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Asmundo L, Zanardo M, Cressoni M, Ambrogi F, Bet L, Giatsidis F, Di Leo G, Sardanelli F, Vitali P. Ischemic core detection threshold of computed tomography perfusion (CTP) in acute stroke. LA RADIOLOGIA MEDICA 2024:10.1007/s11547-024-01868-x. [PMID: 39162940 DOI: 10.1007/s11547-024-01868-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 08/01/2024] [Indexed: 08/21/2024]
Abstract
PURPOSE This study aimed to determine the accuracy of detecting ischemic core volume using computed tomography perfusion (CTP) in patients with suspected acute ischemic stroke compared to diffusion-weighted magnetic resonance imaging (DW-MRI) as the reference standard. METHODS This retrospective monocentric study included patients who underwent CTP and DW-MRI for suspected acute ischemic stroke. The ischemic core size was measured at DW-MRI. The detectability threshold volume was defined as the lowest volume detected by each method. Clinical data on revascularization therapy, along with the clinical decision that influenced the choice, were collected. Volumes of the ischemic cores were compared using the Mann-Whitney U test. RESULTS Of 83 patients who underwent CTP, 52 patients (median age 73 years, IQR 63-80, 36 men) also had DW-MRI and were included, with a total of 70 ischemic cores. Regarding ischemic cores, only 18/70 (26%) were detected by both CTP and DW-MRI, while 52/70 (74%) were detected only by DW-MRI. The median volume of the 52 ischemic cores undetected on CTP (0.6 mL, IQR 0.2-1.3 mL) was significantly lower (p < 0.001) than that of the 18 ischemic cores detected on CTP (14.2 mL, IQR 7.0-18.4 mL). The smallest ischemic core detected on CTP had a volume of 5.0 mL. Among the 20 patients with undetected ischemic core on CTP, only 10% (2/20) received thrombolysis treatment. CONCLUSIONS CTP maps failed in detecting ischemic cores smaller than 5 mL. DW-MRI remains essential for suspected small ischemic brain lesions to guide a correct treatment decision-making.
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Affiliation(s)
- Luigi Asmundo
- Postgraduate School in Radiodiagnostics, Università degli Studi di Milano, Via Festa del Perdono 7, 20122, Milan, Italy
| | - Moreno Zanardo
- Radiology Unit, IRCCS Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Italy.
| | - Massimo Cressoni
- Radiology Unit, IRCCS Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Italy
| | - Federico Ambrogi
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Via Della Commenda 19, 20122, Milan, Italy
- Scientific Directorate, IRCCS Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Italy
| | - Luciano Bet
- Neurology Unit, IRCCS Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Italy
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133, Milan, Italy
| | - Fabio Giatsidis
- Neurology Unit, IRCCS Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Italy
| | - Giovanni Di Leo
- Radiology Unit, IRCCS Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Italy
| | - Francesco Sardanelli
- Radiology Unit, IRCCS Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Italy
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133, Milan, Italy
| | - Paolo Vitali
- Radiology Unit, IRCCS Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Italy
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133, Milan, Italy
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Huo X, Nguyen TN, Sun D, Raynald, Pan Y, Ma G, Tong X, Wang M, Ma N, Gao F, Mo D, Abdalkader M, Masoud HE, Nogueira RG, Miao Z. Association of Mismatch Profiles and Clinical Outcome from Endovascular Therapy in Large Infarct: A Post-Hoc Analysis of the ANGEL-ASPECT Trial. Ann Neurol 2024. [PMID: 38953673 DOI: 10.1002/ana.27017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 06/05/2024] [Accepted: 06/09/2024] [Indexed: 07/04/2024]
Abstract
OBJECTIVES We investigated whether patients with large infarct and the presence or absence of perfusion mismatch are associated with endovascular treatment benefit. METHODS This is a post-hoc analysis of the Endovascular Therapy in Anterior Circulation Large Vessel Occlusion with a Large Infarct (ANGEL-ASPECT) randomized trial, which enrolled patients within 24 hours of onset with ASPECTS 3 to 5 or ASPECTS 0 to 2 with an infarct core 70 to 100 ml. Mismatch ratio was defined as time-to-maximum (Tmax) >6 s cerebral volume/ischemic core volume, and mismatch volume was defined as Tmax >6 s volume minus ischemic core volume. We divided patients into mismatch ratio ≥1.2 and mismatch volume ≥10 ml, and mismatch ratio ≥1.8 and mismatch volume ≥15 ml groups. The primary outcome was the 90-day modified Rankin Scale score ordinal distribution. Safety outcomes were symptomatic intracranial hemorrhage and 90-day mortality. RESULTS There were 425 patients included. In both the mismatch ratio ≥1.2 and mismatch volume ≥10 ml (mismatch+, n = 395; mismatch-, n = 31) and mismatch ratio ≥1.8 and mismatch volume ≥15 ml groups (mismatch+, n = 346; mismatch-, n = 80), better 90-day modified Rankin Scale outcomes were found in the endovascular treatment group compared with the MM group (4 [2-5] vs 4 [3-5], common odds ratio [cOR], 1.9, 95% confidence interval [CI] 1.3-2.7, p = 0.001; 4 [2-5] vs 4 [3-5], cOR, 1.9, 95% CI 1.3-2.8, p = 0.001, respectively), but not in patients without mismatch ratio ≥1.2 and mismatch volume ≥10 ml (5 [3-6] vs 5 [4-6], cOR, 1.2, 95% CI 0.3-4.1, p = 0.83), and mismatch ratio ≥1.8 and mismatch volume ≥15 ml (4 [3-6] vs 5 [3-6], cOR, 1.2, 95% CI 0.6-2.7, p = 0.60). However, no interaction effect was found in both subgroups (p interaction >0.10). CONCLUSION Endovascular treatment was more efficacious than MM in patients with mismatch profiles, but no treatment effect or interaction was noted in the no mismatch profile patients. However, the small sample size of patients with no mismatch may have underpowered our analysis. A pooled analysis of large core trials stratified by mismatch is warranted. ANN NEUROL 2024.
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Affiliation(s)
- Xiaochuan Huo
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Thanh N Nguyen
- Department of Neurology, Radiology, Boston Medical Center, Boston, MA, USA
| | - Dapeng Sun
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Raynald
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuesong Pan
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gaoting Ma
- Department of Neurology, Beijing Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mengxing Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mohamad Abdalkader
- Department of Neurology, Radiology, Boston Medical Center, Boston, MA, USA
| | - Hesham E Masoud
- Department of Neurology, Upstate University Hospital, Syracuse, NY, USA
| | - Raul G Nogueira
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Zhongrong Miao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Sarraj A, Pujara DK, Campbell BC. Current State of Evidence for Neuroimaging Paradigms in Management of Acute Ischemic Stroke. Ann Neurol 2024; 95:1017-1034. [PMID: 38606939 DOI: 10.1002/ana.26925] [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: 08/29/2023] [Revised: 03/08/2024] [Accepted: 03/11/2024] [Indexed: 04/13/2024]
Abstract
Stroke is the chief differential diagnosis in patient presenting to the emergency room with abrupt onset focal neurological deficits. Neuroimaging, including non-contrast computed tomography (CT), magnetic resonance imaging (MRI), vascular and perfusion imaging, is a cornerstone in the diagnosis and treatment decision-making. This review examines the current state of evidence behind the different imaging paradigms for acute ischemic stroke diagnosis and treatment, including current recommendations from the guidelines. Non-contrast CT brain, or in some centers MRI, can help differentiate ischemic stroke and intracerebral hemorrhage (ICH), a pivotal juncture in stroke diagnosis and treatment algorithm, especially for early window thrombolytics. Advanced imaging such as MRI or perfusion imaging can also assist making a diagnosis of ischemic stroke versus mimics such as migraine, Todd's paresis, or functional disorders. Identification of medium-large vessel occlusions with CT or MR angiography triggers consideration of endovascular thrombectomy (EVT), with additional perfusion imaging help identify salvageable brain tissue in patients who are likely to benefit from reperfusion therapies, particularly in the ≥6 h window. We also review recent advances in neuroimaging and ongoing trials in key therapeutic areas and their imaging selection criteria to inform the readers on potential future transitions into use of neuroimaging for stroke diagnosis and treatment decision making. ANN NEUROL 2024;95:1017-1034.
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Affiliation(s)
- Amrou Sarraj
- University Hospital Cleveland Medical Center-Case Western Reserve University, Neurology, Cleveland, Ohio, USA
| | - Deep K Pujara
- University Hospital Cleveland Medical Center-Case Western Reserve University, Neurology, Cleveland, Ohio, USA
| | - Bruce Cv Campbell
- The Royal Melbourne Hospital-The Florey Institute for Neuroscience and Mental Health, Medicine and Neurology, Parkville, Australia
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Sarraj A, Campbell BCV. Does Reperfusion Benefit Patients Without Perfusion Mismatch? Stroke 2024; 55:1326-1328. [PMID: 38572633 DOI: 10.1161/strokeaha.124.046989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Affiliation(s)
- Amrou Sarraj
- Department of Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, OH (A.S.)
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, VIC, Australia (B.C.V.C.)
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Vidovich J, Voleti S, Zhang B, Stephens C, Sriwastwa A, Aziz Y, Corcoran B, Khandwala V, Mistry E, Khatri P, Wang LL, Vagal A. Accuracy of CT perfusion-predicted core in the late window. Interv Neuroradiol 2024; 30:250-254. [PMID: 36285452 PMCID: PMC11095353 DOI: 10.1177/15910199221133863] [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: 03/13/2022] [Accepted: 09/29/2022] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND AND PURPOSE Recent endovascular trials have spurred a paradigm shift toward routine use of CT perfusion (CTP) for decision-making in acute ischemic stroke. CTP use in the late window, however, remains under evaluation. Our objective was to assess the accuracy of CTP-predicted core in the late window. METHODS In a retrospective review of our prospectively identified stroke registry at a single, comprehensive stroke center, we included patients with anterior large vessel occlusions presenting within the 6-24 h window who underwent baseline CTP evaluation and achieved TICI2b or TICI3 reperfusion on endovascular treatment. We recorded baseline CTP-predicted core volumes at relative cerebral blood flow (CBF) thresholds of <30% <34%, and <38% using RAPID software. Final infarct volumes (FIV) were calculated using follow up MRI and CT, obtained within 72 h after stroke onset. RESULTS Of the eligible patients, 134 met our inclusion criteria. Mean FIV was 39.5 (SD 49.6). Median CTP to reperfusion time was 93.5 min. Median absolute differences between CTP-predicted core and FIV were 14.7, 14.9, and 16.0 ml at <30%, <34%, and <38%, respectively. Correlation between CTP-predicted ischemic cores and FIV was moderate and statistically significant at all thresholds: r = 0.43 (p <0.001), r = 0.43 (p <0.001), and r = 0.42 (p <0.001) at the <30%, <34%, and <38% cutoffs, respectively. CONCLUSION CTP cores in the 6-24 h period underestimate FIV, especially with larger infarcts. CTP-predicted core volumes in the late window show moderate positive correlation with FIV.
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Affiliation(s)
- Johnathan Vidovich
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, Cincinnati, OH, United States
| | - Sriharsha Voleti
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, Cincinnati, OH, United States
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, United States
| | - Cody Stephens
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, Cincinnati, OH, United States
| | - Aakanksha Sriwastwa
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, Cincinnati, OH, United States
| | - Yasmin Aziz
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Medical Center, Cincinnati, United States
| | - Brendan Corcoran
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, Cincinnati, OH, United States
| | - Vivek Khandwala
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, Cincinnati, OH, United States
| | - Eva Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Medical Center, Cincinnati, United States
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Medical Center, Cincinnati, United States
| | - Lily L Wang
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, Cincinnati, OH, United States
| | - Achala Vagal
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman St, Cincinnati, OH, United States
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Rau A, Reisert M, Taschner CA, Demerath T, Elsheikh S, Frank B, Köhrmann M, Urbach H, Kellner E. Reducing False-Positives in CT Perfusion Infarct Core Segmentation Using Contralateral Local Normalization. AJNR Am J Neuroradiol 2024; 45:277-283. [PMID: 38302197 DOI: 10.3174/ajnr.a8111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 11/20/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND AND PURPOSE The established global threshold of rCBF <30% for infarct core segmentation can lead to false-positives, as it does not account for the differences in blood flow between GM and WM and patient-individual factors, such as microangiopathy. To mitigate this problem, we suggest normalizing each voxel not only with a global reference value (ie, the median value of normally perfused tissue) but also with its local contralateral counterpart. MATERIALS AND METHODS We retrospectively enrolled 2830 CTP scans with suspected ischemic stroke, of which 335 showed obvious signs of microangiopathy. In addition to the conventional, global normalization, a local normalization was performed by dividing the rCBF maps with their mirrored and smoothed counterpart, which sets each voxel value in relation to the contralateral counterpart, intrinsically accounting for GM and WM differences and symmetric patient individual microangiopathy. Maps were visually assessed and core volumes were calculated for both methods. RESULTS Cases with obvious microangiopathy showed a strong reduction in false-positives by using local normalization (mean 14.7 mL versus mean 3.7 mL in cases with and without microangiopathy). On average, core volumes were slightly smaller, indicating an improved segmentation that was more robust against naturally low blood flow values in the deep WM. CONCLUSIONS The proposed method of local normalization can reduce overestimation of the infarct core, especially in the deep WM and in cases with obvious microangiopathy. False-positives in CTP infarct core segmentation might lead to less-than-optimal therapy decisions when not correctly interpreted. The proposed method might help mitigate this problem.
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Affiliation(s)
- Alexander Rau
- From the Department of Neuroradiology (A.R., C.A.T., T.D., S.E., H.U.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Diagnostic and Interventional Radiology (A.R.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marco Reisert
- Medical Physics, Department of Diagnostic and Interventional Radiology (M.R., E.K.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Stereotactic and Functional Neurosurgery (M.R.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christian A Taschner
- From the Department of Neuroradiology (A.R., C.A.T., T.D., S.E., H.U.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Theo Demerath
- From the Department of Neuroradiology (A.R., C.A.T., T.D., S.E., H.U.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Samer Elsheikh
- From the Department of Neuroradiology (A.R., C.A.T., T.D., S.E., H.U.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Benedikt Frank
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (B.F., M.K.), University Hospital Essen, Essen, Germany
| | - Martin Köhrmann
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (B.F., M.K.), University Hospital Essen, Essen, Germany
| | - Horst Urbach
- From the Department of Neuroradiology (A.R., C.A.T., T.D., S.E., H.U.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Elias Kellner
- Medical Physics, Department of Diagnostic and Interventional Radiology (M.R., E.K.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Westwood M, Ramaekers B, Grimm S, Armstrong N, Wijnen B, Ahmadu C, de Kock S, Noake C, Joore M. Software with artificial intelligence-derived algorithms for analysing CT brain scans in people with a suspected acute stroke: a systematic review and cost-effectiveness analysis. Health Technol Assess 2024; 28:1-204. [PMID: 38512017 PMCID: PMC11017149 DOI: 10.3310/rdpa1487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024] Open
Abstract
Background Artificial intelligence-derived software technologies have been developed that are intended to facilitate the review of computed tomography brain scans in patients with suspected stroke. Objectives To evaluate the clinical and cost-effectiveness of using artificial intelligence-derived software to support review of computed tomography brain scans in acute stroke in the National Health Service setting. Methods Twenty-five databases were searched to July 2021. The review process included measures to minimise error and bias. Results were summarised by research question, artificial intelligence-derived software technology and study type. The health economic analysis focused on the addition of artificial intelligence-derived software-assisted review of computed tomography angiography brain scans for guiding mechanical thrombectomy treatment decisions for people with an ischaemic stroke. The de novo model (developed in R Shiny, R Foundation for Statistical Computing, Vienna, Austria) consisted of a decision tree (short-term) and a state transition model (long-term) to calculate the mean expected costs and quality-adjusted life-years for people with ischaemic stroke and suspected large-vessel occlusion comparing artificial intelligence-derived software-assisted review to usual care. Results A total of 22 studies (30 publications) were included in the review; 18/22 studies concerned artificial intelligence-derived software for the interpretation of computed tomography angiography to detect large-vessel occlusion. No study evaluated an artificial intelligence-derived software technology used as specified in the inclusion criteria for this assessment. For artificial intelligence-derived software technology alone, sensitivity and specificity estimates for proximal anterior circulation large-vessel occlusion were 95.4% (95% confidence interval 92.7% to 97.1%) and 79.4% (95% confidence interval 75.8% to 82.6%) for Rapid (iSchemaView, Menlo Park, CA, USA) computed tomography angiography, 91.2% (95% confidence interval 77.0% to 97.0%) and 85.0 (95% confidence interval 64.0% to 94.8%) for Viz LVO (Viz.ai, Inc., San Fransisco, VA, USA) large-vessel occlusion, 83.8% (95% confidence interval 77.3% to 88.7%) and 95.7% (95% confidence interval 91.0% to 98.0%) for Brainomix (Brainomix Ltd, Oxford, UK) e-computed tomography angiography and 98.1% (95% confidence interval 94.5% to 99.3%) and 98.2% (95% confidence interval 95.5% to 99.3%) for Avicenna CINA (Avicenna AI, La Ciotat, France) large-vessel occlusion, based on one study each. These studies were not considered appropriate to inform cost-effectiveness modelling but formed the basis by which the accuracy of artificial intelligence plus human reader could be elicited by expert opinion. Probabilistic analyses based on the expert elicitation to inform the sensitivity of the diagnostic pathway indicated that the addition of artificial intelligence to detect large-vessel occlusion is potentially more effective (quality-adjusted life-year gain of 0.003), more costly (increased costs of £8.61) and cost-effective for willingness-to-pay thresholds of £3380 per quality-adjusted life-year and higher. Limitations and conclusions The available evidence is not suitable to determine the clinical effectiveness of using artificial intelligence-derived software to support the review of computed tomography brain scans in acute stroke. The economic analyses did not provide evidence to prefer the artificial intelligence-derived software strategy over current clinical practice. However, results indicated that if the addition of artificial intelligence-derived software-assisted review for guiding mechanical thrombectomy treatment decisions increased the sensitivity of the diagnostic pathway (i.e. reduced the proportion of undetected large-vessel occlusions), this may be considered cost-effective. Future work Large, preferably multicentre, studies are needed (for all artificial intelligence-derived software technologies) that evaluate these technologies as they would be implemented in clinical practice. Study registration This study is registered as PROSPERO CRD42021269609. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR133836) and is published in full in Health Technology Assessment; Vol. 28, No. 11. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
| | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre (MUMC), Maastricht, Netherlands
| | | | | | - Ben Wijnen
- Kleijnen Systematic Reviews (KSR) Ltd, York, UK
| | | | | | - Caro Noake
- Kleijnen Systematic Reviews (KSR) Ltd, York, UK
| | - Manuela Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre (MUMC), Maastricht, Netherlands
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He G, Wei L, Lu H, Deng J, Wang F, Zhu Y. Core overestimation of CT perfusion in patients with cardiac insufficiency who had a stroke is mediated by impaired collaterals. J Neurointerv Surg 2023; 16:31-37. [PMID: 36898828 DOI: 10.1136/jnis-2023-020096] [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: 01/15/2023] [Accepted: 02/28/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND We hypothesized that left ventricular systolic dysfunction (LVSD) would lead to an ischemic core overestimation in patients with acute ischemic stroke (AIS), and impaired collateral status might partly mediate this effect. OBJECTIVE A pixel-based analysis of CT perfusion (CTP) and follow-up CT was undertaken to investigate the optimum CTP thresholds for the ischemic core if overestimation was found. METHODS A total of 208 consecutive patients with AIS with large vessel occlusion in the anterior circulation, who received initial CTP evaluation and successful reperfusion, were retrospectively analyzed and divided into an LVSD (left ventricular ejection fraction (LVEF) ratio <50%; n=40) and a normal cardiac function (LVEF≥50%; n=168) group. Ischemic core overestimation was considered when the CTP-derived core was larger than the final infarct volume. We investigated the relationship between cardiac function, probability for core overestimation, and collateral scores using mediation analysis. A pixel-based analysis was undertaken to define the optimum CTP thresholds for ischemic core. RESULTS LVSD was independently associated with impaired collaterals (aOR=4.28, 95% CI 2.01 to 9.80, P<0.001) and core overestimation (aOR=2.52, 95% CI 1.07 to 5.72, P=0.030). In mediation analysis, the total effect on core overestimation is composed of the direct effect of LVSD (+17%, P=0.034) and the mediated indirect effect of collateral status (+6%, P=0.020). Collaterals explained 26% of the effect of LVSD on core overestimation. Compared with relative cerebral blood flow (rCBF) thresholds of <35%, <30%, and <20%, a rCBF <25% cut-off point had the highest correlation (r=0.91) and best agreement (mean difference 3.2±7.3 mL) with the final infarct volume to determine the CTP-derived ischemic core in patients with LVSD. CONCLUSIONS LVSD increased the possibility of ischemic core overestimation on baseline CTP, partly due to impaired collateral status, and a stricter rCBF threshold should be considered.
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Affiliation(s)
- Guangchen He
- Department of Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liming Wei
- Department of Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haitao Lu
- Department of Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiangshan Deng
- Department of Neurology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feng Wang
- Department of Neurology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yueqi Zhu
- Department of Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Fainardi E, Busto G, Morotti A. Automated advanced imaging in acute ischemic stroke. Certainties and uncertainties. Eur J Radiol Open 2023; 11:100524. [PMID: 37771657 PMCID: PMC10523426 DOI: 10.1016/j.ejro.2023.100524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/12/2023] [Accepted: 09/13/2023] [Indexed: 09/30/2023] Open
Abstract
The purpose of this is study was to review pearls and pitfalls of advanced imaging, such as computed tomography perfusion and diffusion-weighed imaging and perfusion-weighted imaging in the selection of acute ischemic stroke (AIS) patients suitable for endovascular treatment (EVT) in the late time window (6-24 h from symptom onset). Advanced imaging can quantify infarct core and ischemic penumbra using specific threshold values and provides optimal selection parameters, collectively called target mismatch. More precisely, target mismatch criteria consist of core volume and/or penumbra volume and mismatch ratio (the ratio between total hypoperfusion and core volumes) with precise cut-off values. The parameters of target mismatch are automatically calculated with dedicated software packages that allow a quick and standardized interpretation of advanced imaging. However, this approach has several limitations leading to a misclassification of core and penumbra volumes. In fact, automatic software platforms are affected by technical artifacts and are not interchangeable due to a remarkable vendor-dependent variability, resulting in different estimate of target mismatch parameters. In addition, advanced imaging is not completely accurate in detecting infarct core, that can be under- or overestimated. Finally, the selection of candidates for EVT remains currently suboptimal due to the high rates of futile reperfusion and overselection caused by the use of very stringent inclusion criteria. For these reasons, some investigators recently proposed to replace advanced with conventional imaging in the selection for EVT, after the demonstration that non-contrast CT ASPECTS and computed tomography angiography collateral evaluation are not inferior to advanced images in predicting outcome in AIS patients treated with EVT. However, other authors confirmed that CTP and PWI/DWI postprocessed images are superior to conventional imaging in establishing the eligibility of patients for EVT. Therefore, the routine application of automatic assessment of advanced imaging remains a matter of debate. Recent findings suggest that the combination of conventional and advanced imaging might improving our selection criteria.
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Affiliation(s)
- Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Italy
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Giorgio Busto
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Andrea Morotti
- Department of Neurological and Vision Sciences, Neurology Unit, ASST Spedali Civili, Brescia, Italy
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10
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Shen GC, Hang Y, Ma G, Lu SS, Wang C, Shi HB, Wu FY, Xu XQ, Liu S. Prognostic value of multiphase CT angiography: estimated infarct core volume in the patients with acute ischaemic stroke after mechanical thrombectomy. Clin Radiol 2023; 78:e815-e822. [PMID: 37607843 DOI: 10.1016/j.crad.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 07/15/2023] [Accepted: 07/26/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND AND PURPOSE Recent studies reported the feasibility of quantifying a reliable infarct core (IC) volume using multiphase computed tomography (mCTA) based on deep learning, however its prognostic value was not fully clarified. Therefore, we aimed to evaluate the prognostic value of mCTA-estimated IC volume in patients with acute ischemic stroke (AIS) after mechanical thrombectomy (MT). MATERIALS AND METHODS We retrospectively reviewed patients who underwent mCTA and MT for large vessel occlusion in middle cerebral artery and (or) internal carotid artery within 6 hours after symptom onset between January 2018 and November 2019. Patients were dichotomized into good (modified Rankin Scale [mRS] score, 0-2) and poor (mRS, 3-6) outcome groups. mCTA-estimated IC volume were generated based on a multi-scale three-dimensional convolutional neural network. Univariate, multivariate logistic regression and receiver operating characteristic (ROC) curve analyses were used to identify the independent variables, and evaluate their performances in predicting the clinical outcome. RESULTS Of 44 included patients, 27 (61.4%) patients achieved good outcome. National Institutes of Health Stroke Scale scores at admission [NIHSSpre] (odds ratio [OR], 1.191; 95%confidence interval [CI], 1.028-1.379; P=0.020) and mCTA-estimated IC volume (OR, 1.076; 95%CI, 1.016-1.140; P=0.013) were found to be independently associated with functional outcome in patients with AIS after MT. After integrating NIHSSpre and mCTA-estimated IC volume, optimal performance (area under the ROC curve, 0.874; 95%CI, 0.739-0.954) could be obtained in predicting the clinical outcome. CONCLUSIONS mCTA-estimated IC volume might be promising for predicting the prognosis, and assisting in making individualized treatment decision in patients with AIS.
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Affiliation(s)
- G-C Shen
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Y Hang
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - G Ma
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - S-S Lu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - C Wang
- Human Phenome Institute, Fudan University, Shanghai, China
| | - H-B Shi
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - F-Y Wu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - X-Q Xu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
| | - S Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
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11
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Yedavalli V, Kihira S, Shahrouki P, Hamam O, Tavakkol E, McArthur M, Qiao J, Johanna F, Doshi A, Vagal A, Khatri P, Srinivasan A, Chaudhary N, Bahr-Hosseini M, Colby GP, Nour M, Jahan R, Duckwiler G, Arnold C, Saver JL, Mocco J, Liebeskind DS, Nael K. CTP-based estimated ischemic core: A comparative multicenter study between Olea and RAPID software. J Stroke Cerebrovasc Dis 2023; 32:107297. [PMID: 37738915 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107297] [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: 06/01/2023] [Revised: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND AND PURPOSE CTP is increasingly used to assess eligibility for endovascular therapy (EVT) in patients with large vessel occlusions (LVO). There remain variability and inconsistencies between software packages for estimation of ischemic core. We aimed to use heterogenous data from four stroke centers to perform a comparative analysis for CTP-estimated ischemic core between RAPID (iSchemaView) and Olea (Olea Medical). METHODS In this retrospective multicenter study, patients with anterior circulation LVO who underwent pretreatment CTP, successful EVT (defined TICI ≥ 2b), and follow-up MRI included. Automated CTP analysis was performed using Olea platform [rCBF < 25% and differential time-to-peak (dTTP)>5s] and RAPID (rCBF < 30%). The CTP estimated core volumes were compared against the final infarct volume (FIV) on post treatment MRI-DWI. RESULTS A total of 151 patients included. The CTP-estimated ischemic core volumes (mean ± SD) were 18.7 ± 18.9 mL on Olea and 10.5 ± 17.9 mL on RAPID significantly different (p < 0.01). The correlation between CTP estimated core and MRI final infarct volume was r = 0.38, p < 0.01 for RAPID and r = 0.39, p < 0.01 for Olea. Both software platforms demonstrated a strong correlation with each other (r = 0.864, p < 0.001). Both software overestimated the ischemic core volume above 70 mL in 4 patients (2.6%). CONCLUSIONS Substantial variation between Olea and RAPID CTP-estimated core volumes exists, though rates of overcalling of large core were low and identical. Both showed comparable core volume correlation to MRI infarct volume.
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Affiliation(s)
- V Yedavalli
- Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - S Kihira
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - P Shahrouki
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - O Hamam
- Massachussetts General Hospital, Boston, MA, United States
| | - E Tavakkol
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - M McArthur
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - J Qiao
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - Fifi Johanna
- Mount Sinai School of Medicine, New York, NY, United States
| | - A Doshi
- Mount Sinai School of Medicine, New York, NY, United States
| | - A Vagal
- University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - P Khatri
- University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - A Srinivasan
- University of Michigan School of Medicine, Ann Arbor, MI, United States
| | - N Chaudhary
- University of Michigan School of Medicine, Ann Arbor, MI, United States
| | - M Bahr-Hosseini
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - G P Colby
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - M Nour
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - R Jahan
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - G Duckwiler
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - C Arnold
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - J L Saver
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - J Mocco
- Mount Sinai School of Medicine, New York, NY, United States
| | - D S Liebeskind
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - K Nael
- David Geffen School of Medicine at the University of California - Los Angeles, United States
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12
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Pisani L, Haussen DC, Mohammaden M, Perry da Camara C, Jillella DV, Rodrigues GM, Bouslama M, Al-Bayati A, Prater A, Liberato B, Frankel MR, Nogueira RG. Comparison of CT Perfusion Software Packages for Thrombectomy Eligibility. Ann Neurol 2023; 94:848-855. [PMID: 37584452 DOI: 10.1002/ana.26748] [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: 06/25/2023] [Revised: 07/20/2023] [Accepted: 07/21/2023] [Indexed: 08/17/2023]
Abstract
INTRODUCTION Computed tomography perfusion (CTP) has played an important role in patient selection for mechanical thrombectomy (MT) in acute ischemic stroke. We aimed to investigate the agreement between perfusion parametric maps of 3 software packages - RAPID (RapidAI-IschemaView), Viz CTP(Viz.ai), and e-CTP(Brainomix) - in estimating baseline ischemic core volumes of near completely/completely reperfused patients. METHODS We retrospectively reviewed a prospectively maintained MT database to identify patients with anterior circulation large vessel occlusion strokes (LVOS) involving the internal carotid artery or middle cerebral artery M1-segment and interpretable CTP maps treated during September 2018 to November 2019. A subset of patients with near-complete/complete reperfusion (expanded thrombolysis in cerebral infarction [eTICI] 2c-3) was used to compare the pre-procedural prediction of final infarct volumes. RESULTS In this analysis of 242 patients with LVOS, RAPID and Viz CTP relative cerebral blood flow (rCBF) < 30% values had substantial agreement (ρ = 0.767 [95% confidence interval [CI] = 0.71-0.81]) as well as for RAPID and e-CTP (ρ = 0.668 [95% CI = 0.61-0.71]). Excellent agreement was seen for time to maximum of the residue function (Tmax ) > 6 seconds between RAPID and Viz CTP (ρ = 0.811 [95% CI = 0.76-0.84]) and substantial for RAPID and e-CTP (ρ = 0.749 [95% CI = 0.69-0.79]). Final infarct volume (FIV) prediction (n = 136) was substantial in all 3 packages (RAPID ρ = 0.744; Viz CTP ρ = 0.711; and e-CTP ρ = 0.600). CONCLUSION Perfusion parametric maps of the RAPID, Viz CTP, and e-CTP software have substantial agreement in predicting final infarct volume in near-completely/completely reperfused patients. ANN NEUROL 2023;94:848-855.
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Affiliation(s)
| | - Diogo C Haussen
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA
| | - Mahmoud Mohammaden
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA
| | | | - Dinesh V Jillella
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA
| | - Gabriel M Rodrigues
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA
| | - Mehdi Bouslama
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA
| | - Alhamza Al-Bayati
- UPMC Stroke Institute, Department of Neurology & Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Adam Prater
- Grady Memorial Hospital, Department of Radiology, Emory University School of Medicine, Atlanta, GA
| | - Bernardo Liberato
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA
| | - Michael R Frankel
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA
| | - Raul G Nogueira
- UPMC Stroke Institute, Department of Neurology & Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
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13
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Ballout AA, Oh SY, Huang B, Patsalides A, Libman RB. Ghost infarct core: A systematic review of the frequency, magnitude, and variables of CT perfusion overestimation. J Neuroimaging 2023; 33:716-724. [PMID: 37248074 DOI: 10.1111/jon.13127] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/16/2023] [Accepted: 05/18/2023] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND AND PURPOSE CT perfusion (CTP) imaging is now widely used to select patients with large vessel occlusions for mechanical thrombectomy. Ghost infarct core (GIC) phenomenon has been coined to describe CTP core overestimation and has been investigated in several retrospective studies. Our aim is to review the frequency, magnitude, and variables associated with this phenomenon. METHODS A primary literature search resulted in eight studies documenting median time from symptom onset to CTP, median estimated core size, median final infarct volume, median core overestimation of the GIC population, recanalization rates, good outcomes, and collateral status for this systematic review. RESULTS All the studies investigated patients who underwent CTP within 6 hours of symptom onset, ranging from median times of 105 to 309 minutes. The frequency of core overestimation varied from 6% to 58.4%, while the median estimated ischemic core and final infarction volume ranged from 7 to 27 mL and 12 to 31 mL, respectively. The median core overestimation ranged from 3.6 to 30 mL with upper quartile ranges up to 58 mL. GIC was found to be a highly time-and-collateral-dependent process that increases in frequency and magnitude as the time from symptom onset to imaging decreases and in the presence of poor collaterals. CONCLUSIONS CTP ischemic core overestimation appears to be a relatively common phenomenon that is most frequent in patients with poor collaterals imaged within the acute time window. Early perfusion imaging should be interpreted with caution to prevent the inadvertent exclusion of patients from highly effective reperfusion therapies.
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Affiliation(s)
- Ahmad A Ballout
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Seok Yoon Oh
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Brendan Huang
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Athos Patsalides
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Richard B Libman
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
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14
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Wagner DT, Tilmans L, Peng K, Niedermeier M, Rohl M, Ryan S, Yadav D, Takacs N, Garcia-Fraley K, Koso M, Dikici E, Prevedello LM, Nguyen XV. Artificial Intelligence in Neuroradiology: A Review of Current Topics and Competition Challenges. Diagnostics (Basel) 2023; 13:2670. [PMID: 37627929 PMCID: PMC10453240 DOI: 10.3390/diagnostics13162670] [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: 05/16/2023] [Revised: 08/07/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
There is an expanding body of literature that describes the application of deep learning and other machine learning and artificial intelligence methods with potential relevance to neuroradiology practice. In this article, we performed a literature review to identify recent developments on the topics of artificial intelligence in neuroradiology, with particular emphasis on large datasets and large-scale algorithm assessments, such as those used in imaging AI competition challenges. Numerous applications relevant to ischemic stroke, intracranial hemorrhage, brain tumors, demyelinating disease, and neurodegenerative/neurocognitive disorders were discussed. The potential applications of these methods to spinal fractures, scoliosis grading, head and neck oncology, and vascular imaging were also reviewed. The AI applications examined perform a variety of tasks, including localization, segmentation, longitudinal monitoring, diagnostic classification, and prognostication. While research on this topic is ongoing, several applications have been cleared for clinical use and have the potential to augment the accuracy or efficiency of neuroradiologists.
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Affiliation(s)
- Daniel T. Wagner
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA (L.M.P.)
| | - Luke Tilmans
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA (L.M.P.)
| | - Kevin Peng
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | | | - Matt Rohl
- College of Arts and Sciences, The Ohio State University, Columbus, OH 43210, USA
| | - Sean Ryan
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA (L.M.P.)
| | - Divya Yadav
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Noah Takacs
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Krystle Garcia-Fraley
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA (L.M.P.)
| | - Mensur Koso
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Engin Dikici
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA (L.M.P.)
| | - Luciano M. Prevedello
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA (L.M.P.)
| | - Xuan V. Nguyen
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA (L.M.P.)
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15
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Nakagawa I, Kotsugi M, Yokoyama S, Maeoka R, Takeshima Y, Matsuda R, Yamada S, Nakase H. Parenchymal Blood Volume Changes Immediately After Endovascular Thrombectomy Predict Futile Recanalization in Patients with Emergent Large Vessel Occlusion. World Neurosurg 2023; 176:e711-e718. [PMID: 37295462 DOI: 10.1016/j.wneu.2023.06.006] [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: 01/15/2023] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVE More than one third of acute ischemic stroke (AIS) patients do not recover to functional independence even if endovascular thrombectomy (EVT) is performed rapidly and successfully. This suggests that angiographic recanalization does not necessarily lead to tissue reperfusion. Although recognition of reperfusion status after EVT is pivotal for optimal postoperative management, reperfusion imaging assessment immediately after recanalization has not been fully investigated. The present study aimed to evaluate whether reperfusion status based on parenchymal blood volume (PBV) assessment after angiographic recanalization influences infarct growth and functional outcome in patients who have undergone EVT following AIS. METHODS Seventy-nine patients who underwent successful EVT for AIS were retrospectively analyzed. PBV maps were acquired from flat-panel detector computed tomography (CT) perfusion images before and after angiographic recanalization. Reperfusion status was assessed from PBV values and their changes in regions of interest and collateral score. RESULTS Post-EVT PBV ratio and ΔPBV ratio, as PBV parameters indicating the degree of reperfusion, were significantly lower in the unfavorable prognosis group (P < 0.01 each). Poor reperfusion on PBV mapping was associated with significantly longer puncture-to-recanalization time, lower collateral score, and higher frequency of infarct growth. Logistic regression analysis identified low collateral score and low ΔPBV ratio as associated with poor prognosis after EVT (odds ratios, 2.48, 3.72; 95% confidence intervals, 1.06-5.81, 1.20-11.53; P = 0.04, 0.02, respectively). CONCLUSIONS Poor reperfusion in severely hypoperfused territories on PBV mapping immediately after recanalization may predict infarct growth and unfavorable prognosis in patients who undergo EVT following AIS.
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Affiliation(s)
- Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, Nara, Japan.
| | - Masashi Kotsugi
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Shohei Yokoyama
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Ryosuke Maeoka
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | | | - Ryosuke Matsuda
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Shuichi Yamada
- Department of Neurosurgery, Nara Medical University, Nara, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, Nara, Japan
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16
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Koopman MS, Hoving JW, Tolhuisen ML, Jin P, Thiele FO, Bremer-van der Heiden L, van Voorst H, Berkhemer OA, Coutinho JM, Beenen LFM, Marquering HA, Emmer BJ, Majoie CBLM. Accuracy of Four Different CT Perfusion Thresholds for Ischemic Core Volume and Location Estimation Using IntelliSpace Portal. J Cardiovasc Dev Dis 2023; 10:239. [PMID: 37367404 PMCID: PMC10299344 DOI: 10.3390/jcdd10060239] [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: 04/17/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 06/28/2023] Open
Abstract
Computed tomography perfusion (CTP) is frequently used in the triage of ischemic stroke patients for endovascular thrombectomy (EVT). We aimed to quantify the volumetric and spatial agreement of the CTP ischemic core estimated with different thresholds and follow-up MRI infarct volume on diffusion-weighted imaging (DWI). Patients treated with EVT between November 2017 and September 2020 with available baseline CTP and follow-up DWI were included. Data were processed with Philips IntelliSpace Portal using four different thresholds. Follow-up infarct volume was segmented on DWI. In 55 patients, the median DWI volume was 10 mL, and median estimated CTP ischemic core volumes ranged from 10-42 mL. In patients with complete reperfusion, the intraclass correlation coefficient (ICC) showed moderate-good volumetric agreement (range 0.55-0.76). A poor agreement was found for all methods in patients with successful reperfusion (ICC range 0.36-0.45). Spatial agreement (median Dice) was low for all four methods (range 0.17-0.19). Severe core overestimation was most frequently (27%) seen in Method 3 and patients with carotid-T occlusion. Our study shows moderate-good volumetric agreement between ischemic core estimates for four different thresholds and subsequent infarct volume on DWI in EVT-treated patients with complete reperfusion. The spatial agreement was similar to other commercially available software packages.
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Affiliation(s)
- Miou S Koopman
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Jan W Hoving
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Manon L Tolhuisen
- Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Peng Jin
- Philips Medical Systems, Philips Healthcare, 5684 PC Best, The Netherlands
| | - Frank O Thiele
- Philips GmbH Innovative Technologies, 52074 Aachen, Germany
| | | | - Henk van Voorst
- Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Olvert A Berkhemer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Ludo F M Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Henk A Marquering
- Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
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17
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Liu J, Wang J, Wu J, Gu S, Yao Y, Li J, Li Y, Ren H, Luo T. Comparison of two computed tomography perfusion post-processing software to assess infarct volume in patients with acute ischemic stroke. Front Neurosci 2023; 17:1151823. [PMID: 37179549 PMCID: PMC10166848 DOI: 10.3389/fnins.2023.1151823] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 04/07/2023] [Indexed: 05/15/2023] Open
Abstract
Objectives We used two automated software commonly employed in clinical practice-Olea Sphere (Olea) and Shukun-PerfusionGo (PerfusionGo)-to compare the diagnostic utility and volumetric agreement of computed tomography perfusion (CTP)-predicted final infarct volume (FIV) with true FIV in patients with anterior-circulation acute ischemic stroke (AIS). Methods In all, 122 patients with anterior-circulation AIS who met the inclusion and exclusion criteria were retrospectively enrolled and divided into two groups: intervention group (n = 52) and conservative group (n = 70), according to recanalization of blood vessels and clinical outcome (NIHSS) after different treatments. Patients in both groups underwent one-stop 4D-CT angiography (CTA)/CTP, and the raw CTP data were processed on a workstation using Olea and PerfusionGo post-processing software, to calculate and obtain the ischemic core (IC) and hypoperfusion (IC plus penumbra) volumes, hypoperfusion in the conservative group and IC in the intervention group were used to define the predicted FIV. The ITK-SNAP software was used to manually outline and measure true FIV on the follow-up non-enhanced CT or MRI-DWI images. Intraclass correlation coefficients (ICC), Bland-Altman, and Kappa analysis were used to compare the differences in IC and penumbra volumes calculated by the Olea and PerfusionGo software to investigate the relationship between their predicted FIV and true FIV. Results The IC and penumbra difference between Olea and PerfusionGo within the same group (p < 0.001) was statistically significant. Olea obtained larger IC and smaller penumbra than PerfusionGo. Both software partially overestimated the infarct volume, but Olea significantly overestimated it by a larger percentage. ICC analysis showed that Olea performed better than PerfusionGo (intervention-Olea: ICC 0.633, 95%CI 0.439-0.771; intervention-PerfusionGo: ICC 0.526, 95%CI 0.299-0.696; conservative-Olea: ICC 0.623, 95%CI 0.457-0.747; conservative-PerfusionGo: ICC 0.507, 95%CI 0.312-0.662). Olea and PerfusionGo had the same capacity in accurately diagnosing and classifying patients with infarct volume <70 ml. Conclusion Both software had differences in the evaluation of the IC and penumbra. Olea's predicted FIV was more closely correlated with the true FIV than PerfusionGo's prediction. Accurate assessment of infarction on CTP post-processing software remains challenging. Our results may have important practice implications for the clinical use of perfusion post-processing software.
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Affiliation(s)
- Jiayang Liu
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jingjie Wang
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiajing Wu
- Department of Radiology, Hospital of PLA Army, Chongqing, China
| | - Sirun Gu
- 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
| | - Jing Li
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yongmei Li
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Huanhuan Ren
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Radiology, Chongqing General Hospital, Chongqing, China
| | - Tianyou Luo
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Hoving JW, van Voorst H, Kappelhof M, Tolhuisen M, Treurniet KM, LeCouffe NE, Rinkel LA, Koopman MS, Cavalcante F, Konduri PR, van den Wijngaard IR, Ghariq E, Anton Meijer FJ, Coutinho JM, Marquering HA, Roos YBWEM, Emmer BJ, Majoie CBLM. Infarct Evolution in Patients with Anterior Circulation Large-Vessel Occlusion Randomized to IV Alteplase and Endovascular Treatment versus Endovascular Treatment Alone. AJNR Am J Neuroradiol 2023; 44:434-440. [PMID: 36958803 PMCID: PMC10084906 DOI: 10.3174/ajnr.a7826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/31/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND AND PURPOSE Infarct evolution after endovascular treatment varies widely among patients with stroke and may be affected by baseline characteristics and procedural outcomes. Moreover, IV alteplase and endovascular treatment may influence the relationship of these factors to infarct evolution. We aimed to assess whether the infarct evolution between baseline and follow-up imaging was different for patients who received IVT and EVT versus EVT alone. MATERIALS AND METHODS We included patients from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN)-NO IV trial with baseline CTP and follow-up imaging. Follow-up infarct volume was segmented on 24-hour or 1-week follow-up DWI or NCCT. Infarct evolution was defined as the follow-up lesion volume: CTP core volume. Substantial infarct growth was defined as an increase in follow-up infarct volume of >10 mL. We assessed whether infarct evolution was different for patients with IV alteplase and endovascular treatment versus endovascular treatment alone and evaluated the association of baseline characteristics and procedural outcomes with infarct evolution using multivariable regression. RESULTS From 228 patients with CTP results available, 145 patients had follow-up imaging and were included in our analysis. For patients with IV alteplase and endovascular treatment versus endovascular treatment alone, the baseline median CTP core volume was 17 (interquartile range = 4-35) mL versus 11 (interquartile range = 6-24) mL. The median follow-up infarct volume was 13 (interquartile range, 4-48) mL versus 17 (interquartile range = 4-50) mL. Collateral status and occlusion location were negatively associated with substantial infarct growth in patients with and without IV alteplase before endovascular treatment. CONCLUSIONS No statistically significant difference in infarct evolution was found in directly admitted patients who received IV alteplase and endovascular treatment within 4.5 hours of symptom onset versus patients who underwent endovascular treatment alone. Collateral status and occlusion location may be useful predictors of infarct evolution prognosis in patients eligible for IV alteplase who underwent endovascular treatment.
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Affiliation(s)
- J W Hoving
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - H van Voorst
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - M Kappelhof
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - M Tolhuisen
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - K M Treurniet
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Department of Radiology (K.M.T., I.R.v.d.W., E.G.), The Hague Medical Centers, The Hague, the Netherlands
| | - N E LeCouffe
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - L A Rinkel
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - M S Koopman
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - F Cavalcante
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - P R Konduri
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - I R van den Wijngaard
- Department of Radiology (K.M.T., I.R.v.d.W., E.G.), The Hague Medical Centers, The Hague, the Netherlands
| | - E Ghariq
- Department of Radiology (K.M.T., I.R.v.d.W., E.G.), The Hague Medical Centers, The Hague, the Netherlands
| | - F J Anton Meijer
- Department of Radiology (F.J.A.M.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - J M Coutinho
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - H A Marquering
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - Y B W E M Roos
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - B J Emmer
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - C B L M Majoie
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
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Otgonbaatar C, Lee JY, Jung KH, Hwang I, Yoo RE, Kang KM, Yun TJ, Choi SH, Kim JH, Sohn CH. Quantifying infarct core volume in ischemic stroke: What is the optimal threshold and parameters of computed tomography perfusion? J Stroke Cerebrovasc Dis 2023; 32:107062. [PMID: 36948076 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107062] [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: 09/28/2022] [Revised: 02/03/2023] [Accepted: 02/20/2023] [Indexed: 03/22/2023] Open
Abstract
OBJECTIVE Although computed tomography perfusion (CTP) is used to select and guide decision-making processes in patients with acute ischemic stroke, there is no clear standardization of the optimal threshold to predict ischemic core volume accurately. The infarct core volume with a relative cerebral blood flow(rCBF) threshold of < 30% is commonly used. We aimed to assess the volumetric agreement of the infarct core volume with different CTP parameters and thresholds using CTP software (RAPID, VITREA) and the infarct volume on diffusion-weighted imaging (DWI), with a short interval time (within 60 min) between CTP and follow-up DWI. MATERIALS AND METHODS This retrospective study included 42 acute ischemic stroke patients with occlusion of the large artery in the anterior circulation between April 2017-November 2020. RAPID identified infarct core as tissue rCBF < 20-38%. VITREA defined the infarct core as cerebral blood volume (CBV) < 26-56%. Olea Sphere was used to measure infarct core volume on DWI. The CTP-infarct core volume with different thresholds of perfusion parameters (CBF threshold vs CBV threshold) were compared with DWI-infarct core volumes. RESULTS The median time between CTP and DWI was 37.5min. The commonly used threshold of CBV< 41% (4.3 mL) resulted in lower median infarct core volume difference compared to the commonly used thresholds of rCBF < 30% (8.2mL). On the other hand, the optimal thresholds of CBV < 26% (-1.0mL; 95% CI, -53.9 to 58.1 mL; 0.945) resulted in the lowest median infarct core volume difference, narrowest limits of agreement, and largest interclass correlation coefficient compared with the optimal thresholds of rCBF < 38% (4.9 mL; 95% CI, -36.4 to 62.9 mL; 0.939). CONCLUSION Our study found that the both optimal and commonly used thresholds of CBV provided a more accurate prediction of the infarct core volume in patients with AIS than rCBF.
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Affiliation(s)
| | - Ji Ye Lee
- Department of Radiology, Seoul National University Hospital, #101 Daehangno, Jongno-gu, Seoul 110-744, Republic of Korea
| | - Keun-Hwa Jung
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Inpyeong Hwang
- Department of Radiology, Seoul National University Hospital, #101 Daehangno, Jongno-gu, Seoul 110-744, Republic of Korea
| | - Roh-Eul Yoo
- Department of Radiology, Seoul National University Hospital, #101 Daehangno, Jongno-gu, Seoul 110-744, Republic of Korea
| | - Koung Mi Kang
- Department of Radiology, Seoul National University Hospital, #101 Daehangno, Jongno-gu, Seoul 110-744, Republic of Korea
| | - Tae Jin Yun
- Department of Radiology, Seoul National University Hospital, #101 Daehangno, Jongno-gu, Seoul 110-744, Republic of Korea
| | - Seung Hong Choi
- Department of Radiology, College of Medicine, Seoul National University, Seoul, Republic of Korea; Department of Radiology, Seoul National University Hospital, #101 Daehangno, Jongno-gu, Seoul 110-744, Republic of Korea
| | - Ji-Hoon Kim
- Department of Radiology, College of Medicine, Seoul National University, Seoul, Republic of Korea; Department of Radiology, Seoul National University Hospital, #101 Daehangno, Jongno-gu, Seoul 110-744, Republic of Korea
| | - Chul-Ho Sohn
- Department of Radiology, College of Medicine, Seoul National University, Seoul, Republic of Korea; Department of Radiology, Seoul National University Hospital, #101 Daehangno, Jongno-gu, Seoul 110-744, Republic of Korea.
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20
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Lacidogna G, Pitocchi F, Mascolo AP, Marrama F, D’Agostino F, Rocco A, Mori F, Maestrini I, Sabuzi F, Cavallo A, Morosetti D, Garaci F, Di Giuliano F, Floris R, Sallustio F, Diomedi M, Da Ros V. CT Perfusion as a Predictor of the Final Infarct Volume in Patients with Tandem Occlusion. J Pers Med 2023; 13:jpm13020342. [PMID: 36836576 PMCID: PMC9964425 DOI: 10.3390/jpm13020342] [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: 12/21/2022] [Revised: 02/01/2023] [Accepted: 02/08/2023] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND CT perfusion (CTP) is used in patients with anterior circulation acute ischemic stroke (AIS) for predicting the final infarct volume (FIV). Tandem occlusion (TO), involving both intracranial large vessels and the ipsilateral cervical internal carotid artery could generate hemodynamic changes altering perfusion parameters. Our aim is to evaluate the accuracy of CTP in the prediction of the FIV in TOs. METHODS consecutive patients with AIS due to middle cerebral artery occlusion, referred to a tertiary stroke center between March 2019 and January 2021, with an automated CTP and successful recanalization (mTICI = 2b - 3) after endovascular treatment were retrospectively included in the tandem group (TG) or in the control group (CG). Patients with parenchymal hematoma type 2, according to ECASS II classification of hemorrhagic transformations, were excluded in a secondary analysis. Demographic, clinical, radiological, time intervals, safety, and outcome measures were collected. RESULTS among 319 patients analyzed, a comparison between the TG (N = 22) and CG (n = 37) revealed similar cerebral blood flow (CBF) > 30% (29.50 ± 32.33 vs. 15.76 ± 20.93 p = 0.18) and FIV (54.67 ± 65.73 vs. 55.14 ± 64.64 p = 0.875). Predicted ischemic core (PIC) and FIV correlated in both TG (tau = 0.761, p < 0.001) and CG (tau = 0.315, p = 0.029). The Bland-Altmann plot showed agreement between PIC and FIV for both groups, mainly in the secondary analysis. CONCLUSION automated CTP could represent a good predictor of FIV in patients with AIS due to TO.
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Affiliation(s)
- Giordano Lacidogna
- Stroke Center, Department of Systems Medicine, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
- Correspondence: ; Tel.: +39-0620903423
| | - Francesca Pitocchi
- Diagnostic Imaging Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Alfredo Paolo Mascolo
- Stroke Center, Department of Systems Medicine, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Federico Marrama
- Stroke Center, Department of Systems Medicine, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Federica D’Agostino
- Stroke Center, Department of Systems Medicine, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Alessandro Rocco
- Stroke Center, Department of Systems Medicine, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Francesco Mori
- Stroke Center, Department of Systems Medicine, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Ilaria Maestrini
- Stroke Center, Department of Systems Medicine, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Federico Sabuzi
- Interventional Radiology Unit, Department of Biomedicine and Prevention, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Armando Cavallo
- Diagnostic Imaging Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Daniele Morosetti
- Interventional Radiology Unit, Department of Biomedicine and Prevention, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Francesco Garaci
- Diagnostic Imaging Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Francesca Di Giuliano
- Diagnostic Imaging Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Roberto Floris
- Diagnostic Imaging Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Fabrizio Sallustio
- Stroke Center, Department of Systems Medicine, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Marina Diomedi
- Stroke Center, Department of Systems Medicine, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Valerio Da Ros
- Interventional Radiology Unit, Department of Biomedicine and Prevention, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
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21
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Xu XQ, Ma G, Shen GC, Lu SS, Shi HB, Zhang YX, Zhang Y, Wu FY, Liu S. Spatial accuracy of computed tomography perfusion to estimate the follow-up infarct on diffusion-weighted imaging after successful mechanical thrombectomy. BMC Neurol 2023; 23:31. [PMID: 36670367 PMCID: PMC9854062 DOI: 10.1186/s12883-023-03075-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/17/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Volumetric accuracy of using computed tomography perfusion (CTP) to estimate the post-treatment infarct in stroke patients with successful recanalization after mechanical thrombectomy (MT) has been studied a lot, however the spatial accuracy and its influence factors has not been fully investigated. METHODS This retrospective study reviewed the data from consecutive anterior large vessel occlusion (LVO) patients who had baseline CTP, successful recanalization after MT, and post-treatment diffusion-weighed imaging (DWI). Ischemic core on baseline CTP was estimated using relative cerebral blood flood (CBF) of < 30%. The infarct area was outlined manually on post-treatment DWI, and registered to CTP. Spatial agreement was assessed using the Dice similarity coefficient (DSC) and average Hausdorff distance. According to the median DSC, the study population was dichotomized into high and low Dice groups. Univariable and multivariable regression analyses were used to determine the factors independently associated with the spatial agreement. RESULTS In 72 included patients, the median DSC was 0.26, and the median average Hausdorff distance was 1.77 mm. High Dice group showed significantly higher median ischemic core volume on baseline CTP (33.90 mL vs 3.40 mL, P < 0.001), lower proportion of moderate or severe leukoaraiosis [27.78% vs 52.78%, P = 0.031], and higher median infarct volume on follow-up DWI (51.17 mL vs 9.42 mL, P < 0.001) than low Dice group. Ischemic core volume on baseline CTP was found to be independently associated with the spatial agreement (OR, 1.092; P < 0.001). CONCLUSIONS CTP could help to spatially locate the post-treatment infarct in anterior LVO patients who achieving successful recanalization after MT. Ischemic core volume on baseline CTP was independently associated with the spatial agreement.
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Affiliation(s)
- Xiao-Quan Xu
- grid.412676.00000 0004 1799 0784Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Gao Ma
- grid.412676.00000 0004 1799 0784Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Guang-Chen Shen
- grid.412676.00000 0004 1799 0784Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shan-Shan Lu
- grid.412676.00000 0004 1799 0784Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hai-Bin Shi
- grid.412676.00000 0004 1799 0784Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ya-Xi Zhang
- Shukun Network Technology Co., Ltd, Beijing, China
| | - Yu Zhang
- Shukun Network Technology Co., Ltd, Beijing, China
| | - Fei-Yun Wu
- grid.412676.00000 0004 1799 0784Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Sheng Liu
- grid.412676.00000 0004 1799 0784Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Giancardo L, Niktabe A, Ocasio L, Abdelkhaleq R, Salazar-Marioni S, Sheth SA. Segmentation of acute stroke infarct core using image-level labels on CT-angiography. Neuroimage Clin 2023; 37:103362. [PMID: 36893661 PMCID: PMC10011814 DOI: 10.1016/j.nicl.2023.103362] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 02/22/2023] [Accepted: 02/24/2023] [Indexed: 03/02/2023]
Abstract
Acute ischemic stroke is a leading cause of death and disability in the world. Treatment decisions, especially around emergent revascularization procedures, rely heavily on size and location of the infarct core. Currently, accurate assessment of this measure is challenging. While MRI-DWI is considered the gold standard, its availability is limited for most patients suffering from stroke. Another well-studied imaging modality is CT-Perfusion (CTP) which is much more common than MRI-DWI in acute stroke care, but not as precise as MRI-DWI, and it is still unavailable in many stroke hospitals. A method to determine infarct core using CT-Angiography (CTA), a much more available imaging modality albeit with significantly less contrast in stroke core area than CTP or MRI-DWI, would enable significantly better treatment decisions for stroke patients throughout the world. Existing deep-learning-based approaches for stroke core estimation have to face the trade-off between voxel-level segmentation / image-level labels and the difficulty of obtaining large enough samples of high-quality DWI images. The former occurs when algorithms can either output voxel-level labeling which is more informative but requires a significant effort by annotators, or image-level labels that allow for much simpler labeling of the images but results in less informative and interpretable output; the latter is a common issue that forces training either on small training sets using DWI as the target or larger, but noisier, dataset using CT-Perfusion (CTP) as the target. In this work, we present a deep learning approach including a new weighted gradient-based approach to obtain stroke core segmentation with image-level labeling, specifically the size of the acute stroke core volume. Additionally, this strategy allows us to train using labels derived from CTP estimations. We find that the proposed approach outperforms segmentation approaches trained on voxel-level data and the CTP estimation themselves.
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Affiliation(s)
- Luca Giancardo
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX 77030 USA.
| | - Arash Niktabe
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030 USA
| | - Laura Ocasio
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX 77030 USA
| | - Rania Abdelkhaleq
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030 USA
| | - Sergio Salazar-Marioni
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030 USA
| | - Sunil A Sheth
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030 USA
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Abdalkader M, Siegler JE, Lee JS, Yaghi S, Qiu Z, Huo X, Miao Z, Campbell BC, Nguyen TN. Neuroimaging of Acute Ischemic Stroke: Multimodal Imaging Approach for Acute Endovascular Therapy. J Stroke 2023; 25:55-71. [PMID: 36746380 PMCID: PMC9911849 DOI: 10.5853/jos.2022.03286] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/04/2023] [Indexed: 02/04/2023] Open
Abstract
Advances in acute ischemic stroke (AIS) treatment have been contingent on innovations in neuroimaging. Neuroimaging plays a pivotal role in the diagnosis and prognosis of ischemic stroke and large vessel occlusion, enabling triage decisions in the emergent care of the stroke patient. Current imaging protocols for acute stroke are dependent on the available resources and clinicians' preferences and experiences. In addition, differential application of neuroimaging in medical decision-making, and the rapidly growing evidence to support varying paradigms have outpaced guideline-based recommendations for selecting patients to receive intravenous or endovascular treatment. In this review, we aimed to discuss the various imaging modalities and approaches used in the diagnosis and treatment of AIS.
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Affiliation(s)
- Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston, MA, USA,Correspondence: Mohamad Abdalkader Department of Radiology, Boston Medical Center, One Boston Medical Center Place, Boston, MA 02118, USA Tel: +1-617-614-4272 E-mail:
| | - James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - Jin Soo Lee
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, RI, USA
| | - Zhongming Qiu
- Department of Neurology, The 903rd Hospital of The Chinese People’s Liberation Army, Hangzhou, China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bruce C.V. Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Thanh N. Nguyen
- Department of Radiology, Boston Medical Center, Boston, MA, USA,Department of Neurology, Boston Medical Center, Boston, MA, USA
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24
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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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25
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Yang W, Hoving JW, Koopman MS, Tolhuisen ML, van Voorst H, Berkheme OA, Coutinho JM, Beenen LFM, Emmer BJ. Agreement between estimated computed tomography perfusion ischemic core and follow-up infarct on diffusion-weighted imaging. Insights Imaging 2022; 13:191. [PMID: 36512159 DOI: 10.1186/s13244-022-01334-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 11/20/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Computed tomography perfusion (CTP) is frequently performed during the diagnostic workup of acute ischemic stroke patients. Yet, ischemic core estimates vary widely between different commercially available software packages. We assessed the volumetric and spatial agreement of the ischemic core on CTP with the follow-up infarct on diffusion-weighted imaging (DWI) using an automated software. METHODS We included successfully reperfused patients who underwent endovascular treatment (EVT) with CTP and follow-up DWI between November 2017 and September 2020. CTP data were processed with a fully automated software using relative cerebral blood flow (rCBF) < 30% to estimate the ischemic core. The follow-up infarct was segmented on DWI imaging data, which were acquired at approximately 24 h. Ischemic core on CTP was compared with the follow-up infarct lesion on DWI using intraclass correlation coefficient (ICC) and Dice similarity coefficient (Dice). RESULTS In 59 patients, the median estimated core volume on CTP was 16 (IQR 8-47) mL. The follow-up infarct volume on DWI was 11 (IQR 6-42) mL. ICC was 0.60 (95% CI 0.33-0.76), indicating moderate volumetric agreement. Median Dice was 0.20 (IQR 0.01-0.35). The median positive predictive value was 0.24 (IQR 0.05-0.57), and the median sensitivity was 0.3 (IQR 0.13-0.47). Severe core overestimation on computed tomography perfusion > 50 mL occurred in 4/59 (7%) of the cases. CONCLUSIONS In patients with successful reperfusion after EVT, CTP-estimated ischemic core showed moderate volumetric and spatial agreement with the follow-up infarct lesion on DWI, similar to the most used commercially available CTP software packages. Severe ischemic core overestimation was relatively uncommon.
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Affiliation(s)
- Wenjin Yang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China.,Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Jan W Hoving
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands.
| | - Miou S Koopman
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Manon L Tolhuisen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands.,Department of Biomedical Engineering and Physics, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands.,Department of Biomedical Engineering and Physics, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Olvert A Berkheme
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Ludo F M Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
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26
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Lu Q, Fu J, Lv K, Han Y, Pan Y, Xu Y, Zhang J, Geng D. Agreement of three CT perfusion software packages in patients with acute ischemic stroke: A comparison with RAPID. Eur J Radiol 2022; 156:110500. [PMID: 36099834 DOI: 10.1016/j.ejrad.2022.110500] [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: 04/10/2022] [Revised: 08/07/2022] [Accepted: 08/22/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE To compare ischemic core volume (ICV) and penumbra volume (PV) measured by MIStar, F-STROKE, and Syngo.via with that measured by RAPID in acute ischemic stroke (AIS), and their concordance in selecting patients for endovascular thrombectomy (EVT). METHODS Computed tomography perfusion (CTP) data were processed with four software packages. Bland-Altman analysis and intraclass correlation coefficient (ICC) were performed to evaluate their agreement in quantifying ICV and PV. Kappa test was conducted to assess consistency in the selection of EVT candidates. The correlation between predicted ICV and segmented final infarct volume (FIV) on follow-up images was investigated. RESULTS A total of 91 patients were retrospectively included. F-STROKE had the best consistency with RAPID (ICV: ICC = 0.97; PV: ICC = 0.84) and Syngo.via had the worst consistency (ICV: ICC = 0.77; PV: ICC = 0.66). F-STROKE had the narrowest limits of agreements both in ICV (-27.02, 24.40 mL) and PV (-85.59, 101.80 mL). When selecting EVT candidates, MIStar (kappa = 0.71-0.88) and F-STROKE (kappa = 0.84-0.90) had good to excellent consistency with RAPID, while Syngo.via had poor consistency (kappa = 0.20-0.41). ICV predicted by MIStar was correlated strongest with FIV (r = 0.77). CONCLUSIONS F-STROKE is most consistent with RAPID in quantitative ICV and PV. F-STROKE and MIStar exhibit similar EVT candidate selection to RAPID. Syngo.via, for its part, seems to have overestimated ICV and underestimated PV, leading to an overly restrictive selection of EVT candidates.
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Affiliation(s)
- Qingqing Lu
- Department of Radiology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai 200040, China; Department of Radiology, Ningbo First Hospital, Ningbo 315000, China
| | - Junyan Fu
- Department of Radiology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai 200040, China
| | - Kun Lv
- Department of Radiology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai 200040, China
| | - Yan Han
- Department of Radiology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai 200040, China
| | - Yuning Pan
- Department of Radiology, Ningbo First Hospital, Ningbo 315000, China
| | - Yiren Xu
- Department of Radiology, Ningbo First Hospital, Ningbo 315000, China
| | - Jun Zhang
- Department of Radiology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Shanghai 200040, China.
| | - Daoying Geng
- Department of Radiology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai 200040, China; Center for Shanghai Intelligent Imaging for Critical Brain Diseases Engineering and Technology Reasearch, Huashan Hospital, Fudan Universtiy, Shanghai 200040, China.
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27
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Kremenova K, Lukavsky J, Holesta M, Peisker T, Lauer D, Weichet J, Malikova H. CT Brain Perfusion in the Prediction of Final Infarct Volume: A Prospective Study of Different Software Settings for Acute Ischemic Core Calculation. Diagnostics (Basel) 2022; 12:diagnostics12102290. [PMID: 36291979 PMCID: PMC9601142 DOI: 10.3390/diagnostics12102290] [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: 08/08/2022] [Revised: 09/14/2022] [Accepted: 09/19/2022] [Indexed: 11/16/2022] Open
Abstract
CT perfusion (CTP) is used for the evaluation of brain tissue viability in patients with acute ischemic stroke (AIS). We studied the accuracy of three different syngo.via software (SW) settings for acute ischemic core estimation in predicting the final infarct volume (FIV). The ischemic core was defined as follows: Setting A: an area with cerebral blood flow (CBF) < 30% compared to the contralateral healthy hemisphere. Setting B: CBF < 20% compared to contralateral hemisphere. Setting C: area of cerebral blood volume (CBV) < 1.2 mL/100 mL. We studied 47 AIS patients (aged 68 ± 11.2 years) with large vessel occlusion in the anterior circulation, treated in the early time window (up to 6 h), who underwent technically successful endovascular thrombectomy (EVT). FIV was measured on MRI performed 24 ± 2 h after EVT. In general, all three settings correlated with each other; however, the absolute agreement between acute ischemic core volume on CTP and FIV on MRI was poor; intraclass correlation for all three settings was between 0.64 and 0.69, root mean square error of the individual observations was between 58.9 and 66.0. Our results suggest that using CTP syngo.via SW for prediction of FIV in AIS patients in the early time window is not appropriate.
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Affiliation(s)
- Karin Kremenova
- Radiology Department, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 100 34 Prague, Czech Republic
- Correspondence:
| | - Jiri Lukavsky
- Institute of Psychology, Czech Academy of Sciences, 110 00 Prague, Czech Republic
| | - Michal Holesta
- Radiology Department, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 100 34 Prague, Czech Republic
| | - Tomas Peisker
- Neurology Department, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 100 34 Prague, Czech Republic
| | - David Lauer
- Neurology Department, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 100 34 Prague, Czech Republic
| | - Jiri Weichet
- Radiology Department, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 100 34 Prague, Czech Republic
| | - Hana Malikova
- Radiology Department, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 100 34 Prague, Czech Republic
- Institute of Anatomy, Second Faculty of Medicine, Charles University, 150 00 Prague, Czech Republic
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28
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Rodríguez-Vázquez A, Laredo C, Renú A, Rudilosso S, Llull L, Amaro S, Obach V, Vera V, Páez A, Oleaga L, Urra X, Chamorro Á. Optimizing the Definition of Ischemic Core in CT Perfusion: Influence of Infarct Growth and Tissue-Specific Thresholds. AJNR Am J Neuroradiol 2022; 43:1265-1270. [PMID: 35981763 PMCID: PMC9451632 DOI: 10.3174/ajnr.a7601] [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: 03/28/2022] [Accepted: 06/20/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE CTP allows estimating ischemic core in patients with acute stroke. However, these estimations have limited accuracy compared with MR imaging. We studied the effect of applying WM- and GM-specific thresholds and analyzed the infarct growth from baseline imaging to reperfusion. MATERIALS AND METHODS This was a single-center cohort of consecutive patients (n = 113) with witnessed strokes due to proximal carotid territory occlusions with baseline CT perfusion, complete reperfusion, and follow-up DWI. We segmented GM and WM, coregistered CTP with DWI, and compared the accuracy of the different predictions for each voxel on DWI through receiver operating characteristic analysis. We assessed the yield of different relative CBF thresholds to predict the final infarct volume and an estimated infarct growth-corrected volume (subtracting the infarct growth from baseline imaging to complete reperfusion) for a single relative CBF threshold and GM- and WM-specific thresholds. RESULTS The fixed threshold underestimated lesions in GM and overestimated them in WM. Double GM- and WM-specific thresholds of relative CBF were superior to fixed thresholds in predicting infarcted voxels. The closest estimations of the infarct on DWI were based on a relative CBF of 25% for a single threshold, 35% for GM, and 20% for WM, and they decreased when correcting for infarct growth: 20% for a single threshold, 25% for GM, and 15% for WM. The combination of 25% for GM and 15% for WM yielded the best prediction. CONCLUSIONS GM- and WM-specific thresholds result in different estimations of ischemic core in CTP and increase the global accuracy. More restrictive thresholds better estimate the actual extent of the infarcted tissue.
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Affiliation(s)
- A Rodríguez-Vázquez
- From the Comprehensive Stroke Center (A.R.-V., C.L., A.R., S.R., L.L., S.A., V.O., V.V., X.U., A.C.), Functional Unit of Cerebrovascular Diseases
| | - C Laredo
- From the Comprehensive Stroke Center (A.R.-V., C.L., A.R., S.R., L.L., S.A., V.O., V.V., X.U., A.C.), Functional Unit of Cerebrovascular Diseases
| | - A Renú
- From the Comprehensive Stroke Center (A.R.-V., C.L., A.R., S.R., L.L., S.A., V.O., V.V., X.U., A.C.), Functional Unit of Cerebrovascular Diseases
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (A.R., S.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
- University of Barcelona (A.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
| | - S Rudilosso
- From the Comprehensive Stroke Center (A.R.-V., C.L., A.R., S.R., L.L., S.A., V.O., V.V., X.U., A.C.), Functional Unit of Cerebrovascular Diseases
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (A.R., S.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
| | - L Llull
- From the Comprehensive Stroke Center (A.R.-V., C.L., A.R., S.R., L.L., S.A., V.O., V.V., X.U., A.C.), Functional Unit of Cerebrovascular Diseases
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (A.R., S.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
- University of Barcelona (A.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
| | - S Amaro
- From the Comprehensive Stroke Center (A.R.-V., C.L., A.R., S.R., L.L., S.A., V.O., V.V., X.U., A.C.), Functional Unit of Cerebrovascular Diseases
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (A.R., S.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
- University of Barcelona (A.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
| | - V Obach
- From the Comprehensive Stroke Center (A.R.-V., C.L., A.R., S.R., L.L., S.A., V.O., V.V., X.U., A.C.), Functional Unit of Cerebrovascular Diseases
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (A.R., S.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
- University of Barcelona (A.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
| | - V Vera
- From the Comprehensive Stroke Center (A.R.-V., C.L., A.R., S.R., L.L., S.A., V.O., V.V., X.U., A.C.), Functional Unit of Cerebrovascular Diseases
| | - A Páez
- Radiology Department (A.P., L.O.), Hospital Clínic, Barcelona, Spain
| | - L Oleaga
- Radiology Department (A.P., L.O.), Hospital Clínic, Barcelona, Spain
| | - X Urra
- From the Comprehensive Stroke Center (A.R.-V., C.L., A.R., S.R., L.L., S.A., V.O., V.V., X.U., A.C.), Functional Unit of Cerebrovascular Diseases
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (A.R., S.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
- University of Barcelona (A.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
| | - Á Chamorro
- From the Comprehensive Stroke Center (A.R.-V., C.L., A.R., S.R., L.L., S.A., V.O., V.V., X.U., A.C.), Functional Unit of Cerebrovascular Diseases
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (A.R., S.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
- University of Barcelona (A.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
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29
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Zhou X, Nan Y, Ju J, Zhou J, Xiao H, Wang S. Comparison of Two Software Packages for Perfusion Imaging: Ischemic Core and Penumbra Estimation and Patient Triage in Acute Ischemic Stroke. Cells 2022; 11:cells11162547. [PMID: 36010624 PMCID: PMC9406974 DOI: 10.3390/cells11162547] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/20/2022] [Accepted: 08/12/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose: Automated postprocessing packages have been developed for managing acute ischemic stroke (AIS). These packages identify ischemic core and penumbra using either computed tomographic perfusion imaging (CTP) data or magnetic resonance imaging (MRI) data. Measurements of abnormal tissues and treatment decisions derived from different vendors can vary. The purpose of this study is to investigate the agreement of volumetric and decision-making outcomes derived from two software packages. Methods: A total of 594 AIS patients (174 underwent CTP and 420 underwent MRI) were included. Imaging data were accordingly postprocessed by two software packages: RAPID and RealNow. Volumetric outputs were compared between packages by performing intraclass correlation coefficient (ICC), Wilcoxon paired test and Bland–Altman analysis. Concordance of selecting patients eligible for mechanical thrombectomy (MT) was assessed based on neuroimaging criteria proposed in DEFUSE3. Results: In the group with CTP data, mean ischemic core volume (ICV)/penumbral volume (PV) was 14.9/81.1 mL via RAPID and 12.6/83.2 mL via RealNow. Meanwhile, in the MRI group, mean ICV/PV were 52.4/68.4 mL and 48.9/61.6 mL via RAPID and RealNow, respectively. Reliability, which was measured by ICC of ICV and PV in CTP and MRI groups, ranged from 0.87 to 0.99. The bias remained small between measurements (CTP ICV: 0.89 mL, CTP PV: −2 mL, MRI ICV: 3.5 mL and MRI PV: 6.8 mL). In comparison with CTP ICV with follow-up DWI, the ICC was 0.92 and 0.94 for RAPID and Realnow, respectively. The bias remained small between CTP ICV and follow-up DWI measurements (Rapid: −4.65 mL, RealNow: −3.65 mL). Wilcoxon paired test showed no significant difference between measurements. The results of patient triage were concordant in 159/174 cases (91%, ICC: 0.90) for CTP and 400/420 cases (95%, ICC: 0.93) for MRI. Conclusion: The CTP ICV derived from RealNow was more accurate than RAPID. The similarity in volumetric measurement between packages did not necessarily relate to equivalent patient triage. In this study, RealNow showed excellent agreement with RAPID in measuring ICV and PV as well as patient triage.
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Affiliation(s)
- Xiang Zhou
- Department of Radiology, Tongji Hospital, School of Medicine, Tongji University, 389 Xincun Rd., Shanghai 200065, China
| | - Yashi Nan
- YIWEI Medical Technology Co., Ltd., Room 1001, MAI KE LONG Building, Shenzhen 518000, China
| | - Jieyang Ju
- The Second Affiliated Hospital of Nanjing Medical University, 121 Jiangjiayuan Rd., Nanjing 210011, China
| | - Jingyu Zhou
- YIWEI Medical Technology Co., Ltd., Room 1001, MAI KE LONG Building, Shenzhen 518000, China
| | - Huanhui Xiao
- YIWEI Medical Technology Co., Ltd., Room 1001, MAI KE LONG Building, Shenzhen 518000, China
| | - Silun Wang
- YIWEI Medical Technology Co., Ltd., Room 1001, MAI KE LONG Building, Shenzhen 518000, China
- Correspondence:
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Sarraj A, Campbell BCV, Christensen S, Sitton CW, Khanpara S, Riascos RF, Pujara D, Shaker F, Sharma G, Lansberg MG, Albers GW. Accuracy of CT Perfusion-Based Core Estimation of Follow-up Infarction: Effects of Time Since Last Known Well. Neurology 2022; 98:e2084-e2096. [PMID: 35450966 PMCID: PMC9169942 DOI: 10.1212/wnl.0000000000200269] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 02/08/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To assess the accuracy of baseline CT perfusion (CTP) ischemic core estimates. METHODS From SELECT (Optimizing Patient Selection for Endovascular Treatment in Acute Ischemic Stroke), a prospective multicenter cohort study of imaging selection, patients undergoing endovascular thrombectomy who achieved complete reperfusion (modified Thrombolysis In Cerebral Ischemia score 3) and had follow-up diffusion-weighted imaging (DWI) available were evaluated. Follow-up DWI lesions were coregistered to baseline CTP. The difference between baseline CTP core (relative cerebral blood flow [rCBF] <30%) volume and follow-up infarct volume was classified as overestimation (core ≥10 mL larger than infarct), adequate, or underestimation (core ≥25 mL smaller than infarct) and spatial overlap was evaluated. RESULTS Of 101 included patients, median time from last known well (LKW) to imaging acquisition was 138 (82-244) minutes. The median baseline ischemic core estimate was 9 (0-31.9) mL and median follow-up infarct volume was 18.4 (5.3-68.7) mL. All 6/101 (6%) patients with overestimation of the subsequent infarct volume were imaged within 90 minutes of LKW and achieved rapid reperfusion (within 120 minutes of CTP). Using rCBF <20% threshold to estimate ischemic core in patients presenting within 90 minutes eliminated overestimation. Volumetric correlation between the ischemic core estimate and follow-up imaging improved as LKW time to imaging acquisition increased: Spearman ρ <90 minutes 0.33 (p = 0.049), 90-270 minutes 0.63 (p < 0.0001), >270 minutes 0.86 (p < 0.0001). Assessment of the spatial overlap between baseline CTP ischemic core lesion and follow-up infarct demonstrated that a median of 3.2 (0.0-9.0) mL of estimated core fell outside the subsequent infarct. These regions were predominantly in white matter. DISCUSSION Significant overestimation of irreversibly injured ischemic core volume was rare, was only observed in patients who presented within 90 minutes of LKW and achieved reperfusion within 120 minutes of CTP acquisition, and occurred primarily in white matter. Use of a more conservative (rCBF <20%) threshold for estimating ischemic core in patients presenting within 90 minutes eliminated all significant overestimation cases. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov: NCT03876457.
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Affiliation(s)
- Amrou Sarraj
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Bruce C V Campbell
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Soren Christensen
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Clark W Sitton
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Shekhar Khanpara
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Roy F Riascos
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Deep Pujara
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Faris Shaker
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Gagan Sharma
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Maarten G Lansberg
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Gregory W Albers
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
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31
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McDonough RV, Qiu W, Ospel JM, Menon BK, Cimflova P, Goyal M. Multiphase CTA-derived tissue maps aid in detection of medium vessel occlusions. Neuroradiology 2022; 64:887-896. [PMID: 34668040 DOI: 10.1007/s00234-021-02830-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/08/2021] [Indexed: 12/30/2022]
Abstract
PURPOSE Medium vessel occlusions (MeVOs) can be challenging to detect on imaging. Multiphase computed tomography angiography (mCTA) has been shown to improve large vessel occlusion (LVO) detection and endovascular treatment (EVT) selection. The aims of this study were to determine if mCTA-derived tissue maps can (1) accurately detect MeVOs and (2) predict infarction on 24-h follow-up imaging with comparable accuracy to CT perfusion (CTP). METHODS Two readers assessed mCTA tissue maps of 116 ischemic stroke patients (58 MeVOs, 58 non-MeVOs) and determined by consensus: (1) MeVO (yes/no) and (2) occlusion site, blinded to clinical or imaging data. Sensitivity, specificity, and area under the curve (AUC) for MeVO detection were estimated in comparison to reference standards of (1) expert readings of baseline mCTA and (2) CTP maps. Volumetric and spatial agreement between mCTA- and CTP-predicted infarcts was assessed using concordance/intraclass correlation and Dice coefficients. Interrater agreement for MeVO detection on mCTA tissue maps was estimated with Cohen's kappa. RESULTS MeVO detection from mCTA-derived tissue maps had a sensitivity of 91% (95% CI: 80-97), specificity of 82% (95% CI: 70-90), and AUC of 0.87 (95% CI: 0.80-0.93) compared to expert reads of baseline mCTA. Interrater reliability was good (0.72, 95% CI: 0.60-0.85). Compared to CTP maps, sensitivity was 87% (95% CI: 75-95), specificity was 78% (95%CI: 65-88), and AUC was 0.83 (95% CI: 0.76-0.90). The mean difference between mCTA- and CTP-predicted final infarct volume was 4.8 mL (limits of agreement: - 58.5 to 68.1) with a Dice coefficient of 33.5%. CONCLUSION mCTA tissue maps can be used to reliably detect MeVO stroke and predict tissue fate.
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Affiliation(s)
- Rosalie V McDonough
- Department of Radiology, Foothills Medical Centre, University of Calgary, AB, Calgary, Canada.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wu Qiu
- Department of Radiology, Foothills Medical Centre, University of Calgary, AB, Calgary, Canada.,Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Johanna M Ospel
- Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Bijoy K Menon
- Department of Radiology, Foothills Medical Centre, University of Calgary, AB, Calgary, Canada.,Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Petra Cimflova
- Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada.,Department of Medical Imaging, St. Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Mayank Goyal
- Department of Radiology, Foothills Medical Centre, University of Calgary, AB, Calgary, Canada. .,Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada.
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Fladt J, d'Esterre CD, Joundi R, McDougall C, Gensicke H, Barber P. Acute stroke imaging selection for mechanical thrombectomy in the extended time window: is it time to go back to basics? A review of current evidence. J Neurol Neurosurg Psychiatry 2022; 93:238-245. [PMID: 35115388 DOI: 10.1136/jnnp-2021-328000] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 01/05/2022] [Indexed: 12/15/2022]
Abstract
Treatment with endovascular therapy in the extended time window for acute ischaemic stroke with large vessel occlusion involves stringent selection criteria based on the two landmark studies DAWN and DEFUSE3. Current protocols typically include the requirement of advanced perfusion imaging which may exclude a substantial proportion of patients from receiving a potentially effective therapy. Efforts to offer endovascular reperfusion therapies to all appropriate candidates may be facilitated by the use of simplified imaging selection paradigms with widely available basic imaging techniques, such as non-contrast CT and CT angiography. Currently available evidence from our literature review suggests that patients meeting simplified imaging selection criteria may benefit as much as those patients selected using advanced imaging techniques (CT perfusion or MRI) from endovascular therapy in the extended time window. A comprehensive understanding of the role of imaging in patient selection is critical to optimising access to endovascular therapy in the extended time window and improving outcomes in acute stroke. This article provides an overview on current developments and future directions in this emerging area.
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Affiliation(s)
- Joachim Fladt
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Christopher D d'Esterre
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Raed Joundi
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Connor McDougall
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Henrik Gensicke
- Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Philip Barber
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Kim HJ, Roh HG. Imaging in Acute Anterior Circulation Ischemic Stroke: Current and Future. Neurointervention 2022; 17:2-17. [PMID: 35114749 PMCID: PMC8891584 DOI: 10.5469/neuroint.2021.00465] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/25/2021] [Accepted: 12/30/2021] [Indexed: 11/24/2022] Open
Abstract
Clinical trials on acute ischemic stroke have demonstrated the clinical effectiveness of revascularization treatments within an appropriate time window after stroke onset: intravenous thrombolysis (NINDS and ECASS-III) through the administration of tissue plasminogen activator within a 4.5-hour time window, endovascular thrombectomy (ESCAPE, REVASCAT, SWIFT-PRIME, MR CLEAN, EXTEND-IA) within a 6-hour time window, and extending the treatment time window up to 24 hours for endovascular thrombectomy (DAWN and DEFUSE 3). However, a substantial number of patients in these trials were ineligible for revascularization treatment, and treatments of some patients were considerably futile or sometimes dangerous in the clinical trials. Guidelines for the early management of patients with acute ischemic stroke have evolved to accept revascularization treatment as standard and include eligibility criteria for the treatment. Imaging has been crucial in selecting eligible patients for revascularization treatment in guidelines and clinical trials. Stroke specialists should know imaging criteria for revascularization treatment. Stroke imaging studies have demonstrated imaging roles in acute ischemic stroke management as follows: 1) exclusion of hemorrhage and stroke mimic disease, 2) assessment of salvageable brain, 3) localization of the site of vascular occlusion and thrombus, 4) estimation of collateral circulation, and 5) prediction of acute ischemic stroke expecting hemorrhagic transformation. Here, we review imaging methods and criteria to select eligible patients for revascularization treatment in acute anterior circulation stroke, focus on 2019 guidelines from the American Heart Association/American Stroke Association, and discuss the future direction of imaging-based patient selection to improve treatment effects.
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Affiliation(s)
- Hyun Jeong Kim
- Department of Radiology, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Hong Gee Roh
- Department of Radiology, Konkuk University Medical Center, Seoul, Korea
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34
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Soltanpour M, Greiner R, Boulanger P, Buck B. Improvement of automatic ischemic stroke lesion segmentation in CT perfusion maps using a learned deep neural network. Comput Biol Med 2021; 137:104849. [PMID: 34530336 DOI: 10.1016/j.compbiomed.2021.104849] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/11/2021] [Accepted: 09/04/2021] [Indexed: 10/20/2022]
Abstract
Acute ischemic stroke is one of the leading causes of death and long-term disability worldwide. It occurs when a blood clot blocks an artery that supplies blood to the brain tissue. Segmentation of acute ischemic stroke lesions plays a vital role to improve diagnosis, outcome assessment, and treatment planning. The current standard approach of ischemic stroke lesion segmentation is simply thresholding the Computed Tomography Perfusion (CTP) maps, i.e., quantitative feature maps created by summarizing CTP time sequence scans. However, this approach is not precise enough (its Dice similarity score is only around 50%) to be used in practice. Numerous machine learning-based techniques have recently been proposed to improve the accuracy of ischemic stroke lesion segmentation. Although they have achieved remarkable results, they still need to be improved before they can be used in actual practice. This paper presents a novel deep learning-based technique, MutiRes U-Net, for the segmentation of ischemic stroke lesions in CTP maps. MultiRes U-Net is a modified version of the original U-Net that is re-designed to be robust to segment the objects in different scales and unusual appearances. Additionally, in this paper, we propose to enrich the input CTP maps by using their contra-lateral and corresponding Tmax images. We evaluated the proposed method using the ISLES challenge 2018 dataset. As compared to the state-of-the-art methods, the results show an improvement in segmentation task accuracy. The dice similarity score (DSC) was 68%, the Jaccard score was 57.13%, and the mean absolute volume error was 22.62(ml).
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Affiliation(s)
| | - Russ Greiner
- Department of Computing Science, University of Alberta, Canada.
| | | | - Brian Buck
- Department of Medicine, University of Alberta, Canada.
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35
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Potreck A, Seker F, Mutke MA, Weyland CS, Herweh C, Heiland S, Bendszus M, Möhlenbruch M. What is the impact of head movement on automated CT perfusion mismatch evaluation in acute ischemic stroke? J Neurointerv Surg 2021; 14:628-633. [PMID: 34301804 DOI: 10.1136/neurintsurg-2021-017510] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 07/04/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Automated CT perfusion mismatch assessment is an established treatment decision tool in acute ischemic stroke. However, the reliability of this method in patients with head motion is unclear. We therefore sought to evaluate the influence of head movement on automated CT perfusion mismatch evaluation. METHODS Using a realistic CT brain-perfusion-phantom, 7 perfusion mismatch scenarios were simulated within the left middle cerebral artery territory. Real CT noise and artificial head movement were added. Thereafter, ischemic core, penumbra volumes and mismatch ratios were evaluated using an automated mismatch analysis software (RAPID, iSchemaView) and compared with ground truth simulated values. RESULTS While CT scanner noise alone had only a minor impact on mismatch evaluation, a tendency towards smaller infarct core estimates (mean difference of -5.3 (-14 to 3.5) mL for subtle head movement and -7.0 (-14.7 to 0.7) mL for strong head movement), larger penumbral estimates (+9.9 (-25 to 44) mL and +35 (-14 to 85) mL, respectively) and consequently larger mismatch ratios (+0.8 (-1.5 to 3.0) for subtle head movement and +1.9 (-1.3 to 5.1) for strong head movement) were noted in dependence of patient head movement. CONCLUSIONS Motion during CT perfusion acquisition influences automated mismatch evaluation. Potentially treatment-relevant changes in mismatch classifications in dependence of head movement were observed and occurred in favor of mechanical thrombectomy.
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Affiliation(s)
- Arne Potreck
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Fatih Seker
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | | | | | - Christian Herweh
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Sabine Heiland
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
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Campbell BCV, Lansberg MG, Broderick JP, Derdeyn CP, Khatri P, Sarraj A, Saver JL, Vagal A, Albers GW. Acute Stroke Imaging Research Roadmap IV: Imaging Selection and Outcomes in Acute Stroke Clinical Trials and Practice. Stroke 2021; 52:2723-2733. [PMID: 34233464 DOI: 10.1161/strokeaha.121.035132] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE The Stroke Treatment Academic Industry Roundtable (STAIR) sponsored an imaging session and workshop during the Stroke Treatment Academic Industry Roundtable XI via webinar on October 1 to 2, 2020, to develop consensus recommendations, particularly regarding optimal imaging at primary stroke centers. METHODS This forum brought together stroke neurologists, neuroradiologists, neuroimaging research scientists, members of the National Institute of Neurological Disorders and Stroke, industry representatives, and members of the US Food and Drug Administration to discuss imaging priorities in the light of developments in reperfusion therapies, particularly in an extended time window, and reinvigorated interest in brain cytoprotection trials. RESULTS The imaging session summarized and compared the imaging components of recent acute stroke trials and debated the optimal imaging strategy at primary stroke centers. The imaging workshop developed consensus recommendations for optimizing the acquisition, analysis, and interpretation of computed tomography and magnetic resonance acute stroke imaging, and also recommendations on imaging strategies for primary stroke centers. CONCLUSIONS Recent positive acute stroke clinical trials have extended the treatment window for reperfusion therapies using imaging selection. Achieving rapid and high-quality stroke imaging is therefore critical at both primary and comprehensive stroke centers. Recommendations for enhancing stroke imaging research are provided.
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Affiliation(s)
- Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (B.C.V.C.), University of Melbourne, Parkville, Victoria, Australia.,Florey Institute of Neuroscience and Mental Health (B.C.V.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Maarten G Lansberg
- Department of Neurology & Stanford Stroke Center, Stanford University School of Medicine, CA (M.G.L., G.W.A.)
| | | | - Colin P Derdeyn
- Department of Radiology, Iowa Institute of Biomedical Imaging, University of Iowa Hospitals and Clinics (C.P.D.)
| | - Pooja Khatri
- Department of Neurology (J.P.B., P.K.), University of Cincinnati, OH
| | - Amrou Sarraj
- UT McGovern Medical School, Department of Neurology, Houston (A.S.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California Los Angeles (J.L.S.)
| | - Achala Vagal
- Department of Radiology (A.V.), University of Cincinnati, OH
| | - Gregory W Albers
- Department of Neurology & Stanford Stroke Center, Stanford University School of Medicine, CA (M.G.L., G.W.A.)
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Liu QC, Jia ZY, Zhao LB, Cao YZ, Ma G, Shi HB, Liu S. Agreement and Accuracy of Ischemic Core Volume Evaluated by Three CT Perfusion Software Packages in Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2021; 30:105872. [PMID: 34153591 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105872] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 04/26/2021] [Accepted: 05/02/2021] [Indexed: 10/21/2022] Open
Abstract
PURPOSE To compare the ischemic core volume estimated by CT Perfusion 4D and Vue PACS with that estimated by RAPID software in acute ischemic stroke (AIS). MATERIALS AND METHODS CT perfusion data from AIS patients were retrospectively post-processed with RAPID, CT Perfusion 4D and Vue PACS software. The Vue PACS application included three different settings: method A (Circular Singular Value Decomposition), method B (Oscillating index Singular Value Decomposition) and method C (Standard Singular Value Decomposition). Bland-Altman analysis, intraclass correlation coefficients (ICCs) and Kappa analysis were used to evaluate concordance between estimated ischemic core values. Final infarct volume (FIV) was measured by follow-up non-contrast CT or MRI 5-7 days after mechanical thrombectomy (MT) in patients with successful recanalization. RESULTS A total of 82 patients were included in the study. Concordance with RAPID ranged from good (method B: ICC 0.780; method C: ICC 0.852) to excellent (CT perfusion 4D: ICC 0.950; method A: ICC 0.954). The limits of agreement (-32.3, 41.8 mL) were the narrowest with method A. For detecting core volumes ≤ 70 ml, method A and CT perfusion 4D showed almost perfect concordance with RAPID (CT perfusion 4D, kappa=0.87; method A, kappa=0.87), whereas methods B and C showed substantial concordance with RAPID (method B, kappa=0.77; method C, kappa =0.73). Thirty-two patients had good reperfusion after MT. RAPID showed the highest accuracy for predicting FIV, followed by method A. CONCLUSION CT perfusion 4D and Vue PACS method A showed excellent concordance with RAPID for quantifying ischemic core volume, which can be considered as alternatives in selecting patients for MT in clinical practice.
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Affiliation(s)
- Qin Chen Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhen Yu Jia
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lin Bo Zhao
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yue Zhou Cao
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Gao Ma
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hai Bin Shi
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
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38
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Magoufis G, Safouris A, Raphaeli G, Kargiotis O, Psychogios K, Krogias C, Palaiodimou L, Spiliopoulos S, Polizogopoulou E, Mantatzis M, Finitsis S, Karapanayiotides T, Ellul J, Bakola E, Brountzos E, Mitsias P, Giannopoulos S, Tsivgoulis G. Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach. Ther Adv Neurol Disord 2021; 14:17562864211021182. [PMID: 34122624 PMCID: PMC8175833 DOI: 10.1177/17562864211021182] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/10/2021] [Indexed: 02/05/2023] Open
Abstract
Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.
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Affiliation(s)
- Georgios Magoufis
- Interventional Neuroradiology Unit, Metropolitan Hospital, Piraeus, Greece
| | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Guy Raphaeli
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | | | - Klearchos Psychogios
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Lina Palaiodimou
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Eftihia Polizogopoulou
- Emergency Medicine Clinic, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Michael Mantatzis
- Department of Radiology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Stephanos Finitsis
- Department of Interventional Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, Aristotle University of Thessaloniki, School of Medicine, Faculty of Health Sciences, AHEPA University Hospital, Thessaloniki, Greece
| | - John Ellul
- Department of Neurology, University Hospital of Patras, School of Medicine, University of Patras, Patras, Greece
| | - Eleni Bakola
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Elias Brountzos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Panayiotis Mitsias
- Department of Neurology Medical School, University of Crete, Heraklion, Crete, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian, University of Athens, School of Medicine, “Attikon” University Hospital, Iras 39, Gerakas Attikis, Athens, 15344, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
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39
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Qiu W, Kuang H, Ospel JM, Hill MD, Demchuk AM, Goyal M, Menon BK. Automated Prediction of Ischemic Brain Tissue Fate from Multiphase Computed Tomographic Angiography in Patients with Acute Ischemic Stroke Using Machine Learning. J Stroke 2021; 23:234-243. [PMID: 34102758 PMCID: PMC8189856 DOI: 10.5853/jos.2020.05064] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/08/2021] [Indexed: 01/11/2023] Open
Abstract
Background and Purpose Multiphase computed tomographic angiography (mCTA) provides time variant images of pial vasculature supplying brain in patients with acute ischemic stroke (AIS). To develop a machine learning (ML) technique to predict tissue perfusion and infarction from mCTA source images.
Methods 284 patients with AIS were included from the Precise and Rapid assessment of collaterals using multi-phase CTA in the triage of patients with acute ischemic stroke for Intra-artery Therapy (Prove-IT) study. All patients had non-contrast computed tomography, mCTA, and computed tomographic perfusion (CTP) at baseline and follow-up magnetic resonance imaging/non-contrast-enhanced computed tomography. Of the 284 patient images, 140 patient images were randomly selected to train and validate three ML models to predict a pre-defined Tmax thresholded perfusion abnormality, core and penumbra on CTP. The remaining 144 patient images were used to test the ML models. The predicted perfusion, core and penumbra lesions from ML models were compared to CTP perfusion lesion and to follow-up infarct using Bland-Altman plots, concordance correlation coefficient (CCC), intra-class correlation coefficient (ICC), and Dice similarity coefficient.
Results Mean difference between the mCTA predicted perfusion volume and CTP perfusion volume was 4.6 mL (limit of agreement [LoA], –53 to 62.1 mL; P=0.56; CCC 0.63 [95% confidence interval [CI], 0.53 to 0.71; P<0.01], ICC 0.68 [95% CI, 0.58 to 0.78; P<0.001]). Mean difference between the mCTA predicted infarct and follow-up infarct in the 100 patients with acute reperfusion (modified thrombolysis in cerebral infarction [mTICI] 2b/2c/3) was 21.7 mL, while it was 3.4 mL in the 44 patients not achieving reperfusion (mTICI 0/1). Amongst reperfused subjects, CCC was 0.4 (95% CI, 0.15 to 0.55; P<0.01) and ICC was 0.42 (95% CI, 0.18 to 0.50; P<0.01); in non-reperfused subjects CCC was 0.52 (95% CI, 0.20 to 0.60; P<0.001) and ICC was 0.60 (95% CI, 0.37 to 0.76; P<0.001). No difference was observed between the mCTA and CTP predicted infarct volume in the test cohort (P=0.67).
Conclusions A ML based mCTA model is able to predict brain tissue perfusion abnormality and follow-up infarction, comparable to CTP.
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Affiliation(s)
- Wu Qiu
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Hulin Kuang
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Johanna M Ospel
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada.,Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Michael D Hill
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Andrew M Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Mayank Goyal
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Bijoy K Menon
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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Sarraj A, Campbell B, Ribo M, Hussain MS, Chen M, Abraham MG, Lansberg MG, Mendes Pereira V, Blackburn S, Sitton CW, Budzik RF, Pérez de la Ossa N, Arenillas JF, Wu T, Blasco J, Mullen M, Schaafsma J, Tsai JP, Sangha N, Kozak O, Gibson D, Warach S, Cordato D, Manning NW, Kleinig TJ, Olivot JM, Elijovich L, Tsivgoulis G, Alexandrov A, Jabbour P, Yan B, Kasner SE, Arthur AS, Parsons M, Grotta JC, Hassan AE, Albers GW. SELECTion criteria for large core trials: dogma or data? J Neurointerv Surg 2021; 13:500-504. [PMID: 33879510 DOI: 10.1136/neurintsurg-2021-017498] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Amrou Sarraj
- Neurology, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Bruce Campbell
- The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Marc Ribo
- Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | | | - Michael Chen
- Neurology, Rush University Medical Center, Chicago, Illinois, USA
| | - Michael G Abraham
- Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Maarten G Lansberg
- Neurology & Neurological Sciences, Stanford University, Stanford, California, USA
| | - Vitor Mendes Pereira
- Surgery, Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Spiros Blackburn
- Neurosurgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Clark W Sitton
- Neuroradiology, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Ronald F Budzik
- Neurology, Riverside Methodist Hospital, Columbus, Ohio, USA
| | - Natalia Pérez de la Ossa
- Stroke Unit, Department of Neurology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Juan F Arenillas
- Stroke Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Teddy Wu
- Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Jordi Blasco
- Interventional Neuroradiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Michael Mullen
- Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joanna Schaafsma
- Medicine, Division of Neurology, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Jenny P Tsai
- Department of Neurological Surgery, Spectrum Health Medical Group, Grand Rapids, Michigan, USA
| | - Navdeep Sangha
- Kaiser Permanente Southern California, Los Angeles, California, USA
| | - Osman Kozak
- Neurosurgery, Jefferson Health - Abington, Abington, Pennsylvania, USA
| | | | - Steven Warach
- Neurology, University of Texas at Austin Dell Seton Medical Center, Austin, Texas, USA
| | - Dennis Cordato
- Neurology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Nathan W Manning
- Neurology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Timothy J Kleinig
- Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jean-Marc Olivot
- Stroke Unit, University Hospital Centre Toulouse, Toulouse, France
| | - Lucas Elijovich
- Neurology, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Georgios Tsivgoulis
- Neurology, The University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Second Department of Neurology, "Attikon" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Andrei Alexandrov
- Neurology, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Pascal Jabbour
- Neurological Surgery, Thomas Jefferson University Hospitals, Wayne, Pennsylvania, USA
| | - Bernard Yan
- The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Scott E Kasner
- Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Adam S Arthur
- Neurosurgery, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Mark Parsons
- Neurology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - James C Grotta
- Neurology, Memorial Hermann Hospital - Texas Medical Center, Houston, Texas, USA
| | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | - Gregory W Albers
- Neurology & Neurological Sciences, Stanford University, Stanford, California, USA
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41
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Brugnara G, Herweh C, Neuberger U, Bo Hansen M, Ulfert C, Mahmutoglu MA, Foltyn M, Nagel S, Schönenberger S, Heiland S, Ringleb PA, Bendszus M, Möhlenbruch M, Pfaff JAR, Vollmuth P. Dynamics of cerebral perfusion and oxygenation parameters following endovascular treatment of acute ischemic stroke. J Neurointerv Surg 2021; 14:neurintsurg-2020-017163. [PMID: 33762405 PMCID: PMC8785045 DOI: 10.1136/neurintsurg-2020-017163] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 02/06/2021] [Accepted: 02/10/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND We studied the effects of endovascular treatment (EVT) and the impact of the extent of recanalization on cerebral perfusion and oxygenation parameters in patients with acute ischemic stroke (AIS) and large vessel occlusion (LVO). METHODS Forty-seven patients with anterior LVO underwent computed tomography perfusion (CTP) before and immediately after EVT. The entire ischemic region (Tmax >6 s) was segmented before intervention, and tissue perfusion (time-to-maximum (Tmax), time-to-peak (TTP), mean transit time (MTT), cerebral blood volume (CBV), cerebral blood flow (CBF)) and oxygenation (coefficient of variation (COV), capillary transit time heterogeneity (CTH), metabolic rate of oxygen (CMRO2), oxygen extraction fraction (OEF)) parameters were quantified from the segmented area at baseline and the corresponding area immediately after intervention, as well as within the ischemic core and penumbra. The impact of the extent of recanalization (modified Treatment in Cerebral Infarction (mTICI)) on CTP parameters was assessed with the Wilcoxon test and Pearson's correlation coefficients. RESULTS The Tmax, MTT, OEF and CTH values immediately after EVT were lower in patients with complete (as compared with incomplete) recanalization, whereas CBF and COV values were higher (P<0.05) and no differences were found in other parameters. The ischemic penumbra immediately after EVT was lower in patients with complete recanalization as compared with those with incomplete recanalization (P=0.002), whereas no difference was found for the ischemic core (P=0.12). Specifically, higher mTICI scores were associated with a greater reduction of ischemic penumbra volumes (R²=-0.48 (95% CI -0.67 to -0.22), P=0.001) but not of ischemic core volumes (P=0.098). CONCLUSIONS Our study demonstrates that the ischemic penumbra is the key target of successful EVT in patients with AIS and largely determines its efficacy on a tissue level. Furthermore, we confirm the validity of the mTICI score as a surrogate parameter of interventional success on a tissue perfusion level.
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Affiliation(s)
- Gianluca Brugnara
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Christian Herweh
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Ulf Neuberger
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Mikkel Bo Hansen
- Center of Functionally Integrative Neuroscience and MINDLab, Aarhus Universitet, Aarhus, Midtjylland, Denmark
| | - Christian Ulfert
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Mustafa Ahmed Mahmutoglu
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Martha Foltyn
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Silvia Schönenberger
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Sabine Heiland
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Peter Arthur Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Johannes Alex Rolf Pfaff
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Philipp Vollmuth
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
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42
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Wei W, Song C, Li X, Jin D. Utility of CT Perfusion Imaging in Patients With Vertebral Artery Stenosis Treated With Balloon Expandable Stent. Front Neurol 2021; 12:650887. [PMID: 33815262 PMCID: PMC8010256 DOI: 10.3389/fneur.2021.650887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 02/17/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To investigate the clinical value of CT perfusion (CTP) imaging in vertebral artery stenosis stenting, so as to provide the basis for preoperative and postoperative evaluation. Ninety-seven patients with vertebral artery stenosis were accepted for endovascular stenting between Jan 2016 and Jan 2020. CT angiography, Digital Subtraction Angiography, and CTP were performed pre-operation and post-operation. The cerebral blood volume (CBV), cerebral blood flow (CBF), and mean transmit time (MTT) between the health and affected sides were analyzed statistically, and the imaging results pre- and post-operation were evaluated. The stenosis was relieved by endovascular stents in all 97 patients without serious complications. The abnormal perfusion was observed in 66 patients (68%). The differences in CBF and MTT between the diseased side and healthy side were statistically significant (P < 0.05). Compared with the preoperative imaging, the postoperative CTP was improved in 59 patients (89%). The differences in CBF and MTT between pre-operation and post-operation were statistically significant (P < 0.05). But there was no significant difference in CBV. CTP can sensitively reflect the perfusion of brain, and can also be used for preoperative and postoperative evaluation of vertebral artery stenting. It may be helpful as an adequate indicator of vertebral artery stenosis stent surgery.
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Affiliation(s)
- Wei Wei
- Department of Neurosurgery, Affiliated Dalian Municipal Central Hospital, Dalian Medical University, Dalian, China
| | - Chong Song
- Department of Neurosurgery, Affiliated Dalian Municipal Central Hospital, Dalian Medical University, Dalian, China
| | - Xuqin Li
- Department of Neurosurgery, Affiliated Dalian Municipal Central Hospital, Dalian Medical University, Dalian, China
| | - Dianshi Jin
- Department of Neurosurgery, Affiliated Dalian Municipal Central Hospital, Dalian Medical University, Dalian, China
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43
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He G, Wei L, Lu H, Li Y, Zhao Y, Zhu Y. Advances in imaging acute ischemic stroke: evaluation before thrombectomy. Rev Neurosci 2021; 32:495-512. [PMID: 33600678 DOI: 10.1515/revneuro-2020-0061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/05/2020] [Indexed: 11/15/2022]
Abstract
Recent advances in neuroimaging have demonstrated significant assessment benefits and appropriate triage of patients based on specific clinical and radiological features in the acute stroke setting. Endovascular thrombectomy is arguably the most important aspect of acute stroke management with an extended time window. Imaging-based physiological information may potentially shift the treatment paradigm from a rigid time-based model to a more flexible and individualized, tissue-based approach, increasing the proportion of patients amenable to treatment. Various imaging modalities are routinely used in the diagnosis and management of acute ischemic stroke, including multimodal computed tomography (CT) and magnetic resonance imaging (MRI). Therefore, these imaging methods should provide information beyond the presence or absence of intracranial hemorrhage as well as the presence and extent of the ischemic core, collateral circulation and penumbra in patients with neurological symptoms. Target mismatch may optimize selection of patients with late or unknown symptom onset who would potentially be eligible for revascularization therapy. The purpose of this study was to provide a comprehensive review of the current evidence about efficacy and theoretical basis of present imaging modalities, and explores future directions for imaging in the management of acute ischemic stroke.
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Affiliation(s)
- Guangchen He
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai200233, China
| | - Liming Wei
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai200233, China
| | - Haitao Lu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai200233, China
| | - Yuehua Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai200233, China
| | - Yuwu Zhao
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai200233, China
| | - Yueqi Zhu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai200233, China
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44
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Rava RA, Podgorsak AR, Waqas M, Snyder KV, Levy EI, Davies JM, Siddiqui AH, Ionita CN. Use of a convolutional neural network to identify infarct core using computed tomography perfusion parameters. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2021; 11596. [PMID: 33707811 DOI: 10.1117/12.2579753] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Purpose Computed tomography perfusion (CTP) is used to diagnose ischemic strokes through contralateral hemisphere comparisons of various perfusion parameters. Various perfusion parameter thresholds have been utilized to segment infarct tissue due to differences in CTP software and patient baseline hemodynamics. This study utilized a convolutional neural network (CNN) to eliminate the need for non-universal parameter thresholds to segment infarct tissue. Methods CTP data from 63 ischemic stroke patients was retrospectively collected and perfusion parameter maps were generated using Vitrea CTP software. Infarct ground truth labels were segmented from diffusion-weighted imaging (DWI) and CTP and DWI volumes were registered. A U-net based CNN was trained and tested five separate times using each CTP parameter (cerebral blood flow (CBF), cerebral blood volume (CBV), time-to-peak (TTP), mean-transit-time (MTT), delay time). 8,352 infarct slices were utilized with a 60:30:10 training:testing:validation split and Monte Carlo cross-validation was conducted using 20 iterations. Infarct volumes were reconstructed following segmentation from each CTP slice. Infarct spatial and volumetric agreement was compared between each CTP parameter and DWI. Results Spatial agreement metrics (Dice coefficient, positive predictive value) for each CTP parameter in predicting infarct volumes are: CBF=(0.67, 0.76), CBV=(0.44, 0.62), TTP=(0.60, 0.67), MTT=(0.58, 0.62), delay time=(0.57, 0.60). 95% confidence intervals for volume differences with DWI infarct are: CBF=14.3±11.5 mL, CBV=29.6±21.2 mL, TTP=7.7±15.2 mL, MTT=-10.7±18.6 mL, delay time=-5.7±23.6 mL. Conclusions CBF is the most accurate CTP parameter in segmenting infarct tissue. Segmentation of infarct using a CNN has the potential to eliminate non-universal CTP contralateral hemisphere comparison thresholds.
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Affiliation(s)
- Ryan A Rava
- Department of Biomedical Engineering, University at Buffalo, Buffalo NY, 14260.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY, 14203
| | - Alexander R Podgorsak
- Department of Biomedical Engineering, University at Buffalo, Buffalo NY, 14260.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY, 14203.,Department of Medical Physics, University at Buffalo, Buffalo NY, 14260
| | - Muhammad Waqas
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY, 14203.,Department of Neurosurgery, University at Buffalo Jacobs School of Medicine, Buffalo NY, 14203
| | - Kenneth V Snyder
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY, 14203.,Department of Neurosurgery, University at Buffalo Jacobs School of Medicine, Buffalo NY, 14203
| | - Elad I Levy
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY, 14203.,Department of Neurosurgery, University at Buffalo Jacobs School of Medicine, Buffalo NY, 14203
| | - Jason M Davies
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY, 14203.,Department of Neurosurgery, University at Buffalo Jacobs School of Medicine, Buffalo NY, 14203
| | - Adnan H Siddiqui
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY, 14203.,Department of Neurosurgery, University at Buffalo Jacobs School of Medicine, Buffalo NY, 14203
| | - Ciprian N Ionita
- Department of Biomedical Engineering, University at Buffalo, Buffalo NY, 14260.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo NY, 14203.,Department of Medical Physics, University at Buffalo, Buffalo NY, 14260.,Department of Neurosurgery, University at Buffalo Jacobs School of Medicine, Buffalo NY, 14203
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45
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Rava RA, Snyder KV, Mokin M, Waqas M, Zhang X, Podgorsak AR, Allman AB, Senko J, Shiraz Bhurwani MM, Hoi Y, Davies JM, Levy EI, Siddiqui AH, Ionita CN. Assessment of computed tomography perfusion software in predicting spatial location and volume of infarct in acute ischemic stroke patients: a comparison of Sphere, Vitrea, and RAPID. J Neurointerv Surg 2021; 13:130-135. [PMID: 32457224 DOI: 10.1136/neurintsurg-2020-015966] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/23/2020] [Accepted: 04/25/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND CT perfusion (CTP) infarct and penumbra estimations determine the eligibility of patients with acute ischemic stroke (AIS) for endovascular intervention. This study aimed to determine volumetric and spatial agreement of predicted RAPID, Vitrea, and Sphere CTP infarct with follow-up fluid attenuation inversion recovery (FLAIR) MRI infarct. METHODS 108 consecutive patients with AIS and large vessel occlusion were included in the study between April 2019 and January 2020 . Patients were divided into two groups: endovascular intervention (n=58) and conservative treatment (n=50). Intervention patients were treated with mechanical thrombectomy and achieved successful reperfusion (Thrombolysis in Cerebral Infarction 2b/2 c/3) while patients in the conservative treatment group did not receive mechanical thrombectomy or intravenous thrombolysis. Intervention and conservative treatment patients were included to assess infarct and penumbra estimations, respectively. It was assumed that in all patients treated conservatively, penumbra converted to infarct. CTP infarct and penumbra volumes were segmented from RAPID, Vitrea, and Sphere to assess volumetric and spatial agreement with follow-up FLAIR MRI. RESULTS Mean infarct differences (95% CIs) between each CTP software and FLAIR MRI for each cohort were: intervention cohort: RAPID=9.0±7.7 mL, Sphere=-0.2±8.7 mL, Vitrea=-7.9±8.9 mL; conservative treatment cohort: RAPID=-31.9±21.6 mL, Sphere=-26.8±17.4 mL, Vitrea=-15.3±13.7 mL. Overlap and Dice coefficients for predicted infarct were (overlap, Dice): intervention cohort: RAPID=(0.57, 0.44), Sphere=(0.68, 0.60), Vitrea=(0.70, 0.60); conservative treatment cohort: RAPID=(0.71, 0.56), Sphere=(0.73, 0.60), Vitrea=(0.72, 0.64). CONCLUSIONS Sphere proved the most accurate in patients who had intervention infarct assessment as Vitrea and RAPID overestimated and underestimated infarct, respectively. Vitrea proved the most accurate in penumbra assessment for patients treated conservatively although all software overestimated penumbra.
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Affiliation(s)
- Ryan A Rava
- Biomedical Engineering, University at Buffalo-The State University of New York, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, Buffalo, New York, USA
| | - Kenneth V Snyder
- Canon Stroke and Vascular Research Center, Buffalo, New York, USA
- Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Maxim Mokin
- Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Muhammad Waqas
- Canon Stroke and Vascular Research Center, Buffalo, New York, USA
- Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Xiaoliang Zhang
- Biomedical Engineering, University at Buffalo-The State University of New York, Buffalo, New York, USA
| | - Alexander R Podgorsak
- Biomedical Engineering, University at Buffalo-The State University of New York, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, Buffalo, New York, USA
- Medical Physics, University at Buffalo - The State University of New York, Buffalo, New York, USA
| | - Ariana B Allman
- Biomedical Engineering, University at Buffalo-The State University of New York, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, Buffalo, New York, USA
| | - Jillian Senko
- Biomedical Engineering, University at Buffalo-The State University of New York, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, Buffalo, New York, USA
| | - Mohammad Mahdi Shiraz Bhurwani
- Biomedical Engineering, University at Buffalo-The State University of New York, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, Buffalo, New York, USA
| | - Yiemeng Hoi
- Canon Medical Systems USA Inc, Tustin, California, USA
| | - Jason M Davies
- Canon Stroke and Vascular Research Center, Buffalo, New York, USA
- Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Biomedical Informatics, University at Buffalo,The State University of New York, Buffalo, New York, USA
| | - Elad I Levy
- Canon Stroke and Vascular Research Center, Buffalo, New York, USA
- Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Canon Stroke and Vascular Research Center, Buffalo, New York, USA
- Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Ciprian N Ionita
- Biomedical Engineering, University at Buffalo-The State University of New York, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, Buffalo, New York, USA
- Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Medical Physics, University at Buffalo - The State University of New York, Buffalo, New York, USA
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Rava RA, Snyder KV, Mokin M, Waqas M, Podgorsak AR, Allman AB, Senko J, Bhurwani MMS, Hoi Y, Davies JM, Levy EI, Siddiqui AH, Ionita CN. Enhancing performance of a computed tomography perfusion software for improved prediction of final infarct volume in acute ischemic stroke patients. Neuroradiol J 2021; 34:222-237. [PMID: 33472519 DOI: 10.1177/1971400920988668] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Computed tomography perfusion (CTP) is crucial for acute ischemic stroke (AIS) patient diagnosis. To improve infarct prediction, enhanced image processing and automated parameter selection have been implemented in Vital Images' new CTP+ software. We compared CTP+ with its previous version, commercially available software (RAPID and Sphere), and follow-up diffusion-weighted imaging (DWI). Data from 191 AIS patients between March 2019 and January 2020 was retrospectively collected and allocated into endovascular intervention (n = 81) and conservative treatment (n = 110) cohorts. Intervention patients were treated for large vessel occlusion, underwent mechanical thrombectomy, and achieved successful reperfusion of thrombolysis in cerebral infarction 2b/2c/3. Conservative treatment patients suffered large or small vessel occlusion and did not receive intravenous thrombolysis or mechanical thrombectomy. Infarct and penumbra were assessed using intervention and conservative treatment patients, respectively. Infarct and penumbra volumes were segmented from CTP+ and compared with 24-h DWI along with RAPID, Sphere, and Vitrea. Mean infarct differences (95% confidence intervals) and Spearman correlation coefficients (SCCs) between DWI and each CTP software product for intervention patients are: CTP+ = (5.8 ± 5.9 ml, 0.62), RAPID = (10.0 ± 5.2 ml, 0.73), Sphere = (3.0 ± 6.0 ml, 0.56), Vitrea = (7.2 ± 4.9 ml, 0.66). For conservative treatment patients, mean infarct differences and SCCs are: CTP+ = (-8.0 ± 5.4 ml, 0.64), RAPID = (-25.6 ± 11.5 ml, 0.60), Sphere = (-25.6 ± 8.0 ml, 0.66), Vitrea = (1.3 ± 4.0 ml, 0.72). CTP+ performed similarly to RAPID and Sphere in addition to its semi-automated predecessor, Vitrea, when assessing intervention patient infarct volumes. For conservative treatment patients, CTP+ outperformed RAPID and Sphere in assessing penumbra. Semi-automated Vitrea remains the most accurate in assessing penumbra, but CTP+ provides an improved workflow from its predecessor.
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Affiliation(s)
- Ryan A Rava
- Department of Biomedical Engineering, University at Buffalo, USA.,Canon Stroke and Vascular Research Center, Buffalo, USA
| | - Kenneth V Snyder
- Canon Stroke and Vascular Research Center, Buffalo, USA.,Department of Neurosurgery, University at Buffalo, USA
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa, USA
| | - Muhammad Waqas
- Canon Stroke and Vascular Research Center, Buffalo, USA.,Department of Neurosurgery, University at Buffalo, USA
| | - Alexander R Podgorsak
- Department of Biomedical Engineering, University at Buffalo, USA.,Canon Stroke and Vascular Research Center, Buffalo, USA.,Department of Medical Physics, University at Buffalo, USA
| | - Ariana B Allman
- Department of Biomedical Engineering, University at Buffalo, USA.,Canon Stroke and Vascular Research Center, Buffalo, USA
| | - Jillian Senko
- Department of Biomedical Engineering, University at Buffalo, USA.,Canon Stroke and Vascular Research Center, Buffalo, USA
| | - Mohammad Mahdi Shiraz Bhurwani
- Department of Biomedical Engineering, University at Buffalo, USA.,Canon Stroke and Vascular Research Center, Buffalo, USA
| | | | - Jason M Davies
- Canon Stroke and Vascular Research Center, Buffalo, USA.,Department of Neurosurgery, University at Buffalo, USA.,Department of Bioinformatics, University at Buffalo, USA
| | - Elad I Levy
- Canon Stroke and Vascular Research Center, Buffalo, USA.,Department of Neurosurgery, University at Buffalo, USA
| | - Adnan H Siddiqui
- Canon Stroke and Vascular Research Center, Buffalo, USA.,Department of Neurosurgery, University at Buffalo, USA
| | - Ciprian N Ionita
- Department of Biomedical Engineering, University at Buffalo, USA.,Canon Stroke and Vascular Research Center, Buffalo, USA.,Department of Neurosurgery, University at Buffalo, USA.,Department of Medical Physics, University at Buffalo, USA
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Pérez-Pelegrí M, Biarnés C, Thió-Henestrosa S, Remollo S, Gimeno A, Cuba V, Teceño M, Martí-Navas M, Serena J, Pedraza S, Ruiz-Constantino JS, Puig J. Higher agreement in endovascular treatment decision-making than in parametric quantifications among automated CT perfusion software packages in acute ischemic stroke. JOURNAL OF X-RAY SCIENCE AND TECHNOLOGY 2021; 29:823-834. [PMID: 34334443 DOI: 10.3233/xst-210898] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND OBJECTIVE Estimates of parameters used to select patients for endovascular thrombectomy (EVT) for acute ischemic stroke differ among software packages for automated computed tomography (CT) perfusion analysis. To determine impact of these differences in decision making, we analyzed intra-observer and inter-observer agreement in recommendations about whether to perform EVT based on perfusion maps from 4 packages. METHODS Perfusion CT datasets from 63 consecutive patients with suspected acute ischemic stroke were retrospectively postprocessed with 4 packages of Minerva, RAPID, Olea, and IntelliSpace Portal (ISP). We used Pearson correlation coefficients and Bland-Altman analysis to compare volumes of infarct core, penumbra, and mismatch calculated by Minerva and RAPID. We used kappa analysis to assess agreement among decisions of 3 radiologists about whether to recommend EVT based on maps generated by 4 packages. RESULTS We found significant differences between using Minerva and RAPID to estimate penumbra (67.39±41.37mL vs. 78.35±45.38 mL, p < 0.001) and mismatch (48.41±32.03 vs. 61.27±32.73mL, p < 0.001), but not of infarct core (p = 0.230). Pearson correlation coefficients were 0.94 (95%CI:0.90-0.96) for infarct core, 0.87 (95%CI:0.79-0.91) for penumbra, and 0.72 (95%CI:0.57-0.83) for mismatch volumes (p < 0.001). Limits of agreements were (-21.22-25.02) for infarct core volumes, (-54.79-32.88) for penumbra volumes, and (-60.16-34.45) for mismatch volumes. Final agreement for EVT decision-making was substantial between Minerva vs. RAPID (k = 0.722), Minerva vs. Olea (k = 0.761), and RAPID vs. Olea (k = 0.782), but moderate for ISP vs. the other three. CONCLUSIONS Despite quantitative differences in estimates of infarct core, penumbra, and mismatch using 4 software packages, their impact on radiologists' decisions about EVT is relatively small.
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Affiliation(s)
| | - Carles Biarnés
- Diagnostic Imaging Institute (IDI), Department of Radiology, Girona Biomedical Research Institute, (IDIBGI), Dr Josep Trueta University Hospital, Girona, Spain
| | - Santiago Thió-Henestrosa
- Department of Computer Science, Applied Mathematics and Statistics, University of Girona, Girona, Spain
| | - Sebastià Remollo
- Department of Radiology, Germans Triasi Pujol University Hospital, Badalona, Spain
| | - Alfredo Gimeno
- Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Víctor Cuba
- Department of Radiology, Bellvitge University Hospital, Barcelona, Spain
| | - Mikel Teceño
- Department of Neurology-IDIBGI, Dr Josep Trueta University Hospital, Girona, Spain
| | - Marian Martí-Navas
- Diagnostic Imaging Institute (IDI), Department of Radiology, Girona Biomedical Research Institute, (IDIBGI), Dr Josep Trueta University Hospital, Girona, Spain
| | - Joaquín Serena
- Department of Neurology-IDIBGI, Dr Josep Trueta University Hospital, Girona, Spain
| | - Salvador Pedraza
- Diagnostic Imaging Institute (IDI), Department of Radiology, Girona Biomedical Research Institute, (IDIBGI), Dr Josep Trueta University Hospital, Girona, Spain
| | | | - Josep Puig
- Diagnostic Imaging Institute (IDI), Department of Radiology, Girona Biomedical Research Institute, (IDIBGI), Dr Josep Trueta University Hospital, Girona, Spain
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48
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Kuang H, Qiu W, Boers AM, Brown S, Muir K, Majoie CBLM, Dippel DWJ, White P, Epstein J, Mitchell PJ, Dávalos A, Bracard S, Campbell B, Saver JL, Jovin TG, Rubiera M, Khaw AV, Shankar JJ, Fainardi E, Hill MD, Demchuk AM, Goyal M, Menon BK. Computed Tomography Perfusion-Based Machine Learning Model Better Predicts Follow-Up Infarction in Patients With Acute Ischemic Stroke. Stroke 2020; 52:223-231. [PMID: 33280549 DOI: 10.1161/strokeaha.120.030092] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Prediction of infarct extent among patients with acute ischemic stroke using computed tomography perfusion is defined by predefined discrete computed tomography perfusion thresholds. Our objective is to develop a threshold-free computed tomography perfusion-based machine learning (ML) model to predict follow-up infarct in patients with acute ischemic stroke. METHODS Sixty-eight patients from the PRoveIT study (Measuring Collaterals With Multi-Phase CT Angiography in Patients With Ischemic Stroke) were used to derive a ML model using random forest to predict follow-up infarction voxel by voxel, and 137 patients from the HERMES study (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) were used to test the derived ML model. Average map, Tmax, cerebral blood flow, cerebral blood volume, and time variables including stroke onset-to-imaging and imaging-to-reperfusion time, were used as features to train the ML model. Spatial and volumetric agreement between the ML model predicted follow-up infarct and actual follow-up infarct were assessed. Relative cerebral blood flow <0.3 threshold using RAPID software and time-dependent Tmax thresholds were compared with the ML model. RESULTS In the test cohort (137 patients), median follow-up infarct volume predicted by the ML model was 30.9 mL (interquartile range, 16.4-54.3 mL), compared with a median 29.6 mL (interquartile range, 11.1-70.9 mL) of actual follow-up infarct volume. The Pearson correlation coefficient between 2 measurements was 0.80 (95% CI, 0.74-0.86, P<0.001) while the volumetric difference was -3.2 mL (interquartile range, -16.7 to 6.1 mL). Volumetric difference with the ML model was smaller versus the relative cerebral blood flow <0.3 threshold and the time-dependent Tmax threshold (P<0.001). CONCLUSIONS A ML using computed tomography perfusion data and time estimates follow-up infarction in patients with acute ischemic stroke better than current methods.
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Affiliation(s)
- Hulin Kuang
- Department of Clinical Neurosciences (H.K., W.Q., M.D.H., A.M.D., M.G., B.K.M.), University of Calgary
| | - Wu Qiu
- Department of Clinical Neurosciences (H.K., W.Q., M.D.H., A.M.D., M.G., B.K.M.), University of Calgary
| | - Anna M Boers
- Department of Biomedical Engineering and Physics (A.M.B.), Amsterdam University Medical Centre
| | - Scott Brown
- Altair Biostatistics, Mooresville, NC (S.B.)
| | - Keith Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital (K.M.)
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine (C.B.L.M.M.), Amsterdam University Medical Centre.,Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centre (C.B.L.M.M.)
| | | | - Phil White
- Institute of Neuroscience, Newcastle University (P.W.)
| | - Jonathan Epstein
- Centre Hospitalier Régional et Universitaire de Nancy, Université de Lorraine (J.E.)
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne (P.J.M.)
| | - Antoni Dávalos
- Department of Neuroscience, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona (A.D.)
| | - Serge Bracard
- IADI, Inserm, Université de Lorraine, CHRU-Nancy, France (S.B.).,Department of Diagnostic and Interventional Neuroradiology, Nancy, France (S.B.)
| | - Bruce Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne (B.C.)
| | - Jeffrey L Saver
- David Geffen School of Medicine, University of Los Angeles (J.L.S.)
| | | | - Marta Rubiera
- Department of Neurology, Hospital Vall d'Hebron, Ps. Vall d'Hebron, Barcelona, Spain (M.R.)
| | - Alexander V Khaw
- Department of Clinical Neurosciences, University of Western Ontario, London, Canada (A.V.K.)
| | - Jai J Shankar
- Department of Radiology, University of Manitoba, Winnipeg, Canada (J.J.S.)
| | - Enrico Fainardi
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Italy (E.F.)
| | - Michael D Hill
- Department of Clinical Neurosciences (H.K., W.Q., M.D.H., A.M.D., M.G., B.K.M.), University of Calgary.,Department of Radiology (M.D.H., A.M.D., M.G., B.K.M.), University of Calgary.,Hotchkiss Brain Institute (M.D.H., A.M.D., M.G., B.K.M.), University of Calgary
| | - Andrew M Demchuk
- Department of Clinical Neurosciences (H.K., W.Q., M.D.H., A.M.D., M.G., B.K.M.), University of Calgary.,Department of Radiology (M.D.H., A.M.D., M.G., B.K.M.), University of Calgary.,Hotchkiss Brain Institute (M.D.H., A.M.D., M.G., B.K.M.), University of Calgary
| | - Mayank Goyal
- Department of Clinical Neurosciences (H.K., W.Q., M.D.H., A.M.D., M.G., B.K.M.), University of Calgary.,Department of Radiology (M.D.H., A.M.D., M.G., B.K.M.), University of Calgary.,Hotchkiss Brain Institute (M.D.H., A.M.D., M.G., B.K.M.), University of Calgary
| | - Bijoy K Menon
- Department of Clinical Neurosciences (H.K., W.Q., M.D.H., A.M.D., M.G., B.K.M.), University of Calgary.,Department of Radiology (M.D.H., A.M.D., M.G., B.K.M.), University of Calgary.,Hotchkiss Brain Institute (M.D.H., A.M.D., M.G., B.K.M.), University of Calgary
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Xu QH, Li QY, Yu K, Ge QM, Shi WQ, Li B, Liang RB, Lin Q, Zhang YQ, Shao Y. Altered Brain Network Centrality in Patients with Diabetic Optic Neuropathy: A Resting-State FMRI Study. Endocr Pract 2020; 26:1399-1405. [PMID: 33471731 DOI: 10.4158/ep-2020-0045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 06/15/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Recent studies have suggested that diabetic optic neuropathy (DON) independently increases the incidence of brain diseases like cerebral infarction and hemorrhage. In this study, voxel-level degree centrality (DC) was used to study potential changes in functional network brain activity in DON patients. METHODS The study included 14 DON patients and 14 healthy controls (HCs) matched by age, sex, and weight. All subjects underwent resting functional magnetic resonance imaging. Receiver operating characteristic curves and Pearson correlation analysis were performed. RESULTS The DC values of the left frontal mid-orb and right middle frontal gyrus/right frontal sup were significantly lower in DON patients compared to HCs. The DC value of the left temporal lobe was also significantly higher than in HCs. CONCLUSION Three different brain regions show DC changes in DON patients, suggesting common optic neuropathy in the context of diabetes and providing new ideas for treating optic nerve disease in patients with long-term diabetes. ABBREVIATIONS AUC = area under the curve; BCVA = best corrected visual acuity; DC = degree centrality; DON = diabetic optic neuropathy; fMRI = functional magnetic resonance imaging; HC = healthy control; LFMO = left frontal mid orb; LTL = left temporal lobe; RFS = right frontal sup; RMFG = right middle frontal gyrus; ROC = receiver operating characteristic.
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Affiliation(s)
- Qian-Hui Xu
- From the (1)Department of Ophthalmology, The First Affiliated Hospital of Nanchang University, Jiangxi Province Ocular Disease Clinical Research Center, Nanchang, Jiangxi, People's Republic of China, and; The First Clinical Medical College, Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Qiu-Yu Li
- From the (1)Department of Ophthalmology, The First Affiliated Hospital of Nanchang University, Jiangxi Province Ocular Disease Clinical Research Center, Nanchang, Jiangxi, People's Republic of China, and
| | - Kang Yu
- From the (1)Department of Ophthalmology, The First Affiliated Hospital of Nanchang University, Jiangxi Province Ocular Disease Clinical Research Center, Nanchang, Jiangxi, People's Republic of China, and; The First Clinical Medical College, Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Qian-Ming Ge
- From the (1)Department of Ophthalmology, The First Affiliated Hospital of Nanchang University, Jiangxi Province Ocular Disease Clinical Research Center, Nanchang, Jiangxi, People's Republic of China, and
| | - Wen-Qing Shi
- From the (1)Department of Ophthalmology, The First Affiliated Hospital of Nanchang University, Jiangxi Province Ocular Disease Clinical Research Center, Nanchang, Jiangxi, People's Republic of China, and
| | - Biao Li
- From the (1)Department of Ophthalmology, The First Affiliated Hospital of Nanchang University, Jiangxi Province Ocular Disease Clinical Research Center, Nanchang, Jiangxi, People's Republic of China, and
| | - Rong-Bin Liang
- From the (1)Department of Ophthalmology, The First Affiliated Hospital of Nanchang University, Jiangxi Province Ocular Disease Clinical Research Center, Nanchang, Jiangxi, People's Republic of China, and
| | - Qi Lin
- From the (1)Department of Ophthalmology, The First Affiliated Hospital of Nanchang University, Jiangxi Province Ocular Disease Clinical Research Center, Nanchang, Jiangxi, People's Republic of China, and
| | - Yu-Qing Zhang
- From the (1)Department of Ophthalmology, The First Affiliated Hospital of Nanchang University, Jiangxi Province Ocular Disease Clinical Research Center, Nanchang, Jiangxi, People's Republic of China, and
| | - Yi Shao
- From the (1)Department of Ophthalmology, The First Affiliated Hospital of Nanchang University, Jiangxi Province Ocular Disease Clinical Research Center, Nanchang, Jiangxi, People's Republic of China, and.
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50
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Goyal M, Ospel JM, Menon B, Almekhlafi M, Jayaraman M, Fiehler J, Psychogios M, Chapot R, van der Lugt A, Liu J, Yang P, Agid R, Hacke W, Walker M, Fischer U, Asdaghi N, McTaggart R, Srivastava P, Nogueira RG, Moret J, Saver JL, Hill MD, Dippel D, Fisher M. Challenging the Ischemic Core Concept in Acute Ischemic Stroke Imaging. Stroke 2020; 51:3147-3155. [DOI: 10.1161/strokeaha.120.030620] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Endovascular treatment is a highly effective therapy for acute ischemic stroke due to large vessel occlusion and has recently revolutionized stroke care. Oftentimes, ischemic core extent on baseline imaging is used to determine endovascular treatment-eligibility. There are, however, 3 fundamental issues with the core concept: First, computed tomography and magnetic resonance imaging, which are mostly used in the acute stroke setting, are not able to precisely determine whether and to what extent brain tissue is infarcted (core) or still viable, due to variability in tissue vulnerability, the phenomenon of selective neuronal loss and lack of a reliable gold standard. Second, treatment decision-making in acute stroke is multifactorial, and as such, the relative importance of single variables, including imaging factors, is reduced. Third, there are often discrepancies between core volume and clinical outcome. This review will address the uncertainty in terminology and proposes a direction towards more clarity. This theoretical exercise needs empirical data that clarify the definitions further and prove its value.
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Affiliation(s)
- Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Canada. (M.G., J.M.O., B.M., M.A., M.D.H.)
- Department of Radiology, University of Calgary, Canada. (M.G., B.M., M.A., M.D.H.)
| | - Johanna M. Ospel
- Department of Clinical Neurosciences, University of Calgary, Canada. (M.G., J.M.O., B.M., M.A., M.D.H.)
- Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Switzerland (J.M.O., M.P.)
| | - Bijoy Menon
- Department of Clinical Neurosciences, University of Calgary, Canada. (M.G., J.M.O., B.M., M.A., M.D.H.)
- Department of Radiology, University of Calgary, Canada. (M.G., B.M., M.A., M.D.H.)
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, University of Calgary, Canada. (M.G., J.M.O., B.M., M.A., M.D.H.)
- Department of Radiology, University of Calgary, Canada. (M.G., B.M., M.A., M.D.H.)
| | - Mahesh Jayaraman
- Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (M.J., R.M.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (J.F.)
| | - Marios Psychogios
- Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Switzerland (J.M.O., M.P.)
| | - Rene Chapot
- Department of Neuroradiology, Alfred Krupp Krankenhaus, Essen, Germany (R.C.)
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, the Netherlands (A.v.d.L.)
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China (J.L.)
| | - Pengfei Yang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China (P.Y.)
| | - Ronit Agid
- Department of Medical Imaging, University of Toronto, Canada (R.A.)
| | - Werner Hacke
- Department of Neurology, University Hospital Heidelberg, Germany (W.H.)
| | - Melanie Walker
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle (M.W.)
| | - Urs Fischer
- Department of Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Switzerland (U.F.)
| | - Negar Asdaghi
- Department of Neurology, University of Miami Miller School of Medicine (N.A.)
| | - Ryan McTaggart
- Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI (M.J., R.M.)
| | - Padma Srivastava
- Department of Neurology, All India Institute of Medicine, New Delhi, India (P.S.)
| | - Raul G. Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta (R.G.N.)
| | - Jacques Moret
- The Brain Vascular Center, Baujon University Hospital, Paris, France (J.M.)
| | - Jeffrey L. Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Michael D. Hill
- Department of Clinical Neurosciences, University of Calgary, Canada. (M.G., J.M.O., B.M., M.A., M.D.H.)
- Department of Radiology, University of Calgary, Canada. (M.G., B.M., M.A., M.D.H.)
| | - Diederik Dippel
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands (D.D.)
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (M.F.)
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