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Xu H, Zheng M, Liu W, Peng W, Qiu J, Huang W, Zhang J, Xin E, Xia N, Lin R, Qiu C, Cao G, Chen W, Yang Y, Qian Y, Chen J. Enhanced Prediction of Malignant Cerebral Edema in Large Vessel Occlusion with Successful Recanalization Through Automated Weighted Net Water Uptake. World Neurosurg 2024; 188:e312-e319. [PMID: 38796145 DOI: 10.1016/j.wneu.2024.05.101] [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: 04/14/2024] [Accepted: 05/16/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Malignant cerebral edema (MCE) is associated with both net water uptake (NWU) and infarct volume. We hypothesized that NWU weighted by the affected Alberta Stroke Program Early Computed Tomography Score (ASPECTS) regions could serve as a quantitative imaging biomarker of aggravated edema development in acute ischemic stroke with large vessel occlusion (LVO). The aim of this study was to evaluate the performance of weighted NWU (wNWU) to predict MCE in patients with mechanical thrombectomy (MT). METHODS We retrospectively analyzed consecutive patients who underwent MT due to LVO. NWU was computed from nonenhanced computed tomography scans upon admission using automated ASPECTS software. wNWU was derived by multiplying NWU with the number of affected ASPECTS regions in the ischemic hemisphere. Predictors of MCE were assessed through multivariate logistic regression analysis and receiver operating characteristic curves. RESULTS NWU and wNWU were significantly higher in MCE patients than in non-MCE patients. Vessel recanalization status influenced the performance of wNWU in predicting MCE. In patients with successful recanalization, wNWU was an independent predictor of MCE (adjusted odds ratio 1.61; 95% confidence interval [CI] 1.24-2.09; P < 0.001). The model integrating wNWU, National Institutes of Health Stroke Scale, and collateral score exhibited an excellent performance in predicting MCE (area under the curve 0.80; 95% CI 0.75-0.84). Among patients with unsuccessful recanalization, wNWU did not influence the development of MCE (adjusted odds ratio 0.99; 95% CI 0.60-1.62; P = 0.953). CONCLUSIONS This study revealed that wNWU at admission can serve as a quantitative predictor of MCE in LVO with successful recanalization after MT and may contribute to the decision for early intervention.
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Affiliation(s)
- Haoli Xu
- Suzhou Medical College of Soochow University, Suzhou, Jiangsu, China; Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Mo Zheng
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Wenhui Liu
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Weili Peng
- Cancer Center, Department of Interventional Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Jiamei Qiu
- Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Wangle Huang
- Department of Nuclear Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jiaqi Zhang
- Cancer Center, Department of Interventional Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Enhui Xin
- Department of Research and Development, Shanghai United Imaging Intelligence Co., Ltd., Shanghai, China
| | - Nengzhi Xia
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Ru Lin
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Chaomin Qiu
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Guoquan Cao
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Weijian Chen
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yunjun Yang
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; Department of Nuclear Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yinfeng Qian
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Jun Chen
- Suzhou Medical College of Soochow University, Suzhou, Jiangsu, China; Cancer Center, Department of Interventional Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China.
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Ghozy S, Amoukhteh M, Hasanzadeh A, Jannatdoust P, Shafie M, Valizadeh P, Hassankhani A, Abbas AS, Kadirvel R, Kallmes DF. Net water uptake as a predictive neuroimaging marker for acute ischemic stroke outcomes: a meta-analysis. Eur Radiol 2024; 34:5308-5316. [PMID: 38276981 DOI: 10.1007/s00330-024-10599-6] [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: 08/09/2023] [Revised: 12/05/2023] [Accepted: 12/23/2023] [Indexed: 01/27/2024]
Abstract
OBJECTIVE To assess the role of net water uptake (NWU) in predicting outcomes in acute ischemic stroke (AIS) patients. METHODS A systematic review and meta-analysis were performed, adhering to established guidelines. The search covered PubMed, Scopus, Web of Science, and Embase databases until July 1, 2023. Eligible studies reporting quantitative ischemic lesion NWU in admission CT scans of AIS patients, stratified based on outcomes, were included. Data analysis was performed using R software version 4.2.1. RESULTS Incorporating 17 original studies with 2217 AIS patients, NWU was significantly higher in patients with poor outcomes compared to those with good outcomes (difference of medians: 5.06, 95% CI: 3.00-7.13, p < 0.001). Despite excluding one outlier study, considerable heterogeneity persisted among the included studies (I2 = 90.8%). The meta-regression and subgroup meta-analyses demonstrated significantly higher NWU in patients with poor functional outcome, as assessed by modified Rankin Scale (difference of medians: 3.83, 95% CI: 1.98-5.68, p < 0.001, I2 = 72.9%), malignant edema/infarct (difference of medians: 8.30, 95% CI: 4.01-12.58, p < 0.001, I2 = 95.6%), and intracranial hemorrhage (difference of medians: 5.43, 95% CI: 0.44-10.43, p = 0.03, I2 = 91.1%). CONCLUSION NWU on admission CT scans shows promise as a predictive marker for outcomes in AIS patients. Prospective, multicenter trials with standardized, automated NWU measurement are crucial for robustly predicting diverse clinical outcomes. CLINICAL RELEVANCE STATEMENT The potential of net water uptake as a biomarker for predicting outcomes in acute ischemic stroke patients holds significant promise. Further validation through additional research could lead to its integration into clinical practice, potentially improving the accuracy of clinical decision-making and allowing for the development of more precise patient care strategies. KEY POINTS • Net water uptake, a CT-based biomarker, quantifies early brain edema after acute ischemic stroke. • Net water uptake is significantly higher in poor outcome acute ischemic stroke patients. • Net water uptake on CT scans holds promise in predicting diverse acute ischemic stroke outcomes.
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Affiliation(s)
- Sherief Ghozy
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Melika Amoukhteh
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | - Alireza Hasanzadeh
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Payam Jannatdoust
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Mahan Shafie
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Parya Valizadeh
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Amir Hassankhani
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA.
| | - Alzhraa Salah Abbas
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Ramanathan Kadirvel
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
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3
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Winkelmeier L, Heit JJ, Broocks G, Prüter J, Heitkamp C, Schell M, Albers GW, Lansberg MG, Wintermark M, Kemmling A, Stracke CP, Guenego A, Paech D, Fiehler J, Faizy TD. Association between occlusion location, net water uptake and ischemic lesion growth in large vessel anterior circulation strokes. J Cereb Blood Flow Metab 2024; 44:1352-1361. [PMID: 38329032 DOI: 10.1177/0271678x241232193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Ischemic lesion net water uptake (NWU) represents a quantitative imaging biomarker for cerebral edema in acute ischemic stroke. Data on NWU for distinct occlusion locations remain scarce, but might help to improve the prognostic value of NWU. In this retrospective multicenter cohort study, we compared NWU between patients with proximal large vessel occlusion (pLVO; ICA or proximal M1) and distal large vessel occlusion (dLVO; distal M1 or M2). NWU was quantified by densitometric measurements of the early ischemic region. Arterial collateral status was assessed using the Maas scale. Regression analysis was used to investigate the relationship between occlusion location, NWU and ischemic lesion growth. A total of 685 patients met inclusion criteria. Early ischemic lesion NWU was higher in patients with pLVO compared with dLVO (7.7% vs 3.9%, P < .001). The relationship between occlusion location and NWU was partially mediated by arterial collateral status. NWU was associated with absolute ischemic lesion growth between admission and follow-up imaging (β estimate, 5.50, 95% CI, 3.81-7.19, P < .001). This study establishes a framework for the relationship between occlusion location, arterial collateral status, early ischemic lesion NWU and ischemic lesion growth. Future prognostic thresholds for NWU might be optimized by adjusting for the occlusion location.
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Affiliation(s)
- Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Department of Neuroradiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Prüter
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Heitkamp
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Schell
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gregory W Albers
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Maarten G Lansberg
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson, Houston, Texas, USA
| | - André Kemmling
- Department of Neuroradiology, University Marburg, Marburg, Germany
| | | | - Adrien Guenego
- Department of Neuroradiology, Erasme Medical Center, Brussels, Belgium
| | - Daniel Paech
- Clinic for Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Ong CJ, Chatzidakis S, Ong JJ, Feske S. Updates in Management of Large Hemispheric Infarct. Semin Neurol 2024; 44:281-297. [PMID: 38759959 PMCID: PMC11210577 DOI: 10.1055/s-0044-1787046] [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] [Indexed: 05/19/2024]
Abstract
This review delves into updates in management of large hemispheric infarction (LHI), a condition affecting up to 10% of patients with supratentorial strokes. While traditional management paradigms have endured, recent strides in research have revolutionized the approach to acute therapies, monitoring, and treatment. Notably, advancements in triage methodologies and the application of both pharmacological and mechanical abortive procedures have reshaped the acute care trajectory for patients with LHI. Moreover, ongoing endeavors have sought to refine strategies for the optimal surveillance and mitigation of complications, notably space-occupying mass effect, which can ensue in the aftermath of LHI. By amalgamating contemporary guidelines with cutting-edge clinical trial findings, this review offers a comprehensive exploration of the current landscape of acute and ongoing patient care for LHI, illuminating the evolving strategies that underpin effective management in this critical clinical domain.
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Affiliation(s)
- Charlene J. Ong
- Department of Neurology, Chobanian and Avedisian School of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, Massachusetts
| | - Stefanos Chatzidakis
- Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jimmy J. Ong
- Department of Neurology, Sidney Kimmel Medical College, Philadelphia, Pennsylvania
- Department of Neurology, Jefferson Einstein Hospital, Philadelphia, Pennsylvania
| | - Steven Feske
- Department of Neurology, Chobanian and Avedisian School of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, Massachusetts
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5
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Guasch-Jiménez M, Dhar R, Kumar A, Cifarelli J, Ezcurra-Díaz G, Lambea-Gil Á, Ramos-Pachón A, Martínez-Domeño A, Prats-Sánchez L, Guisado-Alonso D, Fernández-Cadenas I, Aguilera-Simón A, Marín R, Martínez-González JP, Ortega-Quintanilla J, Fernández-Pérez I, Avellaneda-Gómez C, Rodríguez-Pardo J, de Celis E, Moniche F, Freijo MDM, Cortijo E, Trillo S, Camps-Renom P, Martí-Fábregas J. Early automated cerebral edema assessment following endovascular therapy: impact on stroke outcome. J Neurointerv Surg 2024:jnis-2024-021641. [PMID: 38637151 DOI: 10.1136/jnis-2024-021641] [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: 02/23/2024] [Accepted: 04/02/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Cerebral edema (CED) is associated with poorer outcome in patients with acute ischemic stroke (AIS). The aim of the study was to investigate the factors contributing to greater early CED formation in patients with AIS who underwent endovascular therapy (EVT) and its association with functional outcome. METHODS We conducted a multicenter cohort study of patients with an anterior circulation AIS undergoing EVT. The volume of cerebrospinal fluid (CSF) was extracted from baseline and 24-hour follow-up CT using an automated algorithm. The severity of CED was quantified by the percentage reduction in CSF volume between CT scans (∆CSF). The primary endpoint was a shift towards an unfavorable outcome, assessed by modified Rankin Scale (mRS) score at 3 months. Multivariable ordinal logistic regression analyses were performed. The ∆CSF threshold that predicted unfavorable outcome was selected using receiver operating characteristic curve analysis. RESULTS We analyzed 201 patients (mean age 72.7 years, 47.8% women) in whom CED was assessable for 85.6%. Higher systolic blood pressure during EVT and failure to achieve modified Thrombolysis In Cerebral Infarction (mTICI) 3 were found to be independent predictors of greater CED. ∆CSF was independently associated with the probability of a one-point worsening in the mRS score (common odds ratio (cOR) 1.05, 95% CI 1.03 to 1.08) after adjusting for age, baseline mRS, National Institutes of Health Stroke Scale (NIHSS), and number of passes. Displacement of more than 25% of CSF was associated with an unfavorable outcome (OR 6.09, 95% CI 3.01 to 12.33) and mortality (OR 6.72, 95% CI 2.94 to 15.32). CONCLUSIONS Early CED formation in patients undergoing EVT was affected by higher blood pressure and incomplete reperfusion. The extent of early CED, measured by automated ∆CSF, was associated with worse outcomes.
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Affiliation(s)
- Marina Guasch-Jiménez
- Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rajat Dhar
- Neurology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Atul Kumar
- Neurology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Julien Cifarelli
- Neurology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Garbiñe Ezcurra-Díaz
- Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Stroke Unit, Institut de Recerca Sant Pau (IIB-SANT PAU), Barcelona, Spain
| | - Álvaro Lambea-Gil
- Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Stroke Unit, Institut de Recerca Sant Pau (IIB-SANT PAU), Barcelona, Spain
| | - Anna Ramos-Pachón
- Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Stroke Unit, Institut de Recerca Sant Pau (IIB-SANT PAU), Barcelona, Spain
| | - Alejandro Martínez-Domeño
- Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Stroke Unit, Institut de Recerca Sant Pau (IIB-SANT PAU), Barcelona, Spain
| | - Luis Prats-Sánchez
- Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Stroke Unit, Institut de Recerca Sant Pau (IIB-SANT PAU), Barcelona, Spain
| | - Daniel Guisado-Alonso
- Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Stroke Unit, Institut de Recerca Sant Pau (IIB-SANT PAU), Barcelona, Spain
| | - Israel Fernández-Cadenas
- Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Stroke Unit, Institut de Recerca Sant Pau (IIB-SANT PAU), Barcelona, Spain
| | - Ana Aguilera-Simón
- Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Stroke Unit, Institut de Recerca Sant Pau (IIB-SANT PAU), Barcelona, Spain
| | - Rebeca Marín
- Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Stroke Unit, Institut de Recerca Sant Pau (IIB-SANT PAU), Barcelona, Spain
| | | | | | | | | | | | | | | | | | - Elisa Cortijo
- Neurology, Valladolid University Hospital, Valladolid, Spain
| | - Santiago Trillo
- Neurology, Hospital Universitario de la Princesa, Madrid, Spain
| | - Pol Camps-Renom
- Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Stroke Unit, Institut de Recerca Sant Pau (IIB-SANT PAU), Barcelona, Spain
| | - Joan Martí-Fábregas
- Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Stroke Unit, Institut de Recerca Sant Pau (IIB-SANT PAU), Barcelona, Spain
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Wu H, Shi J, Sun X, Lu M, Liao A, Li Y, Xiao L, Zhou C, Dong W, Geng Z, Yuan L, Guo R, Chen M, Cheng X, Zhu W. Predictive effect of net water uptake on futile recanalisation in patients with acute large-vessel occlusion stroke. Clin Radiol 2024; 79:e599-e606. [PMID: 38310056 DOI: 10.1016/j.crad.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 12/03/2023] [Accepted: 01/06/2024] [Indexed: 02/05/2024]
Abstract
AIM To determine whether net water uptake (NWU) based on automated software evaluation could predict futile recanalisation in patients with acute anterior circulation large-vessel occlusion (LVO). MATERIALS AND METHODS Patients with acute anterior circulation LVO undergoing mechanical thrombectomy in Jinling Hospital were evaluated retrospectively. NWU and other baseline data were evaluated by performing univariate and multivariate analyses. The primary endpoint was 90-day modified Rankin scale score ≥3. A nomogram to predict poor clinical outcomes was developed based on multivariate logistic regression analysis. RESULTS Overall, 135 patients who underwent thrombectomy with a TICI grade ≥2b were enrolled. In multivariate logistic regression analysis, the following factors were identified as independent predictors of futile recanalisation: age (odds ratio [OR]: 1.055, 95 % confidence interval [CI]: 1.004-1.110, p=0.035), female (OR: 0.289, 95 % CI: 0.098-0.850, p=0.024), hypertension (OR: 3.182, 95 % CI: 1.160-8.728, p=0.025), high blood glucose level (OR: 1.36, 95 % CI: 1.087-1.701, p=0.007), admission National Institutes of Health Stroke Scale score (OR: 1.082, 95 % CI: 1.003-1.168, p=0.043), and NWU (OR: 1.312, 95 % CI: 1.038-1.659, p=0.023). CONCLUSIONS NWU based on Alberta Stroke Program Early Computed Tomography (CT) Score (ASPECTS) could be used to predict the occurrence of futile recanalisation in patients with acute anterior circulation LVO ischaemic stroke.
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Affiliation(s)
- H Wu
- Department of Neurology, Third People's Hospital of Yancheng, Yancheng 224001, Jiangsu, China; Department of Neurology, Jinling Hospital, Medical School of Nanjing University, 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
| | - J Shi
- Department of Medical Imaging, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - X Sun
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
| | - M Lu
- Department of Neurology, Jinling Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - A Liao
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
| | - Y Li
- Department of Neurology, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, Jiangsu, China
| | - L Xiao
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
| | - C Zhou
- Department of Medical Imaging, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - W Dong
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
| | - Z Geng
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
| | - L Yuan
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
| | - R Guo
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China
| | - M Chen
- Department of Neurology, Third People's Hospital of Yancheng, Yancheng 224001, Jiangsu, China
| | - X Cheng
- Department of Medical Imaging, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China.
| | - W Zhu
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, 305 Zhongshan East Road, Nanjing 210002, Jiangsu, China.
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7
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Yang LN, Sun Y, Wang YZ, Wang J, Qi YS, Mu SS, Liu YP, Zhang ZQ, Chen ZM, Wang XJ, Xie WX, Wei CW, Wang Y, Wu AS. Effect of Postoperative Prolonged sedation with Dexmedetomidine after successful reperfusion with Endovascular Thrombectomy on long-term prognosis in patients with acute ischemic stroke (PPDET): study protocol for a randomized controlled trial. Trials 2024; 25:166. [PMID: 38439027 PMCID: PMC10913237 DOI: 10.1186/s13063-024-08015-x] [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: 05/29/2023] [Accepted: 02/23/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Endovascular thrombectomy (EVT) is a standard treatment for acute ischemic stroke (AIS) with large vessel occlusion. Hypertension and increased blood pressure variability within the first 24 h after successful reperfusion are related to a higher risk of symptomatic intracerebral hemorrhage and higher mortality. AIS patients might suffer from ischemia-reperfusion injury following reperfusion, especially within 24 h. Dexmedetomidine (DEX), a sedative commonly used in EVT, can stabilize hemodynamics by inhibiting the sympathetic nervous system and alleviate ischemia-reperfusion injury through anti-inflammatory and antioxidative properties. Postoperative prolonged sedation for 24 h with DEX might be a potential pharmacological approach to improve long-term prognosis after EVT. METHODS This single-center, open-label, prospective, randomized controlled trial will include 368 patients. The ethics committee has approved the protocol. After successful reperfusion (modified thrombolysis in cerebral infarction scores 2b-3, indicating reperfusion of at least 50% of the affected vascular territory), participants are randomly assigned to the intervention or control group. In the intervention group, participants will receive 0.1~1.0 μg/kg/h DEX for 24 h. In the control group, participants will receive an equal dose of saline for 24 h. The primary outcome is the functional outcome at 90 days, measured with the categorical scale of the modified Rankin Scale, ranging from 0 (no symptoms) to 6 (death). The secondary outcome includes (1) the changes in stroke severity between admission and 24 h and 7 days after EVT, measured by the National Institute of Health Stroke Scale (ranging from 0 to 42, with higher scores indicating greater severity); (2) the changes in ischemic penumbra volume/infarct volume between admission and 7 days after EVT, measured by neuroimaging scan; (3) the length of ICU/hospital stay; and (4) adverse events and the all-cause mortality rate at 90 days. DISCUSSION This randomized clinical trial is expected to verify the hypothesis that postoperative prolonged sedation with DEX after successful reperfusion may promote the long-term prognosis of patients with AIS and may reduce the related socio-economic burden. TRIAL REGISTRATION ClinicalTrials.gov NCT04916197. Prospectively registered on 7 June 2021.
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Affiliation(s)
- Li-Na Yang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Yi Sun
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Yu-Zhu Wang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Jing Wang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Yi-Sha Qi
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Shan-Shan Mu
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Yun-Peng Liu
- Department of Neurosurgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Zi-Qing Zhang
- Department of Neurosurgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Zi-Mo Chen
- Department of Neurology, Beijing Tian-tan Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Xiao-Jie Wang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Wu-Xiang Xie
- Peking University Clinical Research Institute, Peking University Health Science Center, Beijing, 101125, People's Republic of China
| | - Chang-Wei Wei
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China.
| | - Yang Wang
- Department of Neurosurgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China.
| | - An-Shi Wu
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China.
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Klapproth S, Meyer L, Kniep H, Bechstein M, Kyselyova A, Hanning U, Schön G, Rimmele L, Fiehler J, Broocks G. Effect of short- versus long-term serum glucose levels on early ischemic water homeostasis and functional outcome in patients with large vessel occlusion stroke. Eur J Neurol 2024; 31:e16166. [PMID: 38015448 PMCID: PMC11235831 DOI: 10.1111/ene.16166] [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: 08/25/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND AND PURPOSE In ischemic stroke, the impact of short- versus long-term blood glucose level (BGL) on early lesion pathophysiology and functional outcome has not been assessed. The purpose of this study was to directly compare the effect of long-term blood glucose (glycated hemoglobin [HbA1c]) versus serum BGL on early edema formation and functional outcome. METHODS Anterior circulation ischemic stroke patients who underwent mechanical thrombectomy after multimodal computed tomography (CT) on admission were analyzed. Endpoints were early ischemic cerebral edema, measured by quantitative net water uptake (NWU) on initial CT and functional independence at Day 90. RESULTS A total of 345 patients were included. Patients with functional independence had significantly lower baseline NWU (3.1% vs. 8.3%; p < 0.001) and lower BGL (113 vs. 123 mg/dL; p < 0.001) than those without functional independence, while HbA1c levels did not differ significantly (5.7% vs. 5.8%; p = 0.15). A significant association was found for NWU and BGL (ß = 0.02, 95% confidence interval [CI] 0.006-0.03; p = 0.002), but not for HbA1c and NWU (ß = -0.16, 95% CI -0.53-0.21; p = 0.39). Mediation analysis showed that 67% of the effect of BGL on functional outcome was mediated by early edema formation. CONCLUSION Aggravated early edema and worse functional outcome was associated with elevated short-term serum BGL, but not with HbA1c levels. Hence, the link between short-term BGL and early edema development might be used as a target for adjuvant therapy in patients with ischemic stroke.
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Affiliation(s)
- Susan Klapproth
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Lukas Meyer
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Helge Kniep
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Anna Kyselyova
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Uta Hanning
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Gerhard Schön
- Institute of Medical Biometry and EpidemiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Leander Rimmele
- Department of NeurologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Jens Fiehler
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
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9
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Steffen P, Winkelmeier L, Kniep H, Geest V, Soltanipanah S, Fiehler J, Broocks G. Quantification of ischemic brain edema after mechanical thrombectomy using dual-energy computed tomography in patients with ischemic stroke. Sci Rep 2024; 14:4148. [PMID: 38378795 PMCID: PMC10879140 DOI: 10.1038/s41598-024-54600-0] [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: 09/27/2023] [Accepted: 02/14/2024] [Indexed: 02/22/2024] Open
Abstract
Net water uptake (NWU) is a quantitative imaging biomarker used to assess cerebral edema resulting from ischemia via Computed Tomography (CT)-densitometry. It serves as a strong predictor of clinical outcome. Nevertheless, NWU measurements on follow-up CT scans after mechanical thrombectomy (MT) can be affected by contrast staining. To improve the accuracy of edema estimation, virtual non-contrast images (VNC-I) from dual-energy CT scans (DECT) were compared to conventional polychromatic CT images (CP-I) in this study. We examined NWU measurements derived from VNC-I and CP-I to assess their agreement and predictive value in clinical outcome. 88 consecutive patients who received DECT as follow-up after MT were included. NWU was quantified on CP-I (cNWU) and VNC-I (vNWU). The clinical endpoint was functional independence at discharge. cNWU and vNWU were highly correlated (r = 0.71, p < 0.0001). The median difference between cNWU and vNWU was 8.7% (IQR: 4.5-14.1%), associated with successful vessel recanalization (mTICI2b-3) (ß: 11.6%, 95% CI 2.9-23.0%, p = 0.04), and age (ß: 4.2%, 95% CI 1.3-7.0%, p = 0.005). The diagnostic accuracy to classify outcome between cNWU and vNWU was similar (AUC:0.78 versus 0.77). Although there was an 8.7% median difference, indicating potential edema underestimation on CP-I, it did not have short-term clinical implications.
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Affiliation(s)
- Paul Steffen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany.
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Vincent Geest
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Setareh Soltanipanah
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
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10
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Li Y, Cao W, Xu X, Li T, Chen Y, Wang Y, Chen J, Gao P, Yang B, Dmytriw AA, Regenhardt RW, Chen F, Ma Q, Lu J, Liu Y, Wang C, Bai X, Jiao L. Early venous filling after mechanical thrombectomy in acute ischemic stroke due to large vessel occlusion in anterior circulation. J Neurointerv Surg 2024; 16:248-252. [PMID: 37197935 DOI: 10.1136/jnis-2023-020336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/28/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND The significance of early venous filling (EVF) after mechanical thrombectomy (MT) in acute ischemic stroke (AIS) is not fully understood. In this study, we aimed to investigate the impact of EVF after MT. METHODS From January 2019 to May 2022, AIS patients with successful recanalization (modified Thrombolysis in Cerebral Infarction score (mTICI) ≥2b) after MT were retrospectively reviewed. EVF was evaluated on final digital subtraction angiography runs after successful recanalization and was categorized into phase subgroups (arterial phase and capillary phase) and pathway subgroups (cortical veins subgroup and thalamostriate veins subgroup), respectively. The impact of EVF subgroups on functional outcomes after successful recanalization were both investigated. RESULTS A total of 349 patients achieving successful recanalization after MT were included, including 45 patients in the EVF group and 304 patients in the non-EVF group. Multivariable logistic regression analysis showed the EVF group had a higher rate of intracranial hemorrhage (ICH; 66.7% vs 22%, adjusted odds ratio (aOR) 6.805, 95% CI 3.389 to 13.662, P<0.001), symptomatic ICH (sICH; 28.9% vs 4.9%, aOR 6.011, 95% CI 2.493 to 14.494, P<0.001) and malignant cerebral edema (MCE; 20% vs 6.9%, aOR 2.682, 95% CI 1.086 to 6.624, P=0.032) than the non-EVF group. Furthermore, the cortical veins subgroup of EVF had a higher rate of mortality than the thalamostriate veins subgroup (37.5% vs 10.3%, P=0.029). CONCLUSIONS EVF is independently associated with ICH, sICH and MCE after successful recanalization of MT, but not with favorable outcome and mortality.
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Affiliation(s)
- Yi Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurology, Guangzhou Red Cross Hospital, Guangzhou, China
| | - Wenbo Cao
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Xin Xu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Tianhua Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Yanfei Chen
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Yabing Wang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Jian Chen
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Peng Gao
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Bin Yang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Adam A Dmytriw
- Neurointerventional Program, Departments of Medical Imaging & Clinical Neurological Sciences, London Health Sciences Centre, London, Ontario, Canada
- Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robert W Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fei Chen
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Qingfeng Ma
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jie Lu
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Radiology and Nuclear Medicine, Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China
| | - Yuqi Liu
- Department of Neurological Sciences, Escope Innovation Academy, Beijing, China
| | - Chunliang Wang
- Department of Neurological Sciences, Escope Innovation Academy, Beijing, China
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Department of Neurosurgery, China International Neuroscience Institute, Beijing, China
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11
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Bui Q, Kumar A, Chen Y, Hamzehloo A, Heitsch L, Slowik A, Strbian D, Lee JM, Dhar R. CSF-Based Volumetric Imaging Biomarkers Highlight Incidence and Risk Factors for Cerebral Edema After Ischemic Stroke. Neurocrit Care 2024; 40:303-313. [PMID: 37188885 PMCID: PMC11025464 DOI: 10.1007/s12028-023-01742-0] [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: 01/24/2023] [Accepted: 04/19/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Cerebral edema has primarily been studied using midline shift or clinical deterioration as end points, which only captures the severe and delayed manifestations of a process affecting many patients with stroke. Quantitative imaging biomarkers that measure edema severity across the entire spectrum could improve its early detection, as well as identify relevant mediators of this important stroke complication. METHODS We applied an automated image analysis pipeline to measure the displacement of cerebrospinal fluid (ΔCSF) and the ratio of lesional versus contralateral hemispheric cerebrospinal fluid (CSF) volume (CSF ratio) in a cohort of 935 patients with hemispheric stroke with follow-up computed tomography scans taken a median of 26 h (interquartile range 24-31) after stroke onset. We determined diagnostic thresholds based on comparison to those without any visible edema. We modeled baseline clinical and radiographic variables against each edema biomarker and assessed how each biomarker was associated with stroke outcome (modified Rankin Scale at 90 days). RESULTS The displacement of CSF and CSF ratio were correlated with midline shift (r = 0.52 and - 0.74, p < 0.0001) but exhibited broader ranges. A ΔCSF of greater than 14% or a CSF ratio below 0.90 identified those with visible edema: more than half of the patients with stroke met these criteria, compared with only 14% who had midline shift at 24 h. Predictors of edema across all biomarkers included a higher National Institutes of Health Stroke Scale score, a lower Alberta Stroke Program Early CT score, and lower baseline CSF volume. A history of hypertension and diabetes (but not acute hyperglycemia) predicted greater ΔCSF but not midline shift. Both ΔCSF and a lower CSF ratio were associated with worse outcome, adjusting for age, National Institutes of Health Stroke Scale score, and Alberta Stroke Program Early CT score (odds ratio 1.7, 95% confidence interval 1.3-2.2 per 21% ΔCSF). CONCLUSIONS Cerebral edema can be measured in a majority of patients with stroke on follow-up computed tomography using volumetric biomarkers evaluating CSF shifts, including in many without visible midline shift. Edema formation is influenced by clinical and radiographic stroke severity but also by chronic vascular risk factors and contributes to worse stroke outcomes.
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Affiliation(s)
- Quoc Bui
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA
| | - Atul Kumar
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA
| | - Yasheng Chen
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA
| | - Ali Hamzehloo
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA
| | - Laura Heitsch
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Jin-Moo Lee
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA
| | - Rajat Dhar
- Department of Neurology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8111, St. Louis, MO, USA.
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12
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Pham J, Ng FC. Novel advanced imaging techniques for cerebral oedema. Front Neurol 2024; 15:1321424. [PMID: 38356883 PMCID: PMC10865379 DOI: 10.3389/fneur.2024.1321424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 01/09/2024] [Indexed: 02/16/2024] Open
Abstract
Cerebral oedema following acute ischemic infarction has been correlated with poor functional outcomes and is the driving mechanism of malignant infarction. Measurements of midline shift and qualitative assessment for herniation are currently the main CT indicators for cerebral oedema but have limited sensitivity for small cortical infarcts and are typically a delayed sign. In contrast, diffusion-weighted (DWI) or T2-weighted magnetic resonance imaging (MRI) are highly sensitive but are significantly less accessible. Due to the need for early quantification of cerebral oedema, several novel imaging biomarkers have been proposed. Based on neuroanatomical shift secondary to space-occupying oedema, measures such as relative hemispheric volume and cerebrospinal fluid displacement are correlated with poor outcomes. In contrast, other imaging biometrics, such as net water uptake, T2 relaxometry and blood brain barrier permeability, reflect intrinsic tissue changes from the influx of fluid into the ischemic region. This review aims to discuss quantification of cerebral oedema using current and developing advanced imaging techniques, and their role in predicting clinical outcomes.
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Affiliation(s)
- Jenny Pham
- Department of Radiology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Felix C. Ng
- Department of Neurology, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
- Department of Medicine at Royal Melbourne Hospital, Melbourne Brain Centre, University of Melbourne, Parkville, VIC, Australia
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13
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Jingxuan J, Baohui G, Jingyi Z, Hongmei G, Minda L, Ye H, Yuehua L. Dual-energy computed tomography angiography-based quantification of lesion net water uptake to identify stroke onset time. Heliyon 2024; 10:e23540. [PMID: 38169834 PMCID: PMC10758880 DOI: 10.1016/j.heliyon.2023.e23540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 12/03/2023] [Accepted: 12/06/2023] [Indexed: 01/05/2024] Open
Abstract
Objectives To explore whether dual-energy computed tomography (DECT) angiography can provide reliable quantitative information on net water uptake (NWU) of ischemic brain to identify stroke patients within 4.5 h. Methods We retrospectively reviewed 142 patients with stroke occurrence and who underwent DECT angiography between August 2016 and May 2022. DECT angiography manual drawn the ischemic area by referring to the normal area of the contralateral hemisphere and follow-up images. The NWU in the ischemic area was determined using virtual non-contrast and monoenergetic (VNC &VM) images acquired from DECT angiography. The NWU values in the ischemic area were compared between stroke patients within and beyond 4.5 h. The diagnostic performance of the NWU values derived from the VNC and VM images was assessed through receiver operating characteristic curve analysis. Additionally, Furthermore, we examined the correlation between the NWU values and the stroke onset time. Results Seventy-eight (54.93 %) stroke patients underwent DECT angiography and within 4.5 h. These patients with lower median National Institute of Health stroke scale (NIHSS) scores on admission than those beyond 4.5 h (p < 0.05). Furthermore, the group within 4.5 h had lower NWU values than did the group beyond 4.5 h on all VNC and VM images (p < 0.001). The analysis revealed that the NWU values determined using the VM (60 keV) images had the highest predictive efficiency (AUC, 0.95; sensitivity, 100 %; and specificity, 89.06 %) and showed the strongest positive correlation with stroke onset time (r-value = 0.58, p < 0.001). Conclusions Our findings showed that DECT angiography-based quantification of NWU helps identify the stroke patients within 4.5 h with high predictive efficiency. Thus, NWU values determined using VM (60 keV) images could serve as a significant biomarker for stroke onset time.
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Affiliation(s)
- Jiang Jingxuan
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guan Baohui
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhou Jingyi
- Department of Radiology, Kunshan second People's Hospital, Kunshan, China
| | - Gu Hongmei
- Department of Radiology, Affiliated Hospital of Nantong University, Nantong, China
| | - Li Minda
- Department of Radiology, Affiliated Hospital of Nantong University, Nantong, China
| | - Hua Ye
- Department of Radiology, Affiliated Hospital of Nantong University, Nantong, China
| | - Li Yuehua
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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14
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Schleicher RL, Vorasayan P, McCabe ME, Bevers MB, Davis TP, Griffin JH, Hinduja A, Jadhav AP, Lee JM, Sawyer RN, Zlokovic BV, Sheth KN, Fedler JK, Lyden P, Kimberly WT. Analysis of brain edema in RHAPSODY. Int J Stroke 2024; 19:68-75. [PMID: 37382409 PMCID: PMC10789908 DOI: 10.1177/17474930231187268] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
BACKGROUND Cerebral edema is a secondary complication of acute ischemic stroke, but its time course and imaging markers are not fully understood. Recently, net water uptake (NWU) has been proposed as a novel marker of edema. AIMS Studying the RHAPSODY trial cohort, we sought to characterize the time course of edema and test the hypothesis that NWU provides distinct information when added to traditional markers of cerebral edema after stroke by examining its association with other markers. METHODS A total of 65 patients had measurable supratentorial ischemic lesions. Patients underwent head computed tomography (CT), brain magnetic resonance imaging (MRI) scans, or both at the baseline visit and after 2, 7, 30, and 90 days following enrollment. CT and MRI scans were used to measure four imaging markers of edema: midline shift (MLS), hemisphere volume ratio (HVR), cerebrospinal fluid (CSF) volume, and NWU using semi-quantitative threshold analysis. Trajectories of the markers were summarized, as available. Correlations of the markers of edema were computed and the markers compared by clinical outcome. Regression models were used to examine the effect of 3K3A-activated protein C (APC) treatment. RESULTS Two measures of mass effect, MLS and HVR, could be measured on all imaging modalities, and had values available across all time points. Accordingly, mass effect reached a maximum level by day 7, normalized by day 30, and then reversed by day 90 for both measures. In the first 2 days after stroke, the change in CSF volume was associated with MLS (ρ = -0.57, p = 0.0001) and HVR (ρ = -0.66, p < 0.0001). In contrast, the change in NWU was not associated with the other imaging markers (all p ⩾ 0.49). While being directionally consistent, we did not observe a difference in the edema markers by clinical outcome. In addition, baseline stroke volume was associated with all markers (MLS (p < 0.001), HVR (p < 0.001), change in CSF volume (p = 0.003)) with the exception of NWU (p = 0.5). Exploratory analysis did not reveal a difference in cerebral edema markers by treatment arm. CONCLUSIONS Existing cerebral edema imaging markers potentially describe two distinct processes, including lesional water concentration (i.e. NWU) and mass effect (MLS, HVR, and CSF volume). These two types of imaging markers may represent distinct aspects of cerebral edema, which could be useful for future trials targeting this process.
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Affiliation(s)
- Riana L. Schleicher
- Division of Neurocritical Care and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Pongpat Vorasayan
- Division of Neurocritical Care and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Neurology, Department of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Megan E. McCabe
- Department of Biostatistics, University of Iowa, Iowa City, IA, USA
| | - Matthew B. Bevers
- Divisions of Stroke, Cerebrovascular and Critical Care Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Thomas P. Davis
- Department of Pharmacology, University of Arizona Health Sciences, Tucson, AZ, USA
| | - John H. Griffin
- Department of Molecular Medicine, Scripps Research, La Jolla, CA, USA
| | - Archana Hinduja
- Department of Neurology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Jin-Moo Lee
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Robert N. Sawyer
- Department of Neurology, University of Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Berislav V. Zlokovic
- Department of Physiology & Neuroscience, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Kevin N. Sheth
- Division of Neurocritical Care, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Janel K. Fedler
- Department of Biostatistics, University of Iowa, Iowa City, IA, USA
| | - Patrick Lyden
- Department of Physiology & Neuroscience, Keck School of Medicine of USC, Los Angeles, CA, USA
- Department of Neurology, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - W. Taylor Kimberly
- Division of Neurocritical Care and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
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15
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Hua X, Liu M, Wu S. Definition, prediction, prevention and management of patients with severe ischemic stroke and large infarction. Chin Med J (Engl) 2023; 136:2912-2922. [PMID: 38030579 PMCID: PMC10752492 DOI: 10.1097/cm9.0000000000002885] [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: 07/17/2023] [Indexed: 12/01/2023] Open
Abstract
ABSTRACT Severe ischemic stroke carries a high rate of disability and death. The severity of stroke is often assessed by the degree of neurological deficits or the extent of brain infarct, defined as severe stroke and large infarction, respectively. Critically severe stroke is a life-threatening condition that requires neurocritical care or neurosurgical intervention, which includes stroke with malignant brain edema, a leading cause of death during the acute phase, and stroke with severe complications of other vital systems. Early prediction of high-risk patients with critically severe stroke would inform early prevention and treatment to interrupt the malignant course to fatal status. Selected patients with severe stroke could benefit from intravenous thrombolysis and endovascular treatment in improving functional outcome. There is insufficient evidence to inform dual antiplatelet therapy and the timing of anticoagulation initiation after severe stroke. Decompressive hemicraniectomy (DHC) <48 h improves survival in patients aged <60 years with large hemispheric infarction. Studies are ongoing to provide evidence to inform more precise prediction of malignant brain edema, optimal indications for acute reperfusion therapies and neurosurgery, and the individualized management of complications and secondary prevention. We present an evidence-based review for severe ischemic stroke, with the aims of proposing operational definitions, emphasizing the importance of early prediction and prevention of the evolution to critically severe status, summarizing specialized treatment for severe stroke, and proposing directions for future research.
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Affiliation(s)
- Xing Hua
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Ming Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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16
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Lim GZ, Lai JY, Seet CYH, Tham CH, Venketasubramanian N, Tan BYQ, Jing M, Yeo JYP, Myint MZ, Sia CH, Teoh HL, Sharma VK, Chan BPL, Yang C, Makmur A, Ong SJ, Yeo LLL. Revolutionizing the Management of Large-Core Ischaemic Strokes: Decoding the Success of Endovascular Therapy in the Recent Stroke Trials. J Cardiovasc Dev Dis 2023; 10:499. [PMID: 38132666 PMCID: PMC10743836 DOI: 10.3390/jcdd10120499] [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: 11/10/2023] [Revised: 12/02/2023] [Accepted: 12/15/2023] [Indexed: 12/23/2023] Open
Abstract
Endovascular therapy (EVT) has revolutionized the management of acute ischaemic strokes with large vessel occlusion, with emerging evidence suggesting its benefit also in large infarct core volume strokes. In the last two years, four randomised controlled trials have been published on this topic-RESCUE-Japan LIMIT, ANGEL-ASPECT, SELECT2 and TENSION, with overall results showing that EVT improves functional and neurological outcomes compared to medical management alone. This review aims to summarise the recent evidence presented by these four trials and highlight some of the limitations in our current understanding of this topic.
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Affiliation(s)
- Gareth Zigui Lim
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Jonathan Yexian Lai
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Christopher Ying Hao Seet
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Carol Huilian Tham
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | | | - Benjamin Yong Qiang Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Mingxue Jing
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Joshua Yee Peng Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - May Zin Myint
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
- Department of Cardiology, National University Heart Center, Singapore 119228, Singapore
| | - Hock Luen Teoh
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Vijay Kumar Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Bernard Poon Lap Chan
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Cunli Yang
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Department of Diagnostic Imaging, National University Health System, Singapore 119228, Singapore
| | - Andrew Makmur
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Department of Diagnostic Imaging, National University Health System, Singapore 119228, Singapore
| | - Shao Jin Ong
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Department of Diagnostic Imaging, National University Health System, Singapore 119228, Singapore
| | - Leonard Leong Litt Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Department of Diagnostic Imaging, National University Health System, Singapore 119228, Singapore
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Wu RR, Cao YZ, Xu XQ, Jia ZY, Zhao LB, Shi HB, Liu S, Wu FY, Lu SS. ASPECTS-based net water uptake outperforms target mismatch for outcome prediction in patients with acute ischemic stroke and late therapeutic window. Eur Radiol 2023; 33:9130-9138. [PMID: 37498384 DOI: 10.1007/s00330-023-09965-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 05/18/2023] [Accepted: 05/25/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVE To compare the prognostic value of net water uptake (NWU) and target mismatch (TM) on CT perfusion (CTP) in acute ischemic stroke (AIS) patients with late time window. METHODS One hundred and nine consecutive AIS patients with anterior-circulation large vessel occlusion presenting within 6-24 h from onset/last seen well were enrolled. Automated Alberta Stroke Program Early CT Score-based NWU (ASPECTS-NWU) was calculated from admission CT. The correlation between ASPECTS-NWU and CTP parameters was assessed. Predictors for favorable outcome (modified Rankin Scale score ≤ 2) at 90 days were assessed using logistic regression analysis. The ability of outcome prediction between ASPECTS-NWU and TM (an ischemic core < 70 mL, a mismatch ratio ≥ 1.8, and an absolute difference ≥ 15 mL) was compared using receiver operating characteristic (ROC) curve. RESULTS A higher level of ASPECTS-NWU was associated with a larger ischemic core (r = 0.66, p < 0.001) and a larger hypoperfusion volume (r = 0.38, p < 0.001). ASPECTS-NWU performed better than TM for outcome stratification (area under the curve [AUC], 0.738 vs 0.583, p = 0.004) and was the only independent neuroimaging marker associated with favorable outcomes compared with CTP parameters (odds ratio, 0.73; 95% confidence interval [CI] 0.62-0.87, p < 0.001). An outcome prediction model including ASPECTS-NWU and clinical variables (National Institutes of Health Stroke Scale scores and age) yielded an AUC of 0.828 (95% CI 0.744-0.893; sensitivity 65.4%; specificity 87.7%). CONCLUSION ASPECTS-NWU performed better than TM for outcome prediction in AIS patients with late time window and might be an alternative imaging biomarker to CTP for patient selection. CLINICAL RELEVANCE STATEMENT Automated Alberta Stroke Program Early CT Score-based net water uptake outperforms target mismatch on CT perfusion for the outcome prediction in patients with acute ischemic stroke and can be an alternative imaging biomarker for patient selection in late therapeutic window. KEY POINTS • A higher ASPECTS-based net water uptake was associated with larger ischemic cores and hypoperfusion volumes on CT perfusion. • ASPECTS-based net water uptake outperformed target mismatch for outcome prediction in acute ischemic stroke with extended therapeutic window. • ASPECTS-based net water uptake can be an alternative biomarker to target mismatch for selecting acute ischemic stroke patients with late therapeutic window.
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Affiliation(s)
- Rong-Rong Wu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No.300 Guangzhou Road, Gulou district, Nanjing, Jiangsu Province, China
| | - Yue-Zhou Cao
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Xiao-Quan Xu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No.300 Guangzhou Road, Gulou district, Nanjing, Jiangsu Province, China
| | - Zheng-Yu Jia
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Lin-Bo Zhao
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Hai-Bin Shi
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Fei-Yun Wu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No.300 Guangzhou Road, Gulou district, Nanjing, Jiangsu Province, China.
| | - Shan-Shan Lu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No.300 Guangzhou Road, Gulou district, Nanjing, Jiangsu Province, China.
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18
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Pham J, Gan C, Dabboucy J, Stella DL, Dowling R, Yan B, Bush S, Williams C, Mitchell PJ, Desmond P, Thijs V, Asadi H, Brooks M, Maingard J, Jhamb A, Pavlin-Premrl D, Campbell BC, Ng FC. Occult contrast retention post-thrombectomy on 24-h follow-up dual-energy CT: Associations and impact on imaging analysis. Int J Stroke 2023; 18:1228-1237. [PMID: 37260232 DOI: 10.1177/17474930231182018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Following reperfusion treatment in ischemic stroke, computed tomography (CT) imaging at 24 h is widely used to assess radiological outcomes. Even without visible hyperattenuation, occult angiographic contrast may persist in the brain and confound Hounsfield unit-based imaging metrics, such as net water uptake (NWU). AIMS We aimed to assess the presence and factors associated with retained contrast post-thrombectomy on 24-h imaging using dual-energy CT (DECT), and its impact on the accuracy of NWU as a measure of cerebral edema. METHODS Consecutive patients with anterior circulation large vessel occlusion who had post-thrombectomy DECT performed 24-h post-treatment from two thrombectomy stroke centers were retrospectively studied. NWU was calculated by interside comparison of HUs of the infarct lesion and its mirror homolog. Retained contrast was quantified by the difference in NWU values with and without adjustment for iodine. Patients with visible hyperdensities from hemorrhagic transformation or visible contrast retention and bilateral infarcts were excluded. Cerebral edema was measured by relative hemispheric volume (rHV) and midline shift (MLS). RESULTS Of 125 patients analyzed (median age 71 (IQR = 61-80), baseline National Institutes of Health Stroke Scale (NIHSS) 16 (IQR = 9.75-21)), reperfusion (defined as extended-Thrombolysis-In-Cerebral-Infarction 2b-3) was achieved in 113 patients (90.4%). Iodine-subtracted NWU was significantly higher than unadjusted NWU (17.1% vs 10.8%, p < 0.001). In multivariable median regression analysis, increased age (p = 0.024), number of passes (p = 0.006), final infarct volume (p = 0.023), and study site (p = 0.021) were independently associated with amount of retained contrast. Iodine-subtracted NWU correlated with rHV (rho = 0.154, p = 0.043) and MLS (rho = 0.165, p = 0.033) but unadjusted NWU did not (rHV rho = -0.035, p = 0.35; MLS rho = 0.035, p = 0.347). CONCLUSIONS Angiographic iodine contrast is retained in brain parenchyma 24-h post-thrombectomy, even without visually obvious hyperdensities on CT, and significantly affects NWU measurements. Adjustment for retained iodine using DECT is required for accurate NWU measurements post-thrombectomy. Future quantitative studies analyzing CT after thrombectomy should consider occult contrast retention.
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Affiliation(s)
- Jenny Pham
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Calvin Gan
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Jasmin Dabboucy
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Damien L Stella
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Richard Dowling
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Bernard Yan
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Radiology, Austin Health, Heidelberg, VIC, Australia
| | - Steven Bush
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Cameron Williams
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Peter J Mitchell
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Patricia Desmond
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- The University of Melbourne, Parkville, VIC, Australia
| | - Vincent Thijs
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
- Division of Stroke, Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
| | - Hamed Asadi
- Department of Radiology, Austin Health, Heidelberg, VIC, Australia
| | - Mark Brooks
- Department of Radiology, Austin Health, Heidelberg, VIC, Australia
| | - Julian Maingard
- Department of Radiology, Austin Health, Heidelberg, VIC, Australia
| | - Ash Jhamb
- Department of Radiology, Austin Health, Heidelberg, VIC, Australia
| | - Davor Pavlin-Premrl
- Department of Radiology, Austin Health, Heidelberg, VIC, Australia
- Melbourne Brain Centre, Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Bruce Cv Campbell
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Melbourne Brain Centre, Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Felix C Ng
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
- Melbourne Brain Centre, Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
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19
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Schön F, Wahl H, Grey A, Krukowski P, Müller A, Puetz V, Linn J, Kaiser DPO. Improved Visualization and Quantification of Net Water Uptake in Recent Small Subcortical Infarcts in the Thalamus Using Computed Tomography. Diagnostics (Basel) 2023; 13:3416. [PMID: 37998551 PMCID: PMC10670270 DOI: 10.3390/diagnostics13223416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/01/2023] [Accepted: 11/05/2023] [Indexed: 11/25/2023] Open
Abstract
Diagnosing recent small subcortical infarcts (RSSIs) via early computed tomography (CT) remains challenging. This study aimed to assess CT attenuation values (Hounsfield Units (HU)) and net water uptake (NWU) in RSSI and explore a postprocessing algorithm's potential to enhance thalamic RSSI detection. We examined non-contrast CT (NCCT) data from patients with confirmed thalamic RSSI on diffusion-weighted magnetic resonance imaging (DW-MRI) between January 2010 and October 2017. Co-registered DW-MRI and NCCT images enabled HU and NWU quantification in the infarct area compared to unaffected contralateral tissue. Results were categorized based on symptom onset to NCCT timing. Postprocessing using window optimization and frequency-selective non-linear blending (FSNLB) was applied, with interpretations by three blinded Neuroradiologists. The study included 34 patients (median age 70 years [IQR 63-76], 14 women). RSSI exhibited significantly reduced mean CT attenuation compared to unaffected thalamus (29.6 HU (±3.1) vs. 33.3 HU (±2.6); p < 0.01). Mean NWU in the infarct area increased from 6.4% (±7.2) at 0-6 h to 16.6% (±8.7) at 24-36 h post-symptom onset. Postprocessed NCCT using these HU values improved sensitivity for RSSI detection from 32% in unprocessed CT to 41% in FSNLB-optimized CT, with specificities ranging from 86% to 95%. In conclusion, CT attenuation values and NWU are discernible in thalamic RSSI up to 36 h post-symptom onset. Postprocessing techniques, particularly window optimization and FSNLB, moderately enhance RSSI detection.
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Affiliation(s)
- Felix Schön
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Institute and Polyclinic for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Hannes Wahl
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Arne Grey
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Pawel Krukowski
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Angela Müller
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Volker Puetz
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Department of Neurology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Jennifer Linn
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Daniel P. O. Kaiser
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
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20
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Faizy TD, Winkelmeier L, Mlynash M, Broocks G, Heitkamp C, Thaler C, van Horn N, Seners P, Kniep H, Stracke P, Zelenak K, Lansberg MG, Albers GW, Wintermark M, Fiehler J, Heit JJ. Brain edema growth after thrombectomy is associated with comprehensive collateral blood flow. J Neurointerv Surg 2023:jnis-2023-020921. [PMID: 37918909 DOI: 10.1136/jnis-2023-020921] [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: 08/17/2023] [Accepted: 10/13/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND We determined whether a comprehensive assessment of cerebral collateral blood flow is associated with ischemic lesion edema growth in patients successfully treated by thrombectomy. METHODS This was a multicenter retrospective study of ischemic stroke patients who underwent thrombectomy treatment of large vessel occlusions. Collateral status was determined using the cerebral collateral cascade (CCC) model, which comprises three components: arterial collaterals (Tan Scale) and venous outflow profiles (Cortical Vein Opacification Score) on CT angiography, and tissue-level collaterals (hypoperfusion intensity ratio) on CT perfusion. Quantitative ischemic lesion net water uptake (NWU) was used to determine edema growth between admission and follow-up non-contrast head CT (ΔNWU). Three groups were defined: CCC+ (good pial collaterals, tissue-level collaterals, and venous outflow), CCC- (poor pial collaterals, tissue-level collaterals, and venous outflow), and CCCmixed (remainder of patients). Primary outcome was ischemic lesion edema growth (ΔNWU). Multivariable regression models were used to assess the primary and secondary outcomes. RESULTS 538 patients were included. 157 patients had CCC+, 274 patients CCCmixed, and 107 patients CCC- profiles. Multivariable regression analysis showed that compared with patients with CCC+ profiles, CCC- (β 1.99, 95% CI 0.68 to 3.30, P=0.003) and CCC mixed (β 1.65, 95% CI 0.75 to 2.56, P<0.001) profiles were associated with greater ischemic lesion edema growth (ΔNWU) after successful thrombectomy treatment. ΔNWU (OR 0.74, 95% CI 0.68 to 0.8, P<0.001) and CCC+ (OR 13.39, 95% CI 4.88 to 36.76, P<0.001) were independently associated with functional independence. CONCLUSION A comprehensive assessment of cerebral collaterals using the CCC model is strongly associated with edema growth and functional independence in acute stroke patients successfully treated by endovascular thrombectomy.
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Affiliation(s)
- Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Mlynash
- Department of Neurology, Stanford Stroke Center, Stanford University, Stanford, California, USA
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Heitkamp
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Thaler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Paul Stracke
- Section of Interventional Neuroradiology, University Hospital Munster, Munster, Germany
| | - Kamil Zelenak
- Clinic of Radiology, Comenius University in Bratislava Jessenius Faculty of Medicine in Martin, Martin, Slovakia
- Clinic of Radiology, University Hospital Martin, Martin, Slovakia
| | - Maarten G Lansberg
- Department of Neurology, Stanford Stroke Center, Stanford University, Stanford, California, USA
| | - Gregory W Albers
- Stanford Stroke Center, Stanford Medicine, Stanford, California, USA
| | - Max Wintermark
- Department of Neuroradiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
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21
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Chen C, Yang J, Han Q, Wu Y, Li J, Xu T, Sun J, Gao X, Huang Y, Parsons MW, Lin L. Net water uptake within the ischemic penumbra predicts the presence of the midline shift in patients with acute ischemic stroke. Front Neurol 2023; 14:1246775. [PMID: 37840922 PMCID: PMC10570612 DOI: 10.3389/fneur.2023.1246775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 08/25/2023] [Indexed: 10/17/2023] Open
Abstract
Objective The study aimed to explore the association between midline shift (MLS) and net water uptake (NWU) within the ischemic penumbra in acute ischemic stroke patients. Methods This was a retrospective cohort study that examined patients with anterior circulation stroke. Net water uptake within the acute ischemic core and penumbra was calculated using data from admission multimodal CT scans. The primary outcome was severe cerebral edema measured by the presence of MLS on 24 to 48 h follow-up CT scans. The presence of a significant MLS was defined by a deviation of the septum pellucidum from the midline on follow-up CT scans of at least 3 mm or greater due to the mass effect of ischemic edema. The net water uptake was compared between patients with and without MLS, followed by logistic regression analyses and receiver operating characteristics (ROCs) to assess the predictive power of net water uptake in MLS. Results A total of 133 patients were analyzed: 50 patients (37.6%) with MLS and 83 patients (62.4%) without. Compared to patients without MLS, patients with MLS had higher net water uptake within the core [6.8 (3.2-10.4) vs. 4.9 (2.2-8.1), P = 0.048] and higher net water uptake within the ischemic penumbra [2.9 (1.8-4.3) vs. 0.2 (-2.5-2.7), P < 0.001]. Penumbral net water uptake had higher predictive performance than net water uptake of the core in MLS [area under the curve: 0.708 vs. 0.603, p < 0.001]. Moreover, the penumbral net water uptake predicted MLS in the multivariate regression model, adjusting for age, sex, admission National Institutes of Health Stroke Scale (NIHSS), diabetes mellitus, atrial fibrillation, ischemic core volume, and poor collateral vessel status (OR = 1.165; 95% CI = 1.002-1.356; P = 0.047). No significant prediction was found for the net water uptake of the core in the multivariate regression model. Conclusion Net water uptake measured acutely within the ischemic penumbra could predict severe cerebral edema at 24-48 h.
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Affiliation(s)
- Cuiping Chen
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Jianhong Yang
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Qing Han
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Yuefei Wu
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Jichuan Li
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Tianqi Xu
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Jie Sun
- Department of Neurosurgery, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Xiang Gao
- Department of Neurosurgery, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Yi Huang
- Department of Neurosurgery, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Mark W. Parsons
- Department of Neurology, Liverpool Hospital, Sydney, NSW, Australia
- Sydney Brain Center, University of New South Wales, Sydney, NSW, Australia
| | - Longting Lin
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
- Sydney Brain Center, University of New South Wales, Sydney, NSW, Australia
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22
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Broocks G, Meyer L, Hanning U, Faizy TD, Bechstein M, Kniep H, Van Horn N, Schön G, Barow E, Thomalla G, Fiehler J, Kemmling A. Haemorrhage after thrombectomy with adjuvant thrombolysis in unknown onset stroke depends on high early lesion water uptake. Stroke Vasc Neurol 2023:svn-2022-002264. [PMID: 37699728 DOI: 10.1136/svn-2022-002264] [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: 12/21/2022] [Accepted: 08/29/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND AND PURPOSE In wake-up stroke, CT-based quantitative net water uptake (NWU) might serve as an alternative tool to MRI to guide intravenous thrombolysis with alteplase (IVT). An important complication after IVT is symptomatic intracerebral haemorrhage (sICH). As NWU directly implies ischaemic lesion progression, reflecting blood-brain barrier injury, we hypothesised that NWU predicts sICH in patients who had a ischaemic stroke undergoing thrombectomy with unknown onset. METHODS Consecutive analysis of all patients who had unknown onset anterior circulation ischaemic stroke who underwent CT at baseline and endovascular treatment between December 2016 and October 2020. Quantitative NWU was assessed on baseline CT. The primary endpoint was sICH. The association of NWU and other baseline parameters to sICH was investigated using inverse-probability weighting (IPW) analysis. RESULTS A total of 88 patients were included, of which 46 patients (52.3%) received IVT. The median NWU was 10.7% (IQR: 5.1-17.7). The proportion of patients with any haemorrhage and sICH were 35.2% and 13.6%. NWU at baseline was significantly higher in patients with sICH (19.1% vs 9.6%, p<0.0001) and the median Alberta Stroke Program Early CT Score (ASPECTS) was lower (5 vs 8, p<0.0001). Following IPW, there was no association between IVT and sICH in unadjusted analysis. However, after adjusting for ASPECTS and NWU, there was a significant association between IVT administration and sICH (14.6%, 95% CI: 3.3% to 25.6%, p<0.01). CONCLUSION In patients with ischaemic stroke with unknown onset, the combination of high NWU with IVT is directly linked to higher rates of sICH. Besides ASPECTS for evaluating the extent of the early infarct lesion, quantitative NWU could be used as an imaging biomarker to assess the degree of blood-brain barrier damage in order to predict the risk of sICH in patients with wake up stroke.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias Djamsched Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Noel Van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Ewgenia Barow
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Neuroradiology, University Marburg, Marburg, Germany
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Dhar R, Kumar A, Chen Y, Begunova Y, Olexa M, Prasad A, Carey G, Gonzalez I, Bhatia K, Hamed M, Heitsch L, Mainali S, Petersen N, Lee JM. Imaging biomarkers of cerebral edema automatically extracted from routine CT scans of large vessel occlusion strokes. J Neuroimaging 2023; 33:606-616. [PMID: 37095592 PMCID: PMC10524672 DOI: 10.1111/jon.13109] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/13/2023] [Accepted: 04/15/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND AND PURPOSE Volumetric and densitometric biomarkers have been proposed to better quantify cerebral edema after stroke, but their relative performance has not been rigorously evaluated. METHODS Patients with large vessel occlusion stroke from three institutions were analyzed. An automated pipeline extracted brain, cerebrospinal fluid (CSF), and infarct volumes from serial CTs. Several biomarkers were measured: change in global CSF volume from baseline (ΔCSF); ratio of CSF volumes between hemispheres (CSF ratio); and relative density of infarct region compared with mirrored contralateral region (net water uptake [NWU]). These were compared to radiographic standards, midline shift and relative hemispheric volume (RHV) and malignant edema, defined as deterioration resulting in need for osmotic therapy, decompressive surgery, or death. RESULTS We analyzed 255 patients with 210 baseline CTs, 255 24-hour CTs, and 81 72-hour CTs. Of these, 35 (14%) developed malignant edema and 63 (27%) midline shift. CSF metrics could be calculated for 310 (92%), while NWU could only be obtained from 193 (57%). Peak midline shift was correlated with baseline CSF ratio (ρ = -.22) and with CSF ratio and ΔCSF at 24 hours (ρ = -.55/.63) and 72 hours (ρ = -.66/.69), but not with NWU (ρ = .15/.25). Similarly, CSF ratio was correlated with RHV (ρ = -.69/-.78), while NWU was not. Adjusting for age, National Institutes of Health Stroke Scale, tissue plasminogen activator treatment, and Alberta Stroke Program Early CT Score, CSF ratio (odds ratio [OR]: 1.95 per 0.1, 95% confidence interval [CI]: 1.52-2.59) and ΔCSF at 24 hours (OR: 1.87 per 10%, 95% CI: 1.47-2.49) were associated with malignant edema. CONCLUSION CSF volumetric biomarkers can be automatically measured from almost all routine CTs and correlate better with standard edema endpoints than net water uptake.
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Affiliation(s)
- Rajat Dhar
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
| | - Atul Kumar
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
| | - Yasheng Chen
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
| | | | - Madelynne Olexa
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Ayush Prasad
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Grace Carey
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
| | - Isabella Gonzalez
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
| | - Kunal Bhatia
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
| | - Mohammad Hamed
- Department of Neurology, The Ohio State University, Columbus, OH
| | - Laura Heitsch
- Department of Emergency Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA
| | - Nils Petersen
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Jin-Moo Lee
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO
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24
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Han W, Song Y, Rocha M, Shi Y. Ischemic brain edema: Emerging cellular mechanisms and therapeutic approaches. Neurobiol Dis 2023; 178:106029. [PMID: 36736599 DOI: 10.1016/j.nbd.2023.106029] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 01/14/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
Brain edema is one of the most devastating consequences of ischemic stroke. Malignant cerebral edema is the main reason accounting for the high mortality rate of large hemispheric strokes. Despite decades of tremendous efforts to elucidate mechanisms underlying the formation of ischemic brain edema and search for therapeutic targets, current treatments for ischemic brain edema remain largely symptom-relieving rather than aiming to stop the formation and progression of edema. Recent preclinical research reveals novel cellular mechanisms underlying edema formation after brain ischemia and reperfusion. Advancement in neuroimaging techniques also offers opportunities for early diagnosis and prediction of malignant brain edema in stroke patients to rapidly adopt life-saving surgical interventions. As reperfusion therapies become increasingly used in clinical practice, understanding how therapeutic reperfusion influences the formation of cerebral edema after ischemic stroke is critical for decision-making and post-reperfusion management. In this review, we summarize these research advances in the past decade on the cellular mechanisms, and evaluation, prediction, and intervention of ischemic brain edema in clinical settings, aiming to provide insight into future preclinical and clinical research on the diagnosis and treatment of brain edema after stroke.
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Affiliation(s)
- Wenxuan Han
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA 15213, United States of America
| | - Yang Song
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA 15213, United States of America
| | - Marcelo Rocha
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA 15213, United States of America
| | - Yejie Shi
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA 15213, United States of America.
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25
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Nie X, Leng X, Miao Z, Fisher M, Liu L. Clinically Ineffective Reperfusion After Endovascular Therapy in Acute Ischemic Stroke. Stroke 2023; 54:873-881. [PMID: 36475464 DOI: 10.1161/strokeaha.122.038466] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Endovascular treatment is a highly effective therapy for acute ischemic stroke due to large vessel occlusion. However, in clinical practice, nearly half of the patients do not have favorable outcomes despite successful recanalization of the occluded artery. This unfavorable outcome can be defined as having clinically ineffective reperfusion. The objective of the review is to describe clinically ineffective reperfusion after endovascular therapy and its underlying risk factors and mechanisms, including initial tissue damage, cerebral edema, the no-reflow phenomenon, reperfusion injury, procedural features, and variations in postprocedural management. Further research is needed to more accurately identify patients at a high risk of clinically ineffective reperfusion after endovascular therapy and to improve individualized periprocedural management strategies, to increase the chance of achieving favorable clinical outcomes.
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Affiliation(s)
- Ximing Nie
- Department of Neurology (X.N., L.L.), Beijing Tiantan Hospital, Capital Medical University, China.,China National Clinical Research Center for Neurological Diseases, Beijing (X.N., L.L.)
| | - Xinyi Leng
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, SAR (X.L.)
| | - Zhongrong Miao
- Department of Interventional Neuroradiology (Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.F.)
| | - Liping Liu
- Department of Neurology (X.N., L.L.), Beijing Tiantan Hospital, Capital Medical University, China.,China National Clinical Research Center for Neurological Diseases, Beijing (X.N., L.L.)
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26
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Broocks G, Meyer L, Elsayed S, McDonough R, Bechstein M, Faizy TD, Sporns P, Schön G, Minnerup J, Kniep HC, Hanning U, Barow E, Schramm P, Langner S, Nawabi J, Papanagiotou P, Wintermark M, Lansberg MG, Albers GW, Heit JJ, Fiehler J, Kemmling A. Association Between Net Water Uptake and Functional Outcome in Patients With Low ASPECTS Brain Lesions: Results From the I-LAST Study. Neurology 2023; 100:e954-e963. [PMID: 36414425 PMCID: PMC9990438 DOI: 10.1212/wnl.0000000000201601] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 10/10/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The effect of mechanical thrombectomy (MT) on functional outcome in patients with ischemic stroke with low ASPECTS is still uncertain. ASPECTS rating is based on the presence of ischemic hypoattenuation relative to normal; however, the degree of hypoattenuation, which directly reflects net uptake of water, is currently not considered an imaging biomarker in stroke triage. We hypothesized that the effect of thrombectomy on functional outcome in low ASPECTS patients depends on early lesion water uptake. METHODS For this multicenter observational study, patients with anterior circulation stroke with ASPECTS ≤5 were consecutively analyzed. Net water uptake (NWU) was assessed as a quantitative imaging biomarker in admission CT. The primary end point was the rate of favorable functional outcome defined as modified Rankin Scale score 0-3 at day 90. The effect of recanalization on functional outcome was analyzed according to the degree of NWU within the early infarct lesion. RESULTS A total of 254 patients were included, of which 148 (58%) underwent MT. The median ASPECTS was 4 (interquartile range [IQR] 3-5), and the median NWU was 11.4% (IQR 8.9%-15.1%). The rate of favorable outcome was 27.6% in patients with low NWU (<11.4%) vs 6.3% in patients with high NWU (≥11.4%; p < 0.0001). In multivariable logistic regression analysis, NWU was an independent predictor of outcome, whereas vessel recanalization (modified thrombolysis in cerebral infarction ≥2b) was only significantly associated with better outcomes if NWU was lower than 12.6%. In inverse-probability weighting analysis, recanalization was associated with 20.7% (p = 0.01) increase in favorable outcome in patients with low NWU compared with 9.1% (p = 0.06) in patients with high NWU. DISCUSSION Early NWU was independently associated with clinical outcome and might serve as an indicator of futile MT in low ASPECTS patients. NWU could be tested as a tool to select low ASPECTS patients for MT. TRIAL REGISTRATION INFORMATION The study is registered within the ClinicalTrials.gov Protocol Registration and Results System (NCT04862507).
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Affiliation(s)
- Gabriel Broocks
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany.
| | - Lukas Meyer
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Sarah Elsayed
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Rosalie McDonough
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Matthias Bechstein
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Tobias Djamsched Faizy
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Peter Sporns
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Gerhard Schön
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Jens Minnerup
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Helge C Kniep
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Uta Hanning
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Ewgenia Barow
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Peter Schramm
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Soenke Langner
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Jawed Nawabi
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Panagiotis Papanagiotou
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Max Wintermark
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Maarten G Lansberg
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Gregory W Albers
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Jeremy J Heit
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Jens Fiehler
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Andre Kemmling
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
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Lu SS, Wu RR, Cao YZ, Xu XQ, Jia ZY, Shi HB, Liu S, Wu FY. Automated Estimation of Quantitative Lesion Water Uptake as a Prognostic Biomarker for Patients with Ischemic Stroke and Large-Vessel Occlusion. AJNR Am J Neuroradiol 2023; 44:33-39. [PMID: 36549850 PMCID: PMC9835911 DOI: 10.3174/ajnr.a7741] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/11/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Net water uptake is qualified as an imaging marker of brain edema. We aimed to investigate the ability of net water uptake to predict 90-day functional outcome in patients with acute ischemic stroke and large-vessel occlusion. MATERIALS AND METHODS A total of 295 consecutive patients were retrospectively enrolled. Automated ASPECTS-net water uptake was calculated on the admission CT. The relationship between ASPECTS-net water uptake and 90-day neurologic outcome was assessed. The independent predictors of favorable outcome (mRS score ≤2) were assessed using multivariate logistic regression analysis and receiver operating characteristic curves and stratified by the ASPECTS. RESULTS Favorable 90-day outcomes were observed in 156 (52.9%) patients. ASPECTS-net water uptake (OR, 0.79; 95% CI, 0.70-0.90), NIHSS scores (OR, 0.91; 95% CI, 0.87-0.96), age (OR, 0.96; 95% CI, 0.94-0.99), and vessel recanalization (OR, 7.78; 95% CI, 3.96-15.29) were independently associated with favorable outcomes at 90 days (all, P < .01). A lower ASPECTS-net water uptake independently predicted a good prognosis, even in the subgroup of patients with low ASPECTS (≤5) (P < .05). An outcome-prediction model based on these variables yielded an area under the receiver operating characteristic curve of 0.856 (95% CI, 0.814-0.899; sensitivity, 76.3%; specificity, 81.3%). CONCLUSIONS ASPECTS-net water uptake could independently predict 90-day neurologic outcomes in patients with acute ischemic stroke and large-vessel occlusion. Integrating ASPECTS-net water uptake with clinical models could improve the efficiency of outcome stratification.
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Affiliation(s)
- S S Lu
- From the Departments of Radiology (S.S.L., R.R.W., X.Q.X., F.Y.W.)
| | - R R Wu
- From the Departments of Radiology (S.S.L., R.R.W., X.Q.X., F.Y.W.)
| | - Y Z Cao
- Interventional Radiology (Y.Z.C., Z.Y.J., H.B.S., S.L.), The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - X Q Xu
- From the Departments of Radiology (S.S.L., R.R.W., X.Q.X., F.Y.W.)
| | - Z Y Jia
- Interventional Radiology (Y.Z.C., Z.Y.J., H.B.S., S.L.), The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - H B Shi
- Interventional Radiology (Y.Z.C., Z.Y.J., H.B.S., S.L.), The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - S Liu
- Interventional Radiology (Y.Z.C., Z.Y.J., H.B.S., S.L.), The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - F Y Wu
- From the Departments of Radiology (S.S.L., R.R.W., X.Q.X., F.Y.W.)
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Trofimov AO, Trofimova KA, Lidji-Goryaev K, Martynov D, Nemoto E, Bragina OA, Bragin DE. Cerebral Net Water Uptake in Posttraumatic Cerebral Ischemia. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1438:59-64. [PMID: 37845440 DOI: 10.1007/978-3-031-42003-0_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
We assessed net water uptake changes (NWU) in regions of posttraumatic ischemia in relation to cerebral microcirculation mean transit time (MTT) at moderate-to-severe traumatic brain injury (TBI). MATERIALS AND METHODS 128 moderate-to-severe traumatic brain injury patients (44 women, 84 men, age: 37 ± 12 years) were stratified into 3 groups: Marshall 2-3: 48 patients, Marshall 4: 44 patients, Marshall 5: 36 patients. The groups were matched by sex and age. Patients received multiphase perfusion computed tomography (PCT) 1-5 days after admission. Net water uptake was calculated from non-contrast computed tomography. Data are shown as a median [interquartile range]. P < 0.05 was considered statistically significant. RESULTS Cerebral blood flow in posttraumatic ischemia foci in Marshall 4 group was significantly higher than that in the Marshall 5 group (p = 0.027). Net water uptake in posttraumatic ischemia zones was significantly higher than in zones without posttraumatic ischemia (8.1% versus 4.2%, p < 0.001). Mean transit time in posttraumatic ischemia zones was inversely and significantly correlated with higher net water uptake (R2 = 0,089, p < 0.01). CONCLUSIONS Delay of blood flow through the cerebral microvascular bed was significantly correlated with the increased net water uptake in posttraumatic ischemia foci. Marshall's classification did not predict the progression of posttraumatic ischemia.
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Affiliation(s)
- Alex O Trofimov
- Department of Neurological Diseases, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Kseniia A Trofimova
- Department of Neurological Diseases, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Kyril Lidji-Goryaev
- Department of Neurological Diseases, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Dmitry Martynov
- Technical State University Named After RE Alexeev, Nizhny Novgorod, Russia
| | - Edwin Nemoto
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Olga A Bragina
- Lovelace Biomedical Research Institute, Albuquerque, NM, USA
| | - Denis E Bragin
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, NM, USA
- Lovelace Biomedical Research Institute, Albuquerque, NM, USA
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Zhang S, Zhu C, Broocks G, Huang P, Blair C. Editorial: Neuroimaging study of post-stroke cerebral edema. Front Neurol 2023; 14:1167275. [PMID: 36959828 PMCID: PMC10028285 DOI: 10.3389/fneur.2023.1167275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 02/23/2023] [Indexed: 03/09/2023] Open
Affiliation(s)
- Sheng Zhang
- Department of Neurology, Center for Rehabilitation Medicine, People's Hospital of Hangzhou Medical College, Zhejiang Provincial People's Hospital, Hangzhou, China
- *Correspondence: Sheng Zhang
| | - Chengcheng Zhu
- Department of Radiology, University of Washington, Seattle, WA, United States
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peiyu Huang
- Department of Radiology, School of Medicine, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Christopher Blair
- Sydney Brain Centre, Ingham Institute for Applied Medical Research Senior Lecturer SWS Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
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30
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Sporns PB, Rusche T, Lee S, Hanning U, Meyer L, Faizy T, Fiehler J, Psychogios M, Kemmling A, Broocks G. Impact of edema formation on functional outcome in pediatric stroke patients. Eur J Neurol 2023; 30:150-154. [PMID: 36168926 DOI: 10.1111/ene.15576] [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: 08/18/2022] [Accepted: 09/09/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Quantitative lesion net water uptake (NWU) has been described as an imaging biomarker reflecting vasogenic edema as an early indicator of infarct progression. We hypothesized that edema formation measured by NWU is higher in children compared to adults but despite this functional outcome may be better in children. METHODS This study analyzed children enrolled in the Save ChildS Study who had baseline and follow-up computed tomography available and the data were compared to adult patients. RESULTS Some 207 patients, of whom 13 were children and 194 were adults, were analyzed. Median NWU at baseline was 7.8% (IQR: 4.3-11.3), and there were no significant differences between children and adults (7.5% vs. 7.8%; p = 0.87). The early edema progression rate was 3.0%/h in children and 2.3%/h in adults. Median ΔNWU was 15.1% in children and 10.5% in adults. Children had significantly more often excellent (mRS 0-1; children 10/13 = 77% vs. adults 28/196 = 14%; p < 0.0001) and favorable clinical outcomes (mRS 0-2, 12/13 = 92% vs. 39/196 = 20%; p < 0.0001). CONCLUSIONS In this study, clinical outcomes in children with large vessel occlusion strokes were better than in adults despite similar clinical and imaging characteristics and similar edema formation. This may be impacted by the generally better outcomes of children after strokes but may demonstrate that the degree of early ischemic changes using Alberta Stroke Program Early Computed Tomography Score (ASPECTS) and edema progression rate may not be a reason for exclusion from endovascular thrombectomy.
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Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thilo Rusche
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marios Psychogios
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Andre Kemmling
- Department of Neuroradiology, University Hospital Marburg, Marburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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31
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Trofimov A, Agarkova D, Trofimova K, Lidji-Goryaev C, Atochin D, Bragin D. On Net Water Uptake in Posttraumatic Ischemia Foci. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1425:629-634. [PMID: 37581836 DOI: 10.1007/978-3-031-31986-0_61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
BACKGROUND The influence of cerebral edema and resultant secondary complications on the clinical outcome of traumatic brain injury (TBI) is well known. Clinical studies of brain water homeostasis dynamics in TBI are limited, which determines the relevance of our work. The purpose is to study changes in brain water homeostasis after TBI of varying severity compared to corresponding cerebral microcirculation parameters. MATERIALS This non-randomized retrospective single-center study complies with the Helsinki Declaration for patient's studies. The study included 128 patients with posttraumatic ischemia (PCI) after moderate-to-severe TBI in the middle cerebral artery territory who were admitted to the hospital between July 2015 and February 2022. PCI was evaluated by perfusion computed tomography (CT), and brain edema was determined using net water uptake (NWU) on baseline CT images. The patients were allocated according to Marshall's classification. Multivariate linear regression models were performed to analyze data. RESULTS NWU in PCI areas were significantly higher than in patients with its absence (8.1% vs. 4.2%, accordingly; p < 0.001). In the multivariable regression analysis, the mean transit time increase was significantly and independently associated with higher NWU (R2 = 0.089, p < 0.01). In the PCI zone, cerebral blood flow, cerebral blood volume, and time to peak were not significantly associated with NWU values (p > 0.05). No significant differences were observed between the NWU values in PCI foci in different Marshall groups (p = 0.308). CONCLUSION Marshall's classification does not predict the progression of posttraumatic ischemia. The blood passage delays through the cerebral microvascular bed is associated with brain tissue water content increase in the PCI focus.
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Affiliation(s)
- A Trofimov
- Department of Neurological Diseases, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - D Agarkova
- Department of Neurological Diseases, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - K Trofimova
- Department of Neurological Diseases, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - C Lidji-Goryaev
- Department of Neurological Diseases, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - D Atochin
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - D Bragin
- Lovelace Biomedical Research Institute, Albuquerque, NM, USA
- Department of Neurology, University of New Mexico, School of Medicine, Albuquerque, NM, USA
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Sarraj A, Pujara DK, Churilov L, Sitton CW, Ng F, Hassan AE, Abraham MG, Blackburn SL, Sharma G, Yassi N, Kleinig T, Shah D, Wu TY, Tekle WG, Budzik RF, Hicks WJ, Vora N, Edgell RC, Haussen D, Ortega-Gutierrez S, Toth G, Maali L, Abdulrazzak MA, Al-Shaibi F, AlMaghrabi T, Yogendrakumar V, Shaker F, Mir O, Arora A, Duncan K, Sundararajan S, Opaskar A, Hu Y, Ray A, Sunshine J, Bambakidis N, Martin-Schild S, Hussain MS, Nogueira R, Furlan A, Sila CA, Grotta JC, Parsons M, Mitchell PJ, Donnan GA, Davis SM, Albers GW, Campbell BCV. Mediation of Successful Reperfusion Effect through Infarct Growth and Cerebral Edema: A Pooled, Patient-Level Analysis of EXTEND-IA Trials and SELECT Prospective Cohort. Ann Neurol 2022; 93:793-804. [PMID: 36571388 DOI: 10.1002/ana.26587] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/01/2022] [Accepted: 12/16/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Reperfusion therapy is highly beneficial for ischemic stroke. Reduction in both infarct growth and edema are plausible mediators of clinical benefit with reperfusion. We aimed to quantify these mediators and their interrelationship. METHODS In a pooled, patient-level analysis of the EXTEND-IA trials and SELECT study, we used a mediation analysis framework to quantify infarct growth and cerebral edema (midline shift) mediation effect on successful reperfusion (modified Treatment in Cerebral Ischemia ≥ 2b) association with functional outcome (modified Rankin Scale distribution). Furthermore, we evaluated an additional pathway to the original hypothesis, where infarct growth mediated successful reperfusion effect on midline shift. RESULTS A total 542 of 665 (81.5%) eligible patients achieved successful reperfusion. Baseline clinical and imaging characteristics were largely similar between those achieving successful versus unsuccessful reperfusion. Median infarct growth was 12.3ml (interquartile range [IQR] = 1.8-48.4), and median midline shift was 0mm (IQR = 0-2.2). Of 249 (37%) demonstrating a midline shift of ≥1mm, median shift was 2.75mm (IQR = 1.89-4.21). Successful reperfusion was associated with reductions in both predefined mediators, infarct growth (β = -1.19, 95% confidence interval [CI] = -1.51 to -0.88, p < 0.001) and midline shift (adjusted odds ratio = 0.36, 95% CI = 0.23-0.57, p < 0.001). Successful reperfusion association with improved functional outcome (adjusted common odds ratio [acOR] = 2.68, 95% CI = 1.86-3.88, p < 0.001) became insignificant (acOR = 1.39, 95% CI = 0.95-2.04, p = 0.094) when infarct growth and midline shift were added to the regression model. Infarct growth and midline shift explained 45% and 34% of successful reperfusion effect, respectively. Analysis considering an alternative hypothesis demonstrated consistent results. INTERPRETATION In this mediation analysis from a pooled, patient-level cohort, a significant proportion (~80%) of successful reperfusion effect on functional outcome was mediated through reduction in infarct growth and cerebral edema. Further studies are required to confirm our findings, detect additional mediators to explain successful reperfusion residual effect, and identify novel therapeutic targets to further enhance reperfusion benefits. ANN NEUROL 2023.
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Affiliation(s)
- Amrou Sarraj
- Department of Neurology, Case Western Reserve University, Cleveland, OH, USA.,Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Deep K Pujara
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Leonid Churilov
- Department of Neurology, Royal Melbourne Hospitals, University of Melbourne, Parkville, Victoria, Australia
| | - Clark W Sitton
- Department of Diagnostic and Interventional Radiology, UTHealth McGovern Medical School, Houston, TX, USA
| | - Felix Ng
- Department of Neurology, Royal Melbourne Hospitals, University of Melbourne, Parkville, Victoria, Australia
| | - Ameer E Hassan
- University of Texas Rio Grande Valley-Valley Baptist Medical Center, Harlingen, TX, USA
| | - Michael G Abraham
- Department of Neurology and Radiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Spiros L Blackburn
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX, USA
| | - Gagan Sharma
- Department of Neurology, Royal Melbourne Hospitals, University of Melbourne, Parkville, Victoria, Australia
| | - Nawaf Yassi
- Department of Neurology, Royal Melbourne Hospitals, University of Melbourne, Parkville, Victoria, Australia.,Walter and Eliza Hall Institute of Medical Research, Population Health and Immunity, Parkville, Victoria, Australia
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Darshan Shah
- Department of Neurology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Wondwossen G Tekle
- University of Texas Rio Grande Valley-Valley Baptist Medical Center, Harlingen, TX, USA
| | | | | | - Nirav Vora
- Riverside Methodist Hospital, Colombia, OH, USA
| | - Randall C Edgell
- Department of Neurology, Saint Louis University, Saint Louis, MO, USA
| | - Diogo Haussen
- Department of Neurology, Emory University, Atlanta, GA, USA
| | | | - Gabor Toth
- Department of Neurology, Cleveland Clinic, Cleveland, OH, USA
| | - Laith Maali
- Department of Neurology and Radiology, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Faisal Al-Shaibi
- Department of Neurology, Case Western Reserve University, Cleveland, OH, USA
| | - Tareq AlMaghrabi
- Department of Neurology, University of Tabuk, Tabuk, Kingdom of Saudi Arabia
| | - Vignan Yogendrakumar
- Department of Neurology, Royal Melbourne Hospitals, University of Melbourne, Parkville, Victoria, Australia
| | - Faris Shaker
- Department of Neurosurgery, UTHealth McGovern Medical School, Houston, TX, USA
| | - Osman Mir
- Department of Neurology, Baylor Scott & White Health, Dallas, TX, USA
| | - Ashish Arora
- Department of Neurology, Greensboro
- Cone Health, Greensboro, NC, USA
| | - Kelsey Duncan
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sophia Sundararajan
- Department of Neurology, Case Western Reserve University, Cleveland, OH, USA.,Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Amanda Opaskar
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Yin Hu
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Abhishek Ray
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey Sunshine
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Nicholas Bambakidis
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sheryl Martin-Schild
- Department of Neurology, Touro Infirmary and New Orleans East Hospital, New Orleans, LA, USA
| | | | - Raul Nogueira
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Anthony Furlan
- Department of Neurology, Case Western Reserve University, Cleveland, OH, USA.,Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Cathy A Sila
- Department of Neurology, Case Western Reserve University, Cleveland, OH, USA.,Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - James C Grotta
- Department of Neurology, Memorial Hermann Hospital Texas Medical Center, Houston, TX, USA
| | - Mark Parsons
- Department of Neurology, University of Newcastle, Newcastle, New South Wales, Australia
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital-University of Melbourne, Parkville, Victoria, Australia
| | - Geoffrey A Donnan
- Department of Neurology, Royal Melbourne Hospitals, University of Melbourne, Parkville, Victoria, Australia
| | - Stephen M Davis
- Department of Neurology, Royal Melbourne Hospitals, University of Melbourne, Parkville, Victoria, Australia
| | | | - Bruce C V Campbell
- Department of Neurology, Royal Melbourne Hospitals, University of Melbourne, Parkville, Victoria, Australia
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McDonough R, Elsayed S, Meyer L, Ewers T, Bechstein M, Kniep H, Nawka MT, Faizy TD, Schön G, Thomalla G, Fiehler J, Hanning U, Kemmling A, Broocks G. Low baseline ischemic water uptake is directly related to overestimation of CT perfusion-derived ischemic core volume. Sci Rep 2022; 12:20567. [PMID: 36446862 PMCID: PMC9708677 DOI: 10.1038/s41598-022-19176-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 08/25/2022] [Indexed: 11/30/2022] Open
Abstract
Computed-tomography perfusion (CTP) is frequently used to screen acute ischemic stroke (AIS) patients for endovascular treatment (EVT), despite known problems with ischemic "core" overestimation. This potentially leads to the unfair exclusion of patients from EVT. We propose that net water uptake (NWU) can be used in addition to CTP to more accurately assess the extent and/or stage of tissue infarction. Patients treated for AIS between 06/2015 and 07/2020 were retrospectively analyzed. Baseline CTP-derived core volume (pCore) and NWU were determined. Logistic regression tested the relationship between baseline clinical and imaging variables and core-overestimation (primary outcome). The secondary outcomes comprised 90-day functional independence (modified Rankin score) and lesion growth. 284 patients were included. Median NWU was 7.2% (IQR 2.6-12.8). ASPECTS (RR 1.28, 95% CI 1.09-1.51), NWU (RR 0.94, 95% CI 0.89-0.98), onset to recanalization (RR 1.00, 95% CI 0.99-1.00) and imaging (RR 1.00, 95% CI 1.00-1.00) times, and pCore (RR 1.02, 95% CI 1.01-1.02) were significantly associated with core overestimation. Core-overestimation was more likely to occur in patients with large pCores and low NWU at baseline. NWU was significantly correlated with lesion growth. We conclude that NWU can be used as a supplemental tool to CTP during admission imaging to more accurately assess the extent of ischemia, particularly relevant for patients with large CTP-defined cores who would otherwise be excluded from treatment.
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Affiliation(s)
- Rosalie McDonough
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Sarah Elsayed
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Lukas Meyer
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Theresa Ewers
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Matthias Bechstein
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Helge Kniep
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Marie Teresa Nawka
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Tobias D. Faizy
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Gerhard Schön
- grid.13648.380000 0001 2180 3484Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- grid.13648.380000 0001 2180 3484Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Uta Hanning
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Andre Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - Gabriel Broocks
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
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DeHoff G, Lau W. Medical management of cerebral edema in large hemispheric infarcts. Front Neurol 2022; 13:857640. [DOI: 10.3389/fneur.2022.857640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 08/26/2022] [Indexed: 11/06/2022] Open
Abstract
Acute ischemic stroke confers a high burden of morbidity and mortality globally. Occlusion of large vessels of the anterior circulation, namely the intracranial carotid artery and middle cerebral artery, can result in large hemispheric stroke in ~8% of these patients. Edema from stroke can result in a cascade effect leading to local compression of capillary perfusion, increased stroke burden, elevated intracranial pressure, herniation and death. Mortality from large hemispheric stroke is generally high and surgical intervention may reduce mortality and improve good outcomes in select patients. For those patients who are not eligible candidates for surgical decompression either due timing, medical co-morbidities, or patient and family preferences, the mainstay of medical management for cerebral edema is hyperosmolar therapy. Other neuroprotectants for cerebral edema such as glibenclamide are under investigation. This review will discuss current guidelines and evidence for medical management of cerebral edema in large hemispheric stroke as well as discuss important neuromonitoring and critical care management targeted at reducing morbidity and mortality for these patients.
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Deng Y, Wu S, Liu J, Liu M, Wang L, Wan J, Zhang S, Liu M. The stress hyperglycemia ratio is associated with the development of cerebral edema and poor functional outcome in patients with acute cerebral infarction. Front Aging Neurosci 2022; 14:936862. [PMID: 36118702 PMCID: PMC9474997 DOI: 10.3389/fnagi.2022.936862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background and purposeAbsolute hyperglycemia at admission has been shown to be associated with the development of cerebral edema (CED) after acute cerebral infarction. Stress hyperglycemia is a more objective reflection of hyperglycemic state than absolute hyperglycemia. However, studies on the associations between stress hyperglycemia and CED are limited. We aimed to explore the associations of stress hyperglycemia, measured by stress hyperglycemia ratio (SHR), with the development of CED and poor functional outcome of acute cerebral infarction.MethodsPatients with acute middle artery cerebral infarction admitted to the Department of Neurology, West China Hospital of Sichuan University, within 24 h of symptom onset from January 2017 to March 2021 were included. Stress hyperglycemia was assessed by the SHR: admission fasting plasma glucose (FPG)/hemoglobin A1c (HbA1c). The primary outcome was the degree of CED evaluated on brain image. The secondary outcomes were moderate-to-severe CED, poor functional outcome (modified Rankin Scale score > 2), and death at 90 days. The associations between the SHR and outcomes were assessed with multivariate logistic regression analyses. We further compared the predictive value of the SHR, admission random plasma glucose (RPG), and admission FPG for outcomes in the training dataset and validation dataset.Results638 patients were enrolled. Each 0.1-point increase in the SHR was independently associated with a 1.31-fold increased risk of a higher degree of CED [odds ratio (OR): 1.31 (95% confidence interval (CI): 1.20–1.42), P < 0.001]. The SHR was independently associated with moderate-to-severe CED [per 0.1-point increase: OR: 1.39 (95% CI: 1.24–1.57), P < 0.001], poor functional outcome [per 0.1-point increase: OR: 1.25 (95% CI: 1.12–1.40), P < 0.001], and death [per 0.1-point increase: OR: 1.13 (95% CI: 1.03–1.25), P < 0.05]. The predictive value of the SHR (as a continuous variable), exhibited by the area under the curve in receiver operating characteristic analysis, was higher than that of the RPG and FPG for moderate-to-severe CED and poor functional outcome (P < 0.05).ConclusionThe SHR is independently associated with the severity of CED, poor functional outcome, and death after acute cerebral infarction, and the SHR (as a continuous variable) has a better predictive value for moderate-to-severe CED and poor functional outcome than the RPG and FPG.
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Affiliation(s)
- Yilun Deng
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Junfeng Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Meng Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Lu Wang
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - JinCheng Wan
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Shihong Zhang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Shihong Zhang,
| | - Ming Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
- Ming Liu,
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ASPECTS-based net water uptake predicts poor reperfusion and poor clinical outcomes in patients with ischemic stroke. Eur Radiol 2022; 32:7026-7035. [PMID: 35980434 DOI: 10.1007/s00330-022-09077-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/27/2022] [Accepted: 08/01/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate the value of automated Alberta Stroke Program Early CT Score (ASPECTS)-based net water uptake (NWU) to predict tissue-level reperfusion status and 90-day functional outcomes in acute ischemic stroke (AIS) patients after reperfusion therapy. METHODS One hundred and twelve patients with AIS who received reperfusion therapy were enrolled. ASPECTS-NWU was calculated from admission CT (NWUadmission) and follow-up CT (NWUFCT), and the difference (ΔNWU) was calculated. Tissue-level reperfusion status was evaluated via follow-up arterial spin labeling imaging. The relationship between ASPECTS-NWU and tissue-level reperfusion was evaluated. Predictors of 90-day unfavorable outcomes (modified Rankin Scale score > 2) were assessed by multivariate logistic regression analysis and receiver operating characteristic (ROC) curves. RESULTS Poor reperfusion was observed in 40 patients (35.7%) after therapy. Those patients had significantly elevated NWUFCT (median, 14.15% vs. 8.08%, p = 0.018) and higher ΔNWU (median, 4.12% vs. -2.03%, p < 0.001), compared to patients with good reperfusion. High ΔNWU was a significant marker of poor reperfusion despite successful recanalization. National Institutes of Health Stroke Scale score at admission (odds ratio [OR], 1.11; 95% confidence interval [CI] 1.03-1.20, p = 0.007) and ΔNWU (OR, 1.07; 95% CI 1.02-1.13, p = 0.008) were independently associated with unfavorable outcomes. An outcome prediction model including both parameters yields an area under the curve of 0.762 (sensitivity 70.3%, specificity, 84.2%). CONCLUSIONS Elevated NWUFCT and higher ΔNWU were associated with poor tissue-level reperfusion after therapy. Higher ΔNWU was an independent predictor of poor reperfusion and unfavorable neurological outcomes despite successful recanalization. KEY POINTS • ASPECTS-NWU may provide pathophysiological information about tissue-level reperfusion status and offer prognostic benefits for patients with AIS after reperfusion therapy. • Elevated NWUFCT and higher ΔNWU were correlated with poor tissue-level reperfusion after therapy. • A higher ΔNWU is an independent predictor of poor reperfusion and 90-day unfavorable outcomes despite successful recanalization.
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Xu T, Yang J, Han Q, Wu Y, Gao X, Xu Y, Huang Y, Wang A, Parsons MW, Lin L. Net water uptake, a neuroimaging marker of early brain edema, as a predictor of symptomatic intracranial hemorrhage after acute ischemic stroke. Front Neurol 2022; 13:903263. [PMID: 35968283 PMCID: PMC9363701 DOI: 10.3389/fneur.2022.903263] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/27/2022] [Indexed: 11/15/2022] Open
Abstract
Objective We hypothesized that quantitative net water uptake (NWU), a novel neuroimaging marker of early brain edema, can predict symptomatic intracranial hemorrhage (sICH) after acute ischemic stroke (AIS). Methods We enrolled patients with AIS who completed admission multimodal computed tomography (CT) within 24 h after stroke onset. NWU within the ischemic core and penumbra was calculated based on admission CT, namely NWU-core and NWU-penumbra. sICH was defined as the presence of ICH in the infarct area within 7 days after stroke onset, accompanied by clinical deterioration. The predictive value of NWU-core and NWU-penumbra on sICH was evaluated by logistic regression analyses and the receiver operating characteristic (ROC) curve. A pure neuroimaging prediction model was built considering imaging markers, which has the potential to be automatically quantified with an artificial algorithm on image workstation. Results 154 patients were included, of which 93 underwent mechanical thrombectomy (MT). The median time from symptom onset to admission CT was 262 min (interquartile range, 198–368). In patients with MT, NWU-penumbra (OR =1.442; 95% CI = 1.177–1.766; P < 0.001) and NWU-core (OR = 1.155; 95% CI = 1.027–1.299; P = 0.016) were independently associated with sICH with adjustments for age, sex, time from symptom onset to CT, hypertension, lesion volume, and admission National Institutes of Health Stroke Scale (NIHSS) score. ROC curve showed that NWU-penumbra had better predictive performance than NWU-core on sICH [area under the curve (AUC): 0.773 vs. 0.673]. The diagnostic efficiency of the predictive model was improved with the containing of NWU-penumbra (AUC: 0.853 vs. 0.760). A pure imaging model also presented stable predictive power (AUC = 0.812). In patients without MT, however, only admission NIHSS score (OR = 1.440; 95% CI = 1.055–1.965; P = 0.022) showed significance in predicting sICH in multivariate analyses. Conclusions NWU-penumbra may have better predictive performance than NWU-core on sICH after MT. A pure imaging model showed potential value to automatically screen patients with sICH risk by image recognition, which may optimize treatment strategy.
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Affiliation(s)
- Tianqi Xu
- Department of Neurology, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
| | - Jianhong Yang
- Department of Neurology, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
| | - Qing Han
- Department of Neurology, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
| | - Yuefei Wu
- Department of Neurology, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
| | - Xiang Gao
- Department of Neurosurgery, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
| | - Yao Xu
- Department of Neurology, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
| | - Yi Huang
- Department of Neurosurgery, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
- Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, Ningbo, China
| | - Aiju Wang
- Department of Neurology, Ningbo Fourth Hospital, Ningbo, China
| | - Mark W. Parsons
- Sydney Brain Center, University of New South Wales, Sydney, NSW, Australia
- Department of Neurology, Liverpool Hospital, Sydney, NSW, Australia
- Mark W. Parsons
| | - Longting Lin
- Department of Neurology, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
- Sydney Brain Center, University of New South Wales, Sydney, NSW, Australia
- *Correspondence: Longting Lin
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Li J, Peng Y, Liu J, Wu J, Yao Y, Gu S, Zhang Z, Li Y, Wang J, Li Y. Estimation of ischemic core in acute ischemic stroke with CT angiography and non-contrast CT: Attenuation changes in ASPECTS regions vs. automated ASPECTS scoring. Front Neurosci 2022; 16:933753. [PMID: 35958990 PMCID: PMC9360489 DOI: 10.3389/fnins.2022.933753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/28/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose Reperfusion therapies for acute ischemic stroke due to large-vessel occlusion (AIS-LVO) are highly time-dependent, and large infarction is related to poor outcomes and risk of symptomatic hemorrhage. It is of significance to investigate and optimize the screening means and selection criteria for reperfusion therapies to identify more appropriate patients with better outcomes. This study aimed to compare the performance of attenuation changes vs. automated Alberta Stroke Program Early CT Score (ASPECTS) and using CT angiography (CTA) source images vs. non-contrast CT (NCCT) in distinguishing the infarction extent of ischemic core volumes ≥ 70 ml within different time windows. Methods A total of 73 patients with AIS-LVO who received multimodal CT were analyzed. The automated software was used to calculate ASPECTS. Attenuation change was defined as the sum of products of relative Hounsfield unit (rHU) values times weighting factors of all 10 ASPECTS regions. rHU value of each region was the HU of the ischemic side over that of the contralateral. The corresponding weighting factors were the regression coefficients derived from a multivariable linear regression model which was used to correlate regional rHU with ischemic core volumes, because each region in the ASPECTS template is weighted disproportionally in the ASPECTS system. Automated ASPECTS and attenuation changes were both calculated using CTA and NCCT, respectively. Results Attenuation changes were correlated with ischemic core volumes within different time windows (Rho ranging from 0.439 to 0.637). In classification of the ischemic core ≥ 70 ml, the performances of attenuation changes were comparable with ASPECTS (area under the curve [AUC] ranging from 0.799 to 0.891), with DeLong’s test (P = 0.079, P = 0.373); using CTA (AUC = 0.842) was not different from NCCT (AUC = 0.838). Conclusion Attenuation changes in ASPECTS regions were correlated with ischemic core volumes. In the classification of infarction volumes, attenuation changes had a high diagnostic ability comparable with automated ASPECTS. Measurement of attenuation changes is not involved in complicated scoring algorithms. This measurement can be used as an available, rapid, reliable, and accurate means to evaluate infarction extent within different time windows. The usefulness of infarction volumes measured by attenuation changes to identify more appropriate patients for reperfusion therapies can be validated in future clinical trials.
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Affiliation(s)
- Jing Li
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Medical Imaging Center, Central Hospital of Shaoyang, Shaoyang, China
| | - Yuling Peng
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiayang Liu
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiajing Wu
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yunzhuo Yao
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Sirun Gu
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhiwei Zhang
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yi Li
- Artificial Intelligence and Clinical Innovation Research, Neusoft Research of Intelligent Healthcare Technology, Co., Ltd., Shanghai, China
| | - Jingjie Wang
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- *Correspondence: Jingjie Wang,
| | - Yongmei Li
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Yongmei Li,
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Broocks G, Haupt W, McDonough R, Elsayed S, Flottmann F, Bechstein M, Schön G, Kniep H, Kemmling A, Zeleňák K, Fiehler J, Hanning U, Meyer L. Impact of relative cerebral blood volume reduction on early neurological improvement in extensive ischemic stroke. Eur J Neurol 2022; 29:3264-3272. [PMID: 35808904 DOI: 10.1111/ene.15491] [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: 06/08/2022] [Accepted: 06/29/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE The benefit of endovascular treatment (EVT) for patients with low ASPECTS is yet ambiguous and currently investigated in randomized trials. As a tool for estimation of infarct extent and progression, CT-perfusion might predict early neurological improvement (ENI) after EVT. OBJECTIVE We hypothesized that the degree of relative cerebral blood volume (rCBV) reduction is directly associated with ENI in low ASPECTS patients undergoing EVT. METHODS Ischemic stroke patients with ASPECTS≤5 who received multimodal-CT and underwent thrombectomy were analyzed. The rCBV reduction was defined as the ratio of CBV measured in the ischemic lesion and contralateral CBV. Complete reperfusion was defined as eTICI 2c-3. Clinical endpoint was early neurological improvement (ENI) at 24-hours defined continuously (NIHSS change from baseline to 24-hours) and binarized (NIHSS at 24-hours≤8). RESULTS 102 patients were included. Lower rCBV reduction and complete EVT were independently associated with ENI (-11.4 NIHSS points, p=0.04; -7.3 points, p<0.0001, respectively). The effect of complete EVT on ENI was directly linked to the degree of rCBV reduction: the probability for binary ENI was +34.6%, p=0.004 in patients with low rCBV reduction versus +8.2%, p=0.28 in patients with high rCBV reduction. CONCLUSION In ischemic stroke with low ASPECTS, ENI was directly linked to the degree of rCBV reduction as a potential indicator of ischemia depth in extensive baseline infarction. Lower rCBV reduction was associated with higher probability of ENI after complete reperfusion suggesting a less pronounced lesion progression despite its large extent and hence, a higher susceptibility to EVT.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Wolfgang Haupt
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Sarah Elsayed
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Gerhard Schön
- Department of Neuroradiology, University Medical Center Marburg, Marburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Andre Kemmling
- Department of Neuroradiology, University Medical Center Marburg, Marburg, Germany
| | - Kamil Zeleňák
- Department of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
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Haupt W, Meyer L, Wagner M, McDonough R, Elsayed S, Bechstein M, Schön G, Kniep H, Kemmling A, Fiehler J, Hanning U, Broocks G. Assessment of Irreversible Tissue Injury in Extensive Ischemic Stroke-Potential of Quantitative Cerebral Perfusion. Transl Stroke Res 2022:10.1007/s12975-022-01058-9. [PMID: 35778671 DOI: 10.1007/s12975-022-01058-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 06/07/2022] [Accepted: 06/23/2022] [Indexed: 10/17/2022]
Abstract
Computed tomography perfusion (CTP) is used as a tool to select ischemic stroke patients for endovascular treatment (EVT) and is currently investigated in the setting of extensive stroke with low Alberta Stroke Program Early CT scores (ASPECTS). The purpose of this study was to perform a comprehensive quantitative analysis of cerebral blood flow within the ischemic lesion compared to threshold-derived core lesion volumes. We hypothesized that the degree of cerebral blood volume (CBV) reduction within the ischemic lesion is predictive of irreversible tissue injury and functional outcome in patients with low ASPECTS. Ischemic stroke patients with an ASPECTS ≤ 5 who received multimodal CT on admission and underwent thrombectomy were analyzed. The ischemic lesion on CTP was identified, and CTP-derived parameters were measured as absolute means within the lesion and relative to the physiological perfusion measured in a contralateral region of interest. The degree of irreversible tissue injury was assessed using quantitative net water uptake (NWU). Functional endpoint was good outcome defined as modified Rankin Scale (mRS) scores 0-3 at day 90. One hundred eleven patients were included. The median core lesion volume was 71 ml (IQR: 25-107), and the median quantitative NWU was 9.5% (IQR: 6-13). Relative CBV (rCBV) reduction and ASPECTS at baseline were independently associated with NWU in multivariable linear regression analysis (ß: 12.4, 95%CI: 6.0-18.9, p < 0.0001) and (ß: - 0.78, 95% CI: - 1.53 to - 0.02; p = 0.045), respectively. Furthermore, rCBV was significantly associated with good outcome in patients with core volumes > 50 ml (OR: 0.16, 95% CI: 0.05-0.49, p = 0.001). Our study shows that rCBV reduction serves as an early surrogate for increase of NWU as a marker of irreversible tissue injury and lesion progression. Thus, the analysis of rCBV reduction within ischemic lesions may add another dimension to acute stroke triage in addition to core volumes or ASPECTS as indicators of the infarct extent and viability.
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Affiliation(s)
- Wolfgang Haupt
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Maximilian Wagner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.,Departments of Clinical Neuroscience and Radiology, Cummings School of Medicine, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Sarah Elsayed
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Andre Kemmling
- Department of Neuroradiology, University Medical Center Marburg, Marburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
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Kumar A, Chen Y, Corbin A, Hamzehloo A, Abedini A, Vardar Z, Carey G, Bhatia K, Heitsch L, Derakhshan JJ, Lee JM, Dhar R. Automated Measurement of Net Water Uptake From Baseline and Follow-Up CTs in Patients With Large Vessel Occlusion Stroke. Front Neurol 2022; 13:898728. [PMID: 35832178 PMCID: PMC9271791 DOI: 10.3389/fneur.2022.898728] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/06/2022] [Indexed: 11/13/2022] Open
Abstract
Quantifying the extent and evolution of cerebral edema developing after stroke is an important but challenging goal. Lesional net water uptake (NWU) is a promising CT-based biomarker of edema, but its measurement requires manually delineating infarcted tissue and mirrored regions in the contralateral hemisphere. We implement an imaging pipeline capable of automatically segmenting the infarct region and calculating NWU from both baseline and follow-up CTs of large-vessel occlusion (LVO) patients. Infarct core is extracted from CT perfusion images using a deconvolution algorithm while infarcts on follow-up CTs were segmented from non-contrast CT (NCCT) using a deep-learning algorithm. These infarct masks were flipped along the brain midline to generate mirrored regions in the contralateral hemisphere of NCCT; NWU was calculated as one minus the ratio of densities between regions, removing voxels segmented as CSF and with HU outside thresholds of 20-80 (normal hemisphere and baseline CT) and 0-40 (infarct region on follow-up). Automated results were compared with those obtained using manually-drawn infarcts and an ASPECTS region-of-interest based method that samples densities within the infarct and normal hemisphere, using intraclass correlation coefficient (ρ). This was tested on serial CTs from 55 patients with anterior circulation LVO (including 66 follow-up CTs). Baseline NWU using automated core was 4.3% (IQR 2.6-7.3) and correlated with manual measurement (ρ = 0.80, p < 0.0001) and ASPECTS (r = -0.60, p = 0.0001). Automatically segmented infarct volumes (median 110-ml) correlated to manually-drawn volumes (ρ = 0.96, p < 0.0001) with median Dice similarity coefficient of 0.83 (IQR 0.72-0.90). Automated NWU was 24.6% (IQR 20-27) and highly correlated to NWU from manually-drawn infarcts (ρ = 0.98) and the sampling-based method (ρ = 0.68, both p < 0.0001). We conclude that this automated imaging pipeline is able to accurately quantify region of infarction and NWU from serial CTs and could be leveraged to study the evolution and impact of edema in large cohorts of stroke patients.
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Affiliation(s)
- Atul Kumar
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Yasheng Chen
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Aaron Corbin
- Saint Louis University School of Medicine, Saint Louis, MO, United States
| | - Ali Hamzehloo
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Amin Abedini
- Department of Radiology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Zeynep Vardar
- Department of Radiology, University of Massachusetts Medical School, Worcester, MA, United States
| | - Grace Carey
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Kunal Bhatia
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Laura Heitsch
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Jamal J. Derakhshan
- Department of Radiology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Jin-Moo Lee
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Rajat Dhar
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States,*Correspondence: Rajat Dhar
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Irvine HJ, Acharjee A, Wolcott Z, Ament Z, Hinson HE, Molyneaux BJ, Simard JM, Sheth KN, Kimberly WT. Hypoxanthine is a pharmacodynamic marker of ischemic brain edema modified by glibenclamide. Cell Rep Med 2022; 3:100654. [PMID: 35700741 PMCID: PMC9244997 DOI: 10.1016/j.xcrm.2022.100654] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 03/16/2022] [Accepted: 05/17/2022] [Indexed: 11/13/2022]
Abstract
Brain edema after a large stroke causes significant morbidity and mortality. Here, we seek to identify pharmacodynamic markers of edema that are modified by intravenous (i.v.) glibenclamide (glyburide; BIIB093) treatment. Using metabolomic profiling of 399 plasma samples from patients enrolled in the phase 2 Glyburide Advantage in Malignant Edema and Stroke (GAMES)-RP trial, 152 analytes are measured using liquid chromatography-tandem mass spectrometry. Associations with midline shift (MLS) and the matrix metalloproteinase-9 (MMP-9) level that are further modified by glibenclamide treatment are compared with placebo. Hypoxanthine is the only measured metabolite that associates with MLS and MMP-9. In sensitivity analyses, greater hypoxanthine levels also associate with increased net water uptake (NWU), as measured on serial head computed tomography (CT) scans. Finally, we find that treatment with i.v. glibenclamide reduces plasma hypoxanthine levels across all post-treatment time points. Hypoxanthine, which has been previously linked to inflammation, is a biomarker of brain edema and a treatment response marker of i.v. glibenclamide treatment.
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Affiliation(s)
- Hannah J Irvine
- Division of Neurocritical Care and Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; Department of Neurology, NYU Langone Health, New York, NY 10016, USA
| | - Animesh Acharjee
- College of Medical and Dental Sciences, Institute of Cancer and Genomic Sciences, Centre for Computational Biology, University of Birmingham, Birmingham B15 2TT, UK; Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK; NIHR Surgical Reconstruction and Microbiology Research Centre, Birmingham B15 2TT, UK
| | - Zoe Wolcott
- Division of Neurocritical Care and Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Zsuzsanna Ament
- Division of Neurocritical Care and Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - H E Hinson
- Department of Neurology, Oregon Health Sciences University, Portland, OR 97239, USA
| | - Bradley J Molyneaux
- Division of Neurocritical Care, Department of Neurology, Brigham & Women's Hospital, Boston, MA 02115, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland, Baltimore, MD 21201, USA
| | - Kevin N Sheth
- Division of Neurocritical Care, Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
| | - W Taylor Kimberly
- Division of Neurocritical Care and Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Sim JE, Chung JW, Seo WK, Bang OY, Kim GM. Association of Systolic Blood Pressure and Cerebral Collateral Flow in Acute Ischemic Stroke by Stroke Subtype. Front Neurol 2022; 13:863483. [PMID: 35645966 PMCID: PMC9136006 DOI: 10.3389/fneur.2022.863483] [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: 01/27/2022] [Accepted: 04/14/2022] [Indexed: 11/30/2022] Open
Abstract
Background and Purpose Collateral flow in acute ischemic stroke is known as a predictor of treatment outcome and long-term prognosis. However, factors determining the initial collateral flow remain unclear. We investigated factors related to collateral flow in patients with acute ischemic stroke caused by large vessel occlusion (AIS-LVO) and further analyzed the results according to stroke etiology. Methods This was a retrospective study using prospective stroke registry data from a single university hospital from October 2014 to May 2021. AIS-LVO with middle cerebral artery M1 occlusion identified by pre-treatment multiphasic computed tomography angiography was included. Collateral flow score was graded on a 6-point ordinal scale according to pial arterial filling. Results A total of 74 patients [cardioembolism (CE): 57; large artery atherosclerosis (LAA): 17] was included. The mean age of all patients was 72.2 ± 11.7 years, and 37.8 % (n = 28) were men. Multivariate regression analysis showed that initial SBP [odds ratio (OR): 0.994; 95% confidence interval (CI): 0.990–0.998; p = 0.002] and stroke etiology (OR: 0.718; 95% CI: 0.548–0.940; p = 0.019) were independent factors of the collateral flow grade. Collateral flow grade was independently associated with initial SBP in the CE group (OR: 0.993; 95% CI: 0.989–0.998; p = 0.004) but not in the LAA group (OR: 0.992; 95% CI: 0.980–1.004; p = 0.218). Initial SBP was significantly correlated with NIHSS score in the CE group but not in the LAA group (r2= 0.091, p = 0.023; r2 = 0.043, p = 0.426, respectively). Conclusions Elevated initial SBP was associated with poor cerebral collateral flow and more severe symptoms in the CE group, but not in the LAA group in patients with AIS-LVO. These findings suggest differential effects of initial SBP elevation on collateral flow by stroke subtypes.
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van Horn N, Broocks G, Kabiri R, Kraemer MC, Christensen S, Mlynash M, Meyer L, Lansberg MG, Albers GW, Sporns P, Guenego A, Fiehler J, Wintermark M, Heit JJ, Faizy TD. Cerebral Hypoperfusion Intensity Ratio Is Linked to Progressive Early Edema Formation. J Clin Med 2022; 11:jcm11092373. [PMID: 35566500 PMCID: PMC9105689 DOI: 10.3390/jcm11092373] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 04/09/2022] [Accepted: 04/16/2022] [Indexed: 11/16/2022] Open
Abstract
The hypoperfusion intensity ratio (HIR) is associated with collateral status and reflects the impaired microperfusion of brain tissue in patients with acute ischemic stroke and large vessel occlusion (AIS-LVO). As a deterioration in cerebral blood flow is associated with brain edema, we aimed to investigate whether HIR is correlated with the early edema progression rate (EPR) determined by the ischemic net water uptake (NWU) in a multicenter retrospective analysis of AIS-LVO patients anticipated for thrombectomy treatment. HIR was automatically calculated as the ratio of time-to-maximum (TMax) > 10 s/(TMax) > 6 s. HIRs < 0.4 were regarded as favorable (HIR+) and ≥0.4 as unfavorable (HIR−). Quantitative ischemic lesion NWU was delineated on baseline NCCT images and EPR was calculated as the ratio of NWU/time from symptom onset to imaging. Multivariable regression analysis was used to assess the association of HIR with EPR. This study included 731 patients. HIR+ patients exhibited a reduced median NWU upon admission CT (4% (IQR: 2.1−7.6) versus 8.2% (6−10.4); p < 0.001) and less median EPR (0.016%/h (IQR: 0.007−0.04) versus 0.044%/h (IQR: 0.021−0.089; p < 0.001) compared to HIR− patients. Multivariable regression showed that HIR+ (β: 0.53, SE: 0.02; p = 0.003) and presentation of the National Institutes of Health Stroke Scale (β: 0.2, SE: 0.0006; p = 0.001) were independently associated with EPR. In conclusion, favorable HIR was associated with lower early edema progression and decreased ischemic edema formation on baseline NCCT.
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Affiliation(s)
- Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (N.v.H.); (G.B.); (R.K.); (M.C.K.); (L.M.); (J.F.)
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (N.v.H.); (G.B.); (R.K.); (M.C.K.); (L.M.); (J.F.)
| | - Reza Kabiri
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (N.v.H.); (G.B.); (R.K.); (M.C.K.); (L.M.); (J.F.)
| | - Michel C. Kraemer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (N.v.H.); (G.B.); (R.K.); (M.C.K.); (L.M.); (J.F.)
| | - Soren Christensen
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.C.); (M.M.); (M.G.L.); (G.W.A.)
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.C.); (M.M.); (M.G.L.); (G.W.A.)
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (N.v.H.); (G.B.); (R.K.); (M.C.K.); (L.M.); (J.F.)
| | - Maarten G. Lansberg
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.C.); (M.M.); (M.G.L.); (G.W.A.)
| | - Gregory W. Albers
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.C.); (M.M.); (M.G.L.); (G.W.A.)
| | - Peter Sporns
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, 4031 Basel, Switzerland;
| | - Adrien Guenego
- Department of Interventional Neuroradiology, Erasme University Hospital, 1070 Brussels, Belgium;
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (N.v.H.); (G.B.); (R.K.); (M.C.K.); (L.M.); (J.F.)
| | - Max Wintermark
- Department of Radiology, Stanford University School of Medicine, Stanford, CA 94305, USA; (M.W.); (J.J.H.)
| | - Jeremy J. Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, CA 94305, USA; (M.W.); (J.J.H.)
| | - Tobias D. Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (N.v.H.); (G.B.); (R.K.); (M.C.K.); (L.M.); (J.F.)
- Correspondence: ; Tel.: +49-0-152-2283-5161
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Ng FC, Yassi N, Sharma G, Brown SB, Goyal M, Majoie CBLM, Jovin TG, Hill MD, Muir KW, Saver JL, Guillemin F, Demchuk AM, Menon BK, San Roman L, White P, van der Lugt A, Ribo M, Bracard S, Mitchell PJ, Davis SM, Sheth KN, Kimberly WT, Campbell BCV. Correlation Between Computed Tomography-Based Tissue Net Water Uptake and Volumetric Measures of Cerebral Edema After Reperfusion Therapy. Stroke 2022; 53:2628-2636. [PMID: 35450438 DOI: 10.1161/strokeaha.121.037073] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cerebral edema after large hemispheric infarction is associated with poor functional outcome and mortality. Net water uptake (NWU) quantifies the degree of hypoattenuation on unenhanced-computed tomography (CT) and is increasingly used to measure cerebral edema in stroke research. Hemorrhagic transformation and parenchymal contrast staining after thrombectomy may confound NWU measurements. We investigated the correlation of NWU measured postthrombectomy with volumetric markers of cerebral edema and association with functional outcomes. METHODS In a pooled individual patient level analysis of patients presenting with anterior circulation large hemispheric infarction (core 80-300 mL or Alberta Stroke Program Early CT Score ≤5) in the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke trials) data set, cerebral edema was defined as the volumetric expansion of the ischemic hemisphere expressed as a ratio to the contralateral hemisphere(rHV). NWU and midline-shift were compared with rHV as the reference standard on 24-hour follow-up CT, adjusted for hemorrhagic transformation and the use of thrombectomy. Association between edema markers and day 90 functional outcomes (modified Rankin Scale) was assessed using ordinal logistic regression. RESULTS Overall (n=144), there was no correlation between NWU and rHV (rs=0.055, P=0.51). In sub-group analyses, a weak correlation between NWU with rHV was observed after excluding patients with any degree of hemorrhagic transformation (rs=0.211, P=0.015), which further improved after excluding thrombectomy patients (rs=0.453, P=0.001). Midline-shift correlated strongly with rHV in all sub-group analyses (rs>0.753, P=0.001). Functional outcome at 90 days was negatively associated with rHV (adjusted common odds ratio, 0.46 [95% CI, 0.32-0.65]; P<0.001) and midline-shift (adjusted common odds ratio, 0.85 [95% CI, 0.78-0.92]; P<0.001) but not NWU (adjusted common odds ratio, 1.00 [95% CI, 0.97-1.03]; P=0.84), adjusted for age, baseline National Institutes of Health Stroke Scale, and thrombectomy. Prognostic performance of NWU improved after excluding patients with hemorrhagic transformation and thrombectomy (adjusted odds ratio, 0.90 [95% CI, 0.80-1.02]; P=0.10). CONCLUSIONS NWU correlated poorly with conventional markers of cerebral edema and was not associated with clinical outcome in the presence of hemorrhagic transformation and thrombectomy. Measuring NWU postthrombectomy requires validation before implementation into clinical research. At present, the use of NWU should be limited to baseline CT, or follow-up CT only in patients without hemorrhagic transformation or treatment with thrombectomy.
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Affiliation(s)
- Felix C Ng
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., N.Y., G.S., S.M.D., B.C.V.C.).,Austin Health, Heidelberg, Australia (F.C.N.)
| | - Nawaf Yassi
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia (N.Y.)
| | - Gagan Sharma
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., N.Y., G.S., S.M.D., B.C.V.C.)
| | | | - Mayank Goyal
- Department of Radiology, University of Calgary, Foothills Hospital, AB, Canada (M.G.)
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, the Netherlands (C.B.L.M.M.)
| | - Tudor G Jovin
- Cooper Neurological Institute, Cooper University Health Care, Camden, NJ (T.G.J.)
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, AB, Canada (M.D.H., A.M.D., B.K.M.)
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Queen Elizabeth University Hospital, United Kingdom (K.W.M.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at the University of California, Los Angeles, California Stanford Stroke Center, Stanford University (J.L.S.)
| | - Francis Guillemin
- Clinical Investigation Centre-Clinical Epidemiology INSERM 1433, University of Lorraine and University Hospital of Nancy, France (F.G.)
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, AB, Canada (M.D.H., A.M.D., B.K.M.)
| | - Bijoy K Menon
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, AB, Canada (M.D.H., A.M.D., B.K.M.)
| | - Luis San Roman
- Department of Radiology, Hospital Clínic, Barcelona, Spain (L.S.R.)
| | - Philip White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom (P.W.)
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands (A.v.d.L.)
| | - Marc Ribo
- Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain (M.R.)
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, Université de Lorraine, Inserm, IADI, CHRU Nancy, France (S.B.)
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (P.J.M.)
| | - Stephen M Davis
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., N.Y., G.S., S.M.D., B.C.V.C.)
| | - Kevin N Sheth
- Department of Neurology, Yale New Haven Hospital, CT (K.N.S.)
| | - W Taylor Kimberly
- Center for Genomic Medicine and Department of Neurology, Massachusetts General Hospital, Boston (W.T.K.)
| | - Bruce C V Campbell
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., N.Y., G.S., S.M.D., B.C.V.C.)
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Han Q, Yang J, Gao X, Li J, Wu Y, Xu Y, Shang Q, Parsons MW, Lin L. Early Edema Within the Ischemic Core Is Time-Dependent and Associated With Functional Outcomes of Acute Ischemic Stroke Patients. Front Neurol 2022; 13:861289. [PMID: 35463133 PMCID: PMC9021998 DOI: 10.3389/fneur.2022.861289] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/08/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo investigate the difference in early edema, quantified by net water uptake (NWU) based on computed tomography (CT) between ischemic core and penumbra and to explore predictors of NWU and test its predictive power for clinical outcome.MethodsRetrospective analysis was conducted on patients admitted to Ningbo First Hospital with anterior circulation stroke and multi-modal CT. In 154 included patients, NWU of the ischemic core and penumbra were calculated and compared by Mann–Whitney U test. Correlations between NWU and variables including age, infarct time (time from symptom onset to imaging), volume of ischemic core, collateral status, and National Institutes of Health Stroke Scale (NIHSS) scores were investigated by Spearman's correlation analyses. Clinical outcome was defined using the modified Rankin Scale (mRS) at 90 days. Logistic regression and receiver operating characteristic analyses were performed to test the predictive value of NWU. Summary statistics are presented as median (interquartile range), mean (standard deviation) or estimates (95% confidence interval).ResultsThe NWU within the ischemic core [6.1% (2.9–9.2%)] was significantly higher than that of the penumbra [1.8% (−0.8–4.0%)]. The only significant predictor of NWU within the ischemic core was infarct time (p = 0.004). The NWU within the ischemic core [odds ratio = 1.23 (1.10–1.39)], the volume of ischemic core [1.04, (1.02–1.06)], age [1.09 (1.01–1.17)], and admission NHISS score [1.05 (1.01–1.09)] were associated with the outcome of patients adjusted for sex and treatment. The predictive power for the outcome of the model was significantly higher when NWU was included (area under the curve 0.875 vs. 0.813, p < 0.05 by Delong test).ConclusionsEarly edema quantified by NWU is relatively limited in the ischemic core and develops in a time-dependent manner. NWU estimates within the ischemic core may help to predict clinical outcomes of patients with acute ischemic stroke.
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Affiliation(s)
- Qing Han
- Department of Neurology, Ningbo First Hospital, Ningbo, China
| | - Jianhong Yang
- Department of Neurology, Ningbo First Hospital, Ningbo, China
| | - Xiang Gao
- Department of Neurosurgery, Ningbo First Hospital, Ningbo, China
| | - Jichuan Li
- Department of Neurology, Ningbo First Hospital, Ningbo, China
| | - Yuefei Wu
- Department of Neurology, Ningbo First Hospital, Ningbo, China
| | - Yao Xu
- Department of Neurology, Ningbo First Hospital, Ningbo, China
| | - Qing Shang
- Department of Neurology, Ningbo First Hospital, Ningbo, China
| | - Mark W. Parsons
- Sydney Brain Center, University of New South Wales, Sydney, NSW, Australia
- Mark W. Parsons
| | - Longting Lin
- Department of Neurology, Ningbo First Hospital, Ningbo, China
- Sydney Brain Center, University of New South Wales, Sydney, NSW, Australia
- *Correspondence: Longting Lin
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47
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Review of net water uptake in the management of acute ischemic stroke. Eur Radiol 2022; 32:5517-5524. [DOI: 10.1007/s00330-022-08658-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/24/2022] [Accepted: 02/12/2022] [Indexed: 12/15/2022]
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48
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Broocks G, Minnerup J, Kamalian S, Kemmling A. Editorial: Mechanisms, Measurement, and Management of Vasogenic Edema After Stroke. Front Neurol 2022; 13:865078. [PMID: 35280263 PMCID: PMC8907884 DOI: 10.3389/fneur.2022.865078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 02/01/2022] [Indexed: 11/20/2022] Open
Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- *Correspondence: Gabriel Broocks
| | - Jens Minnerup
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Shervin Kamalian
- Department of Neuroradiology, Harvard Medical School and Massachusetts General Hospital, Boston, MA, United States
| | - Andre Kemmling
- Department of Neuroradiology, University Marburg, Marburg, Germany
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49
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Jiang QM, Yu S, Dong XF, Wang HS, Hou J, Huang ZC, Guo ZL, You SJ, Xiao GD. Predictors and Dynamic Nomogram to Determine the Individual Risk of Malignant Brain Edema After Endovascular Thrombectomy in Acute Ischemic Stroke. J Clin Neurol 2022; 18:298-307. [PMID: 35196752 PMCID: PMC9163945 DOI: 10.3988/jcn.2022.18.3.298] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/11/2021] [Accepted: 11/11/2021] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose This study aimed to construct an optimal dynamic nomogram for predicting malignant brain edema (MBE) in acute ischemic stroke (AIS) patients after endovascular thrombectomy (ET). Methods We enrolled AIS patients after ET from May 2017 to April 2021. MBE was defined as a midline shift of >5 mm at the septum pellucidum or pineal gland based on follow-up computed tomography within 5 days after ET. Multivariate logistic regression and LASSO (least absolute shrinkage and selection operator) regression were used to construct the nomogram. The area under the receiver operating characteristic curve (AUC) and decision-curve analysis were used to compare our nomogram with two previous risk models for predicting brain edema after ET. Results MBE developed in 72 (21.9%) of the 329 eligible patients. Our dynamic web-based nomogram (https://successful.shinyapps.io/DynNomapp/) consisted of five parameters: basal cistern effacement, postoperative National Institutes of Health Stroke Scale (NIHSS) score, brain atrophy, hypoattenuation area, and stroke etiology. The nomogram showed good discrimination ability, with a C-index (Harrell’s concordance index) of 0.925 (95% confidence interval=0.890–0.961), and good calibration (Hosmer-Lemeshow test, p=0.386). All variables had variance inflation factors of <1.5 and tolerances of >0.7, suggesting no significant collinearity among them. The AUC of our nomogram (0.925) was superior to those of Xiang-liang Chen and colleagues (0.843) and Ming-yang Du and colleagues (0.728). Conclusions Our web-based dynamic nomogram reliably predicted the risk of MBE in AIS patients after ET, and hence is worthy of further evaluation.
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Affiliation(s)
- Qian-Mei Jiang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Shuai Yu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiao-Feng Dong
- Department of Neurology, Suzhou Municipal Hospital, Suzhou, China
| | - Huai-Shun Wang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jie Hou
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhi-Chao Huang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhi-Liang Guo
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Shou-Jiang You
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China.
| | - Guo-Dong Xiao
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China.
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50
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Wolff L. Editorial comment on "Automated quantitative lesion water uptake in acute stroke is a predictor of malignant cerebral edema". Eur Radiol 2022; 32:2769-2770. [PMID: 35103830 DOI: 10.1007/s00330-022-08544-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 11/05/2021] [Accepted: 11/18/2021] [Indexed: 11/25/2022]
Abstract
KEY POINTS • In patients with acute ischemic stroke, automated measurements of net water uptake in baseline CTA an NCCT scans can be used as predictor for developing malignant cerebral edema. • A creative approach can lead to broader usability of automated tools.
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Affiliation(s)
- Lennard Wolff
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands.
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