset was: wake-up stroke (55.3%, n=114), witnessed onset (12.1%, n=25), and unwitnessed onset (32.5%, n=67) with median time last seen well to randomization (13.4±3.7, 10.0±3.7, 14.1±4.9 hours) respectively. Rates of 90-day modified Rankin Scale score of 0 to 2 and symptomatic intracerebral hemorrhage in the thrombectomy arm were not statistically different across patient onset subtypes (
P
=0.79 and
P
=0.40, respectively). The benefit of thrombectomy compared with best medical therapy was maintained across all 3 onset modes (rates of 90-day modified Rankin Scale score of 0 to 2 in patients allocated to thrombectomy versus control: wake-up stroke—49.3% versus 10.6%, witnessed onset—63.6% versus 21.4%, UW—41.4% versus 13.2%;
P
×interaction=0.79). In univariable and multivariable analyses, mode of onset was not identified as a significant predictor of modified Rankin Scale score 0 to 2 at 90 days.
Conclusions—
In patients with acute ischemic stroke presenting between 6 and 24 hours from time last seen well and harboring clinical-infarct mismatch, the benefit of thrombectomy was similar regardless of the wake-up, unwitnessed, or witnessed mode of onset.
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Affiliation(s)
- Ashutosh P. Jadhav
- From the Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, PA (A.P.J.)
| | | | - Brian T. Jankowitz
- Associate Professor of Neurosurgery, Cooper University Hospital, Neurological Institute, Camden, NJ, (B.T.J.)
| | - Diogo C. Haussen
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA (D.C.H., R.G.N.)
| | | | - Alain Bonafe
- Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France (A.B.)
| | - Parita Bhuva
- Division of Neurointervention, Texas Stroke Institute, Dallas-Fort Worth (P.B.)
| | - Dileep R. Yavagal
- Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine–Jackson Memorial Hospital, FL (D.R.Y.)
| | | | - Ameer E. Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Valley Baptist Hospital, Harlingen (A.E.H.)
| | - Marc Ribo
- Stroke Unit, Hospital Vall d’Hebrón, Barcelona, Spain (M.R.)
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.)
| | - Cathy A. Sila
- Department of Neurology, University Hospitals of Cleveland, OH (C.A.S.)
| | | | - Wade S. Smith
- Department of Neurology, University of California, San Francisco (UCSF) (W.S.S.)
| | - Jeffrey L. Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles (UCLA) (J.L.S., D.S.L.)
| | - David S. Liebeskind
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles (UCLA) (J.L.S., D.S.L.)
| | - Raul G. Nogueira
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA (D.C.H., R.G.N.)
| | - Tudor G. Jovin
- Department of Neurology, Cooper University Hospital, Neurological Institute, Camden, NJ (T.G.J.)
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7
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Mikati AG, Mandelbaum M, Sapnar S, Puri AS, Silver B, Goddeau RP, Haussen DC, Moonis M, Jun-O'Connell AH, Henninger N. Impact of Leukoaraiosis Severity on the Association of Time to Successful Reperfusion with 90-Day Functional Outcome After Large Vessel Occlusion Stroke. Transl Stroke Res 2019; 11:39-49. [PMID: 30980282 DOI: 10.1007/s12975-019-00703-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/22/2019] [Accepted: 03/27/2019] [Indexed: 12/17/2022]
Abstract
The chance for a favorable outcome after mechanical thrombectomy (MT) for large vessel occlusion stroke decreases with the symptom onset-to-reperfusion time (OTR). Patients with severe leukoaraiosis are at increased risk for a poor outcome after MT. However, whether leukoaraiosis modulates to the association between OTR and 90-day functional outcome is uncertain. We retrospectively analyzed 144 consecutive patients with successful (TICI ≥ 2b/3) MT for anterior circulation large vessel occlusion within 24 h form OTR between January 2012 to November 2016. Leukoaraiosis was dichotomized to absent-to-mild (van Swieten scale score 0-2) versus moderate-to-severe (3-4) as assessed on admission head CT. Multiple linear, logistic, and ordinal regression analyses were used to determine the association between leukoaraiosis, OTR, and 90-day modified Rankin Scale (mRS) score, after adjustment for pertinent covariates. Leukoaraiosis was independently associated with the OTR on multivariable linear regression (p = 0.003). The association between OTR and 90-day outcome depended on the degree of pre-existing leukoaraiosis burden as shown by a significant leukoaraiosis-by-OTR interaction on multivariable logistic regression (OR 0.76, 95% CI 0.58-0.98, p = 0.037) and multivariable ordinal regression (OR 0.87, 95% CI 0.78-0.97, p = 0.011). Pre-existing leukoaraiosis is associated with the 90-day functional outcome after successful reperfusion and impacts the association between the OTR and 90-day mRS among patients undergoing MT. Patients with high leukoaraiosis burden need to present earlier than patients with low leukoaraiosis burden for a similar favorable outcome. Pending confirmation, these results may have important implications for optimizing patient selection for acute stroke therapies.
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Affiliation(s)
- Abdul Ghani Mikati
- Department of Neurology, University of Massachusetts Medical School, 55 Lake Ave, North Worcester, MA, 01655, USA
| | - Max Mandelbaum
- Department of Neurology, University of Massachusetts Medical School, 55 Lake Ave, North Worcester, MA, 01655, USA
| | - Shweta Sapnar
- Department of Neurology, University of Massachusetts Medical School, 55 Lake Ave, North Worcester, MA, 01655, USA
| | - Ajit S Puri
- Department of Radiology, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Neurosurgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Brian Silver
- Department of Neurology, University of Massachusetts Medical School, 55 Lake Ave, North Worcester, MA, 01655, USA
| | - Richard P Goddeau
- Department of Neurology, University of Massachusetts Medical School, 55 Lake Ave, North Worcester, MA, 01655, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University/Marcus Stroke and Neuroscience Center-Grady Memorial Hospital, Atlanta, GA, USA
| | - Majaz Moonis
- Department of Neurology, University of Massachusetts Medical School, 55 Lake Ave, North Worcester, MA, 01655, USA
| | - Adalia H Jun-O'Connell
- Department of Neurology, University of Massachusetts Medical School, 55 Lake Ave, North Worcester, MA, 01655, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Medical School, 55 Lake Ave, North Worcester, MA, 01655, USA. .,Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA.
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8
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El-Ghanem M, Gomez FE, Koul P, Nuoman R, Santarelli JG, Amuluru K, Gandhi CD, Cohen ER, Meyers P, Al-Mufti F. Mandatory Neuroendovascular Evolution: Meeting the New Demands. INTERVENTIONAL NEUROLOGY 2018; 8:69-81. [PMID: 32231697 DOI: 10.1159/000495075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 11/02/2018] [Indexed: 01/01/2023]
Abstract
Background Traditionally, patients undergoing acute ischemic strokes were candidates for mechanical thrombectomy if they were within the 6-h window from onset of symptoms. This timeframe would exclude many patient populations, such as wake-up strokes. However, the most recent clinical trials, DAWN and DEFUSE3, have expanded the window of endovascular treatment for acute ischemic stroke patients to within 24 h from symptom onset. This expanded window increases the number of potential candidates for endovascular intervention for emergent large vessel occlusions and raises the question of how to efficiently screen and triage this increase of patients. Summary Abbreviated pre-hospital stroke scales can be used to guide EMS personnel in quickly deciding if a patient is undergoing a stroke. Telestroke networks connect remote hospitals to stroke specialists to improve the transportation time of the patient to a comprehensive stroke center for the appropriate level of care. Mobile stroke units, mobile interventional units, and helistroke reverse the traditional hub-and-spoke model by bringing imaging, tPA, and expertise to the patient. Smartphone applications and social media aid in educating patients and the public regarding acute and long-term stroke care. Key Messages The DAWN and DEFUSE3 trials have expanded the treatment window for certain acute ischemic stroke patients with mechanical thrombectomy and subsequently have increased the number of potential candidates for endovascular intervention. This expansion brings patient screening and triaging to greater importance, as reducing the time from symptom onset to decision-to-treat and groin puncture can better stroke patient outcomes. Several strategies have been employed to address this issue by reducing the time of symptom onset to decision-to-treat time.
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Affiliation(s)
| | - Francisco E Gomez
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Prateeka Koul
- Department of Internal Medicine, Stamford Hospital, Stamford, Connecticut, USA
| | - Rolla Nuoman
- Department of Neurology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Justin G Santarelli
- Department of Neurosurgery, New York Medical College, Westchester Medical Center, Valhalla, New York, USA
| | - Krishna Amuluru
- University of Pittsburgh Medical Center Hamot, Great Lakes Neurosurgery and Neurointervention, Erie, Pennsylvania, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, New York Medical College, Westchester Medical Center, Valhalla, New York, USA
| | - Eric R Cohen
- Department of Neurology and Neurosurgery, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
| | - Philip Meyers
- Department of Radiology, Columbia University Medical Center, New York, New York, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, New York Medical College, Westchester Medical Center, Valhalla, New York, USA
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9
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“X-Map 2.0” for Edema Signal Enhancement for Acute Ischemic Stroke Using Non–Contrast-Enhanced Dual-Energy Computed Tomography. Invest Radiol 2018; 53:432-439. [DOI: 10.1097/rli.0000000000000461] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Kim BJ, Kim H, Jeong HG, Yang MH, Jung CK, Han MK, Kim JH, Demchuk AM, Bae HJ. Tenacity of Collateral Perfusion in Proximal Cerebral Arterial Occlusions 6-12 h after Onset. Cerebrovasc Dis 2018; 45:263-269. [PMID: 29879696 DOI: 10.1159/000489894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 05/07/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Clinical trials have shown that benefits of endovascular recanalization (EVT) for acute ischemic stroke patients with sizable penumbral tissues seems plausible even beyond 6 h after their last seen normal (LSN). Persistency of ischemic penumbra remains unclear in delayed periods. METHODS From a prospective stroke registry database, we identified 111 acute ischemic stroke patients who had internal carotid artery or middle cerebral artery occlusion with baseline National Institutes of Health Stroke Scale scores ≥6 points and arrived 6-12 h after LSN. Baseline information and functional outcomes were prospectively collected as a clinical registry. Attending physicians made treatment decisions for EVT based on the current guidelines and institutional protocols. MR image parameters, including the volume of diffusion-restricted lesions and mapping of the -hypoperfused area, were quantified using automated commercial software. Binary logistic regression analysis models, with modified Rankin Scale (mRS) scores of 0-1 at 3 months after stroke included as a dependent variable, were constructed. RESULTS Between 6 and 12 h after onset, 58% had a mismatch ratio of ≥1.8 at baseline and 42% had favorable imaging profiles as determined by DEFUSE 2 study. After 9 h, there was a mismatch ratio of ≥1.8 in 47 and 38% favorable profiles. EVT was performed in 54% of cases. A 3-month mRS score of 0-1 was found in 19% (25% in EVT and 12% in medical treatment groups) of cases. EVT was associated with an increased OR of having a mRS score of 0-1 at 3 months after stroke (adjusted OR 7.59 [95% CI 1.28-61.60]). CONCLUSIONS Penumbral tissues were persistent in a substantial proportion of anterior circulation occlusion cases 6-12 h after LSN. EVT at 6-12 h in a predominantly Asian cohort resulted in better outcomes.
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Affiliation(s)
- Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hyeran Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Han-Gil Jeong
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Mi Hwa Yang
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Cheol Kyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Moon-Ku Han
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jae Hyoung Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Andrew M Demchuk
- Department of Clinical Neuroscience and Radiology, Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Hee-Joon Bae
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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