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Feiger B, Jensen CW, Bryner BS, Segars WP, Randles A. Modeling the effect of patient size on cerebral perfusion during veno-arterial extracorporeal membrane oxygenation. Perfusion 2024; 39:1295-1303. [PMID: 37395266 PMCID: PMC10786318 DOI: 10.1177/02676591231187962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
INTRODUCTION A well-known complication of veno-arterial extracorporeal membrane oxygenation (VA ECMO) is differential hypoxia, in which poorly-oxygenated blood ejected from the left ventricle mixes with and displaces well-oxygenated blood from the circuit, thereby causing cerebral hypoxia and ischemia. We sought to characterize the impact of patient size and anatomy on cerebral perfusion under a range of different VA ECMO flow conditions. METHODS We use one-dimensional (1D) flow simulations to investigate mixing zone location and cerebral perfusion across 10 different levels of VA ECMO support in eight semi-idealized patient geometries, for a total of 80 scenarios. Measured outcomes included mixing zone location and cerebral blood flow (CBF). RESULTS Depending on patient anatomy, we found that a VA ECMO support ranging between 67-97% of a patient's ideal cardiac output was needed to perfuse the brain. In some cases, VA ECMO flows exceeding 90% of the patient's ideal cardiac output are needed for adequate cerebral perfusion. CONCLUSIONS Individual patient anatomy markedly affects mixing zone location and cerebral perfusion in VA ECMO. Future fluid simulations of VA ECMO physiology should incorporate varied patient sizes and geometries in order to best provide insights toward reducing neurologic injury and improved outcomes in this patient population.
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Affiliation(s)
- Bradley Feiger
- Department of Bioengineering, School of Medicine, Duke University, Durham, NC, USA
| | - Christopher W Jensen
- Department of Bioengineering, School of Medicine, Duke University, Durham, NC, USA
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, NC, USA
| | - Benjamin S Bryner
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, NC, USA
| | - William P Segars
- Department of Radiology, School of Medicine, Duke Medicine, Chicago, IL, USA
| | - Amanda Randles
- Department of Bioengineering, School of Medicine, Duke University, Durham, NC, USA
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2
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Nguyen TN, Abdalkader M, Fischer U, Qiu Z, Nagel S, Chen HS, Miao Z, Khatri P. Endovascular management of acute stroke. Lancet 2024; 404:1265-1278. [PMID: 39341645 DOI: 10.1016/s0140-6736(24)01410-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 03/30/2024] [Accepted: 07/04/2024] [Indexed: 10/01/2024]
Abstract
Stroke related to large vessel occlusion is a leading cause of disability and death worldwide. Advances in endovascular therapy to reopen occluded arteries have been shown to reduce patient disability and mortality. Expanded indications to treat patients with large vessel occlusion in the late window (>6 h from symptom onset), with basilar artery occlusion, and with large ischaemic core at presentation have enabled treatment of more patients with simplified imaging methods. Ongoing knowledge gaps include an understanding of which patients with large ischaemic infarct are more likely to benefit from endovascular therapy, the role of endovascular therapy in patients who present with low National Institutes of Health Stroke Scale scores or medium or distal vessel occlusion, and optimal management of patients with underlying intracranial atherosclerotic disease. As reperfusion can now be facilitated by intravenous thrombolysis, mechanical thrombectomy, or both, the development of cytoprotective or adjunctive drugs to slow infarct growth, enhance reperfusion, or decrease haemorrhagic risk has gained renewed interest with the hope to improve patient outcomes.
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Affiliation(s)
- Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA; Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA.
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Bern, Switzerland
| | - Zhongming Qiu
- Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China
| | - Simon Nagel
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen, Germany; Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Pooja Khatri
- Department of Neurology and Rehabilitation, University of Cincinnati, Cincinnati, OH, USA
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3
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Luo L, Liu P, Ye W, Chen F, Liu Y, Liu Z, Jing J, Xiong Y, Zhu W, Jiang Y, Cheng J, Wang Y, Liu T. CT perfusion parameter estimation in stroke using neural network with transformer and physical model priors. Comput Biol Med 2024; 182:109134. [PMID: 39278163 DOI: 10.1016/j.compbiomed.2024.109134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 07/23/2024] [Accepted: 09/07/2024] [Indexed: 09/17/2024]
Abstract
OBJECTIVES CT perfusion (CTP) imaging is vital in treating acute ischemic stroke by identifying salvageable tissue and the infarcted core. CTP images allow quantitative estimation of CT perfusion parameters, which can provide information on the degree of tissue hypoperfusion and its salvage potential. Traditional methods for estimating perfusion parameters, such as singular value decomposition (SVD) and its variations, are known to be sensitive to noise and inaccuracies in the arterial input function. To our knowledge, there has been no implementation of deep learning methods for CT perfusion parameter estimation. MATERIALS & METHODS In this work, we propose a deep learning method based on the Transformer model, named CTPerformer-Net, for CT perfusion parameter estimation. In addition, our method incorporates some physical priors. We integrate physical consistency prior, smoothness prior and the physical model prior through the design of the loss function. We also generate a simulation dataset based on physical model prior for training the network model. RESULTS In the simulation dataset, CTPerformer-Net exhibits a 23.4 % increase in correlation coefficients, a 95.2 % decrease in system error, and a 90.7 % reduction in random error when contrasted with block-circulant SVD. CTPerformer-Net successfully identifies hypoperfused and infarcted lesions in 103 real CTP images from the ISLES 2018 challenge dataset. It achieves a mean dice score of 0.36 for the infarct core segmentation, which is slightly higher than the commercially available software (dice coefficient: 0.34) used as a reference level by the challenge. CONCLUSION Experimental results on the simulation dataset demonstrate that CTPerformer-Net achieves better performance compared to block-circulant SVD. The real-world patient dataset confirms the validity of CTPerformer-Net.
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Affiliation(s)
- Luyao Luo
- Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Pan Liu
- Medical Big Data Research Center, Chinese PLA General Hospital, Beijing, China
| | - Wanxing Ye
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Fengwei Chen
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yu Liu
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ziyang Liu
- Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Jing Jing
- China National Clinical Research Center for Neurological Diseases, Beijing, China; Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yunyun Xiong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wanlin Zhu
- China National Clinical Research Center for Neurological Diseases, Beijing, China; Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing, China; Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian Cheng
- School of Computer Science and Engineering, Beihang University, Beijing, China
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China; Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tao Liu
- Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China.
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4
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Salim HA, Huang S, Lakhani DA, Mei J, Balar A, Musmar B, Adeeb N, Hoseinyazdi M, Luna L, Deng F, Hyson NZ, Bahouth M, Dmytriw AA, Guenego A, Albers's GW, Lu H, Urrutia VC, Nael K, Marsh EB, Hillis AE, Llinas R, Wintermark M, Heit JJ, Faizy TD, Yedavalli V. Perfusion imaging predicts short-term clinical outcome in isolated posterior cerebral artery occlusion stroke. J Neuroimaging 2024. [PMID: 39223766 DOI: 10.1111/jon.13235] [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: 07/18/2024] [Revised: 08/21/2024] [Accepted: 08/22/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND AND PURPOSE Ischemic strokes due to isolated posterior cerebral artery (PCA) occlusions represent 5% of all strokes but have significant impacts on patients' quality of life, primarily due to visual deficits and thalamic involvement. Current guidelines for acute PCA occlusion management are sparse, and the prognostic value of perfusion imaging parameters remains underexplored. METHODS We conducted a retrospective analysis of 32 patients with isolated PCA occlusions treated at Johns Hopkins Medical Institutions between January 2017 and March 2023. Patients underwent pretreatment perfusion imaging, with perfusion parameters analyzed using RAPID software. The primary outcome was short-term clinical outcome as measured by the National Institutes of Health Stroke Scale (NIHSS) at discharge. RESULTS The median age of the cohort was 70 years, with 34% female and 66% male. Significant correlations were found between NIHSS at discharge and various perfusion parameters, including time-to-maximum (Tmax) >6 seconds (ρ = .55, p = .004), Tmax >8 seconds (ρ = .59, p = .002), Tmax >10 seconds (ρ = .6, p = .001), mismatch volume (ρ = .51, p = .008), and cerebral blood volume (CBV) < 34% (ρ = .59, p = .002). CONCLUSIONS Tmax and CBV volumes significantly correlated with discharge NIHSS with marginal superiority of Tmax >10 seconds and CBV <42% volumes. These findings suggest that CT and MR perfusion imaging can play a crucial role in the acute management of PCA strokes, though larger, standardized studies are needed to validate these results and refine imaging thresholds specific to posterior circulation infarcts.
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Affiliation(s)
- Hamza Adel Salim
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Shenwen Huang
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Dhairya A Lakhani
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Janet Mei
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Aneri Balar
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Basel Musmar
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Baton Rouge, Louisiana, USA
| | - Nimer Adeeb
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Baton Rouge, Louisiana, USA
| | - Meisam Hoseinyazdi
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Licia Luna
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Francis Deng
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Nathan Z Hyson
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Mona Bahouth
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Adrien Guenego
- Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Gregory W Albers's
- Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, California, USA
| | - Hanzhang Lu
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Victor C Urrutia
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Kambiz Nael
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Elisabeth B Marsh
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Argye E Hillis
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Raf Llinas
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson Medical Center, Houston, Texas, USA
| | - Jeremy J Heit
- Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, California, USA
| | - Tobias D Faizy
- Department of Radiology, Neuroendovascular Program, Münster University Medical Center, Münster, Germany
| | - Vivek Yedavalli
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
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Mujanovic A, Imhof A, Zheng S, Piechowiak EI, Serrallach BL, Meinel TR, Dobrocky T, Aziz YN, Seiffge DJ, Goeldlin M, Arnold M, Hakim A, Wiest R, Gralla J, Mistry EA, Fischer U, Wegener S, Kaesmacher J. Perfusion Abnormalities on 24-Hour Perfusion Imaging in Patients With Complete Endovascular Reperfusion. Stroke 2024; 55:2315-2324. [PMID: 39145382 PMCID: PMC11346709 DOI: 10.1161/strokeaha.124.047441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 07/11/2024] [Accepted: 07/19/2024] [Indexed: 08/16/2024]
Abstract
BACKGROUND Perfusion abnormalities in the infarct and salvaged penumbra have been proposed as a potential reason for poor clinical outcome (modified Rankin Scale score >2) despite complete angiographic reperfusion (Thrombolysis in Cerebral Infarction [TICI3]). In this study, we aimed to identify different microvascular perfusion patterns and their association with clinical outcomes among TICI3 patients. METHODS University Hospital Bern's stroke registry of all patients between February 2015 and December 2021. Macrovascular reperfusion was graded using the TICI scale. Microvascular reperfusion status was evaluated within the infarct area on cerebral blood volume and cerebral blood flow perfusion maps obtained 24-hour postintervention. Primary outcome was functional independence (90-day modified Rankin Scale score 0-2) evaluated with the logistic regression analysis adjusted for age, sex, and 24-hour infarct volume from follow-up imaging. RESULTS Based on microvascular perfusion findings, the entire cohort (N=248) was stratified into one of the 4 clusters: (1) normoperfusion (no perfusion abnormalities; n=143/248); (2) hyperperfusion (hyperperfusion on both cerebral blood volume and cerebral blood flow; n=54/248); (3) hypoperfusion (hypoperfusion on both cerebral blood volume and cerebral blood flow; n=14/248); and (4) mixed (discrepant findings, eg, cerebral blood volume hypoperfusion and cerebral blood flow hyperperfusion; n=37/248). Compared with the normoperfusion cluster, patients in the hypoperfusion cluster were less likely to achieve functional independence (adjusted odds ratio, 0.3 [95% CI, 0.1-0.9]), while patients in the hyperperfusion cluster tended to have better outcomes (adjusted odds ratio, 3.3 [95% CI, 1.3-8.8]). CONCLUSIONS In around half of TICI3 patients, perfusion abnormalities on the microvascular level can be observed. Microvascular hypoperfusion, despite complete macrovascular reperfusion, is rare but may explain the poor clinical course among some TICI3 patients, while a detrimental effect of hyperperfusion after reperfusion could not be confirmed.
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Affiliation(s)
- Adnan Mujanovic
- Department of Diagnostic and Interventional Neuroradiology (A.M., A.I., S.Z., E.I.P., B.L.S., T.D., A.H., R.W., J.G., J.K.), University of Bern, Switzerland
- Graduate School for Health Sciences (A.M.), University of Bern, Switzerland
| | - Anick Imhof
- Department of Diagnostic and Interventional Neuroradiology (A.M., A.I., S.Z., E.I.P., B.L.S., T.D., A.H., R.W., J.G., J.K.), University of Bern, Switzerland
| | - Shaokai Zheng
- Department of Diagnostic and Interventional Neuroradiology (A.M., A.I., S.Z., E.I.P., B.L.S., T.D., A.H., R.W., J.G., J.K.), University of Bern, Switzerland
- ARTORG Center for Biomedical Engineering Research (S.Z.), University of Bern, Switzerland
| | - Eike I. Piechowiak
- Department of Diagnostic and Interventional Neuroradiology (A.M., A.I., S.Z., E.I.P., B.L.S., T.D., A.H., R.W., J.G., J.K.), University of Bern, Switzerland
| | - Bettina L. Serrallach
- Department of Diagnostic and Interventional Neuroradiology (A.M., A.I., S.Z., E.I.P., B.L.S., T.D., A.H., R.W., J.G., J.K.), University of Bern, Switzerland
| | - Thomas R. Meinel
- Department of Neurology, University Hospital Bern, Inselspital (T.R.M., D.J.S., M.G., M.A., U.F.), University of Bern, Switzerland
| | - Tomas Dobrocky
- Department of Diagnostic and Interventional Neuroradiology (A.M., A.I., S.Z., E.I.P., B.L.S., T.D., A.H., R.W., J.G., J.K.), University of Bern, Switzerland
| | - Yasmin N. Aziz
- Department of Neurology, UC Medical Center, University of Cincinnati, Ohio (Y.N.A., E.A.M.)
| | - David J. Seiffge
- Department of Neurology, University Hospital Bern, Inselspital (T.R.M., D.J.S., M.G., M.A., U.F.), University of Bern, Switzerland
| | - Martina Goeldlin
- Department of Neurology, University Hospital Bern, Inselspital (T.R.M., D.J.S., M.G., M.A., U.F.), University of Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern, Inselspital (T.R.M., D.J.S., M.G., M.A., U.F.), University of Bern, Switzerland
| | - Arsany Hakim
- Department of Diagnostic and Interventional Neuroradiology (A.M., A.I., S.Z., E.I.P., B.L.S., T.D., A.H., R.W., J.G., J.K.), University of Bern, Switzerland
| | - Roland Wiest
- Department of Diagnostic and Interventional Neuroradiology (A.M., A.I., S.Z., E.I.P., B.L.S., T.D., A.H., R.W., J.G., J.K.), University of Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology (A.M., A.I., S.Z., E.I.P., B.L.S., T.D., A.H., R.W., J.G., J.K.), University of Bern, Switzerland
| | - Eva A. Mistry
- Department of Neurology, UC Medical Center, University of Cincinnati, Ohio (Y.N.A., E.A.M.)
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Inselspital (T.R.M., D.J.S., M.G., M.A., U.F.), University of Bern, Switzerland
- Department of Neurology, University Hospital Basel, University of Basel, Switzerland (U.F.)
| | - Susanne Wegener
- Department of Neurology, University Hospital Zürich, University of Zürich, Switzerland (S.W.)
| | - Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology (A.M., A.I., S.Z., E.I.P., B.L.S., T.D., A.H., R.W., J.G., J.K.), University of Bern, Switzerland
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6
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Hamam O, Gudenkauf J, Moustafa R, Cho A, Montes D, Sharara M, Moustafa A, Radmard M, Nabi M, Chen K, Sepehri S, Shin C, Mazumdar I, Kim M, Mohseni A, Malhotra A, Romero J, Yedavalli V. Hypoperfusion Intensity Ratio as an Indirect Imaging Surrogate in Patients With Anterior Circulation Large-Vessel Occlusion and Association of Baseline Characteristics With Poor Collateral Status. J Am Heart Assoc 2024; 13:e030897. [PMID: 39158547 DOI: 10.1161/jaha.123.030897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 11/15/2023] [Indexed: 08/20/2024]
Abstract
BACKGROUND Collateral status (CS) plays a crucial role in infarct growth rate, risk of postthrombectomy hemorrhage, and overall clinical outcomes in patients with acute ischemic stroke (AIS) secondary to anterior circulation large-vessel occlusions (LVOs). Hypoperfusion intensity ratio has been previously validated as an indirect noninvasive pretreatment imaging biomarker of CS. In addition to imaging, derangements in admission laboratory findings can also influence outcomes in patients with AIS-LVO. Therefore, our study aims to assess the relationship between admission laboratory findings, baseline characteristics, and CS, as assessed by hypoperfusion intensity ratio in patients with AIS-LVO. METHODS AND RESULTS In this retrospective study, consecutive patients presenting with AIS secondary to anterior circulation LVO who underwent pretreatment computed tomography perfusion were included. The computed tomography perfusion data processed by RAPID (Ischema View, Menlo Park, CA) generated the hypoperfusion intensity ratio. Binary logistic regression models were used to assess the relationship between patients' baseline characteristics, admission laboratory findings, and poor CS. A total of 221 consecutive patients with AIS-LVO between January 2017 and September 2022 were included in our study (mean±SD age, 67.0±15.8 years; 119 men [53.8%]). Multivariable logistic regression showed that patients with AIS caused by cardioembolic and cryptogenic causes (adjusted odds ratio [OR], 2.67; 95% CI, 1.20-5.97; P=0.016), those who presented with admission National Institutes of Health Stroke Scale score ≥12 (adjusted OR, 3.12; 95% CI, 1.61-6.04; P=0.001), and male patients (adjusted OR, 2.06; 95% CI, 1.13-3.77; P=0.018) were associated with poor CS. CONCLUSIONS Stroke caused by cardioembolic or cryptogenic causes, admission National Institutes of Health Stroke Scale score of ≥12, and male sex were associated with poor CS, as defined by hypoperfusion intensity ratio in the patients with AIS-LVO.
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Affiliation(s)
- Omar Hamam
- Department of Radiology, Massachusetts General Hospital Harvard Medical School Boston MA
| | - Julie Gudenkauf
- Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD
| | - Rawan Moustafa
- Department of Cardiovascular Medicine Robert Wood Johnson Medical School New Brunswick NJ
- School of Arts and Sciences Rutgers University-Newark Newark NJ
| | - Andrew Cho
- Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD
| | - Daniel Montes
- Radiology Resident University of Colorado, Anschutz Medical Campus Aurora CO
| | | | - Abdallah Moustafa
- Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD
| | - Mahla Radmard
- Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD
| | - Mehreen Nabi
- Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD
| | - Kevin Chen
- Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD
| | - Sadra Sepehri
- Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD
| | | | - Ishan Mazumdar
- Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD
| | - Minsoo Kim
- Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD
| | - Alireza Mohseni
- Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD
| | | | - Javier Romero
- Department of Radiology, Massachusetts General Hospital Harvard Medical School Boston MA
| | - Vivek Yedavalli
- Department of Radiology and Radiological Science Johns Hopkins University School of Medicine Baltimore MD
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7
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Robbe MMQ, Pinckaers FME, van Kuijk SMJ, van Oostenbrugge RJ, van Zwam WH, Postma AA. Post-endovascular therapy contrast extravasation in the mesial temporal region on dual-energy CT is associated with outcome in acute ischemic stroke patients. J Stroke Cerebrovasc Dis 2024; 33:107949. [PMID: 39159900 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 08/07/2024] [Accepted: 08/14/2024] [Indexed: 08/21/2024] Open
Abstract
PURPOSE Pre- and post-endovascular treatment (EVT) imaging may aid in predicting functional outcomes in acute middle cerebral artery (MCA) ischemic stroke. Low post-EVT contrast extravasation (CE)-ASPECTS is associated with poor functional outcomes. Besides the MCA regions included in the ASPECTS score, CE may be seen in the mesial temporal (MT) region. In this study, we investigated the frequency and prognostic implication of MT-CE in acute ischemic stroke patients. METHODS Patients with an acute ischemic stroke due to anterior large vessel occlusion who received EVT and post-EVT DECT between 2010 and 2019 were included. Iodine overlay maps of DECT were assessed for the occurrence of CE, using the ASPECTS for occurrence in the MCA region and, calculating a CE-ASPECTS, for whether the MT region was involved. Multivariable linear and logistic regression were used to assess the relationship between involvement of MT-CE and 24-48h NIHSS, mRS, and mortality on a multiple imputed dataset. All models were adjusted significant variables in univariate analyses and for total CE-ASPECTS. RESULTS 501/651 patients met the inclusion criteria. MT-CE occurred in 97 (19 %) patients, and was more often present in patients with internal carotid artery occlusions. MT-CE was associated with higher NIHSS scores at 24-hours (aβ 2.2, 95 % CI 0.09-4.31), with increased risk of higher mRS scores (acOR 1.88, 95 % CI 1.16-3.06), and with increased risk of mortality (aOR 2.12, 95 % CI 1.16-3.86). CONCLUSION MT-CE is a common finding on post-EVT DECT and is an independent predictor for worse functional outcomes.
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Affiliation(s)
- M M Q Robbe
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands.
| | - F M E Pinckaers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - S M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, The Netherlands
| | - R J van Oostenbrugge
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands; Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - W H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - A A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands; School for Mental Health and Neuroscience (MHeNs), University Maastricht, Maastricht, The Netherlands
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Hidayat R, Ulwanda RS, Irfannadhira AC, Rachmawati EZK, Pangeran D, Yunus RE, Mesiano T, Kurniawan M, Rasyid A, Harris S. Obstructive sleep apnea exaggeration as predictor of poor outcome post thrombolytic stroke. Radiol Case Rep 2024; 19:3324-3328. [PMID: 38860268 PMCID: PMC11163142 DOI: 10.1016/j.radcr.2024.04.069] [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: 12/12/2023] [Revised: 04/19/2024] [Accepted: 04/23/2024] [Indexed: 06/12/2024] Open
Abstract
Obstructive sleep apnea (OSA) is a common sleep disordered breathing in stroke patients. This case report aimed to show the presence of OSA in stroke can contribute to the increasing chance of mortality and morbidity. We presented a case of first-time stroke in a 64-year-old female with a history of pre-stroke OSA. She underwent intravenous thrombolysis as main therapy within the time limit under 4.5 hours since the stroke onset. She had prolonged hospital stay due to complications from OSA, even though she only had a small ischemic core (9 mL) in follow-up radiological imaging and was discharged with a greater National Institutes of Health Stroke Scale (NIHSS) score than admission (5 to 10). OSA can be one of warning signs for poor prognosis in stroke patients. Understanding the presence of OSA not only can be beneficial toward choosing the next steps of therapy, but also important for the rehabilitation and recovery period of stroke patients.
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Affiliation(s)
- Rakhmad Hidayat
- Faculty of Medicine Universitas Indonesia, Indonesia
- Dr. Cipto Mangunkusumo Hospital, Indonesia
| | | | | | | | | | - Reyhan Eddy Yunus
- Faculty of Medicine Universitas Indonesia, Indonesia
- Dr. Cipto Mangunkusumo Hospital, Indonesia
| | - Taufik Mesiano
- Faculty of Medicine Universitas Indonesia, Indonesia
- Dr. Cipto Mangunkusumo Hospital, Indonesia
| | - Mohammad Kurniawan
- Faculty of Medicine Universitas Indonesia, Indonesia
- Dr. Cipto Mangunkusumo Hospital, Indonesia
| | - Al Rasyid
- Faculty of Medicine Universitas Indonesia, Indonesia
- Dr. Cipto Mangunkusumo Hospital, Indonesia
| | - Salim Harris
- Faculty of Medicine Universitas Indonesia, Indonesia
- Dr. Cipto Mangunkusumo Hospital, Indonesia
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9
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Chen L, Bian G, Zhu X, Duan X, Meng Y, Li L. Importance of computed tomography perfusion on assessing collateral circulation and prognosis of patients with acute anterior circulation large vessel occlusion after endovascular therapy. SLAS Technol 2024; 29:100139. [PMID: 38734181 DOI: 10.1016/j.slast.2024.100139] [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: 01/24/2024] [Revised: 04/11/2024] [Accepted: 05/03/2024] [Indexed: 05/13/2024]
Abstract
This study probed the importance of computed tomography perfusion (CTP) on assessing collateral circulation and prognosis in patients with acute anterior circulation large vessel occlusion (AAC-LVO) after endovascular therapy (EVT). Retrospective analysis was performed on the case data of 124 AAC-LVO patients who achieved EVT in the First People's Hospital of Lianyungang. All patients received computed tomography (CT) examination. Based on the multi-phase computed tomography angiography (mCTA) score, patients were separated into poor collateral circulation group and good collateral circulation group. Based on modified Rankin scale (mRS) score, patients were separated into good prognosis group and poor prognosis group. The receiver operating characteristic (ROC) curve was used to measure the efficacy of CTP parameters in predicting good collateral circulation or good prognosis. Correlation between CTP parameters with mCTA collateral and 90-day mRS circulation score was analyzed using the Spearman correlation analysis. The age and admission national Institutes of Health stroke scale (NIHSS) scores of the good collateral circulation group were lower than the poor collateral circulation group, and low perfusion area volume with Tmax > 6 s (VTmax>6 s), infarct core area volume (VCBF<30 %)and hypoperfusion intensity ratio (HIR) were also lower. The mCTA collateral cycle score was negatively related to VTmax>6s, VCBF<30 % and HIR. The area under the curve (AUC) values of VTmax>6s and VCBF<30 % and HIR for predicting good collateral circulation were 0.763, 0.884 and 0.842, respectively, which suggested that perfusion parameters VTmax>6s, VCBF<30 % and HIR could effectively indicate the status of patients' collateral circulation. Relative to the poor prognosis group, patients in the good prognosis group possessed lower admission NIHSS score, younger age, smaller final infarct volume, lower HIR, VCBF<30 %, VTmax>6 s, Alberta Stroke Program Early CT(ASPECT) score, and higher mCTA score. Spearman correlation analysis unveiled that ASPECT score, mCTA score and 90-day mRS were negatively correlated. The final infarct volume, perfusion parameters HIR and VCBF<30 % were positively correlated with 90-day mRS. ROC analysis showed that all variates had good prognostic value for acute anterior circulation great vessel occlusion patients, while VCBF<30 % and HIR had high diagnostic value for prognosis. To sum up, CTP can provide a comprehensive imaging assessment of the collateral circulation of patients with AAC-LVO and has a higher predictive value for the prognosis assessment of patients with EVT in terms of VCBF<30 %, HIR score and mCTA collateral circulation score.
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Affiliation(s)
- Lei Chen
- Department of Medical Imaging, The First Affiliated Hospital of Kangda College of Nanjing Medical University/The First People's Hospital of Lianyungang, Lianyungang, Jiangsu 222000, China
| | - Guangjun Bian
- Department of Medical Imaging, The First Affiliated Hospital of Kangda College of Nanjing Medical University/The First People's Hospital of Lianyungang, Lianyungang, Jiangsu 222000, China
| | - Xiufang Zhu
- Department of Medical Imaging, The First Affiliated Hospital of Kangda College of Nanjing Medical University/The First People's Hospital of Lianyungang, Lianyungang, Jiangsu 222000, China
| | - Xinxiu Duan
- Department of Medical Imaging, The First Affiliated Hospital of Kangda College of Nanjing Medical University/The First People's Hospital of Lianyungang, Lianyungang, Jiangsu 222000, China
| | - Yue Meng
- Department of Medical Imaging, The First Affiliated Hospital of Kangda College of Nanjing Medical University/The First People's Hospital of Lianyungang, Lianyungang, Jiangsu 222000, China
| | - Lei Li
- Department of Medical Imaging, The First Affiliated Hospital of Kangda College of Nanjing Medical University/The First People's Hospital of Lianyungang, Lianyungang, Jiangsu 222000, China.
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10
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Chen Q, Zhang S, Liu W, Sun X, Luo Y, Sun X. Application of emerging technologies in ischemic stroke: from clinical study to basic research. Front Neurol 2024; 15:1400469. [PMID: 38915803 PMCID: PMC11194379 DOI: 10.3389/fneur.2024.1400469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 05/24/2024] [Indexed: 06/26/2024] Open
Abstract
Stroke is a primary cause of noncommunicable disease-related death and disability worldwide. The most common form, ischemic stroke, is increasing in incidence resulting in a significant burden on patients and society. Urgent action is thus needed to address preventable risk factors and improve treatment methods. This review examines emerging technologies used in the management of ischemic stroke, including neuroimaging, regenerative medicine, biology, and nanomedicine, highlighting their benefits, clinical applications, and limitations. Additionally, we suggest strategies for technological development for the prevention, diagnosis, and treatment of ischemic stroke.
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Affiliation(s)
- Qiuyan Chen
- Institute of Medicinal Plant Development, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Beijing Key Laboratory of Innovative Drug Discovery of Traditional Chinese Medicine (Natural Medicine) and Translational Medicine, Beijing, China
- Key Laboratory of Bioactive Substances and Resource Utilization of Chinese Herbal Medicine, Ministry of Education, Beijing, China
| | - Shuxia Zhang
- Institute of Medicinal Plant Development, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Beijing Key Laboratory of Innovative Drug Discovery of Traditional Chinese Medicine (Natural Medicine) and Translational Medicine, Beijing, China
- Key Laboratory of Bioactive Substances and Resource Utilization of Chinese Herbal Medicine, Ministry of Education, Beijing, China
| | - Wenxiu Liu
- Institute of Medicinal Plant Development, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Beijing Key Laboratory of Innovative Drug Discovery of Traditional Chinese Medicine (Natural Medicine) and Translational Medicine, Beijing, China
- Key Laboratory of Bioactive Substances and Resource Utilization of Chinese Herbal Medicine, Ministry of Education, Beijing, China
| | - Xiao Sun
- Institute of Medicinal Plant Development, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Beijing Key Laboratory of Innovative Drug Discovery of Traditional Chinese Medicine (Natural Medicine) and Translational Medicine, Beijing, China
- Key Laboratory of Bioactive Substances and Resource Utilization of Chinese Herbal Medicine, Ministry of Education, Beijing, China
| | - Yun Luo
- Institute of Medicinal Plant Development, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Beijing Key Laboratory of Innovative Drug Discovery of Traditional Chinese Medicine (Natural Medicine) and Translational Medicine, Beijing, China
- Key Laboratory of Bioactive Substances and Resource Utilization of Chinese Herbal Medicine, Ministry of Education, Beijing, China
| | - Xiaobo Sun
- Institute of Medicinal Plant Development, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Beijing Key Laboratory of Innovative Drug Discovery of Traditional Chinese Medicine (Natural Medicine) and Translational Medicine, Beijing, China
- Key Laboratory of Bioactive Substances and Resource Utilization of Chinese Herbal Medicine, Ministry of Education, Beijing, China
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11
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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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12
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Gutierrez A, Amador K, Winder A, Wilms M, Fiehler J, Forkert ND. Annotation-free prediction of treatment-specific tissue outcome from 4D CT perfusion imaging in acute ischemic stroke. Comput Med Imaging Graph 2024; 114:102376. [PMID: 38537536 DOI: 10.1016/j.compmedimag.2024.102376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 01/31/2024] [Accepted: 03/21/2024] [Indexed: 04/01/2024]
Abstract
Acute ischemic stroke is a critical health condition that requires timely intervention. Following admission, clinicians typically use perfusion imaging to facilitate treatment decision-making. While deep learning models leveraging perfusion data have demonstrated the ability to predict post-treatment tissue infarction for individual patients, predictions are often represented as binary or probabilistic masks that are not straightforward to interpret or easy to obtain. Moreover, these models typically rely on large amounts of subjectively segmented data and non-standard perfusion analysis techniques. To address these challenges, we propose a novel deep learning approach that directly predicts follow-up computed tomography images from full spatio-temporal 4D perfusion scans through a temporal compression. The results show that this method leads to realistic follow-up image predictions containing the infarcted tissue outcomes. The proposed compression method achieves comparable prediction results to using perfusion maps as inputs but without the need for perfusion analysis or arterial input function selection. Additionally, separate models trained on 45 patients treated with thrombolysis and 102 treated with thrombectomy showed that each model correctly captured the different patient-specific treatment effects as shown by image difference maps. The findings of this work clearly highlight the potential of our method to provide interpretable stroke treatment decision support without requiring manual annotations.
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Affiliation(s)
- Alejandro Gutierrez
- Department of Radiology, University of Calgary, Calgary, AB T2N 1N4, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, AB T2N 1N4, Canada; Biomedical Engineering Graduate Program, University of Calgary, Calgary, AB T2N 1N4, Canada; Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB T2N 1N4, Canada.
| | - Kimberly Amador
- Department of Radiology, University of Calgary, Calgary, AB T2N 1N4, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, AB T2N 1N4, Canada; Biomedical Engineering Graduate Program, University of Calgary, Calgary, AB T2N 1N4, Canada; Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Anthony Winder
- Department of Radiology, University of Calgary, Calgary, AB T2N 1N4, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Matthias Wilms
- Department of Radiology, University of Calgary, Calgary, AB T2N 1N4, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, AB T2N 1N4, Canada; Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB T2N 1N4, Canada; Department of Pediatrics, University of Calgary, Calgary, AB T2N 1N4, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20251, Germany
| | - Nils D Forkert
- Department of Radiology, University of Calgary, Calgary, AB T2N 1N4, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, AB T2N 1N4, Canada; Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB T2N 1N4, Canada; Department of Clinical Neurosciences, University of Calgary, Calgary, AB T2N 1N4, Canada
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13
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Pan Y, Chen P, Chen S, Li Y, Wang J, Xia S, Rao J, Gao R, Lu C, Ji J. Computed tomography perfusion deficit volume predicts the functional outcome of endovascular therapy for basilar artery occlusion. J Stroke Cerebrovasc Dis 2024; 33:107677. [PMID: 38460777 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107677] [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: 09/20/2023] [Revised: 03/03/2024] [Accepted: 03/06/2024] [Indexed: 03/11/2024] Open
Abstract
OBJECTIVES To investigate the relationship between baseline computed tomography perfusion deficit volumes and functional outcomes in patients with basilar artery occlusion (BAO) undergoing endovascular therapy. METHODS This was a single-center study in which the data of 64 patients with BAO who underwent endovascular therapy were retrospectively analyzed. All the patients underwent multi-model computed tomography on admission. The posterior-circulation Acute Stroke Prognosis Early Computed Tomography Score was applied to assess the ischemic changes. Perfusion deficit volumes were obtained using Syngo.via software. The primary outcome of the analysis was a good functional outcome (90-day modified Rankin Scale score ≤ 3). Logistic regression and receiver operating characteristic curves were used to explore predictors of functional outcome. RESULTS A total of 64 patients (median age, 68 years; 72 % male) were recruited, of whom 26 (41 %) patients achieved good functional outcomes, while 38 (59 %) had poor functional outcomes. Tmax > 10 s, Tmax > 6 s, and rCBF < 30 % volume were independent predictors of good functional outcomes (odds ratio range, 1.0-1.2; 95 % confidence interval [CI], 1.0-1.4]) and performed well in the receiver operating characteristic curve analyses, exhibiting positive prognostic value; the areas under the curve values were 0.85 (95 % CI, 0.75-0.94), 0.81 (95 % CI, 0.70-0.90), and 0.78 (95 % CI, 0.67-0.89). CONCLUSION Computed tomography perfusion deficit volume represents a valuable tool in predicting high risk of disability and mortality in patients with BAO after endovascular treatment.
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Affiliation(s)
- Yiying Pan
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, 323000, PR China
| | - Pengjun Chen
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, 323000, PR China
| | - Shunyang Chen
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, 323000, PR China
| | - Yanjun Li
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, 323000, PR China
| | - Junhe Wang
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, 323000, PR China
| | - Shuiwei Xia
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, 323000, PR China
| | - Jie Rao
- Department of Neurology, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, 323000, PR China
| | - Ruijie Gao
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, 323000, PR China
| | - Chenying Lu
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, 323000, PR China
| | - Jiansong Ji
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, 323000, PR China.
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14
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Shalom ES, Van Loo S, Khan A, Sourbron SP. Identifiability of spatiotemporal tissue perfusion models. Phys Med Biol 2024; 69:115034. [PMID: 38636525 DOI: 10.1088/1361-6560/ad4087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 04/18/2024] [Indexed: 04/20/2024]
Abstract
Objective.Standard models for perfusion quantification in DCE-MRI produce a bias by treating voxels as isolated systems. Spatiotemporal models can remove this bias, but it is unknown whether they are fundamentally identifiable. The aim of this study is to investigate this question in silico using one-dimensional toy systems with a one-compartment blood flow model and a two-compartment perfusion model.Approach.For each of the two models, identifiability is explored theoretically and in-silico for three systems. Concentrations over space and time are simulated by forward propagation. Different levels of noise and temporal undersampling are added to investigate sensitivity to measurement error. Model parameters are fitted using a standard gradient descent algorithm, applied iteratively with a stepwise increasing time window. Model fitting is repeated with different initial values to probe uniqueness of the solution. Reconstruction accuracy is quantified for each parameter by comparison to the ground truth.Main results.Theoretical analysis shows that flows and volume fractions are only identifiable up to a constant, and that this degeneracy can be removed by proper choice of parameters. Simulations show that in all cases, the tissue concentrations can be reconstructed accurately. The one-compartment model shows accurate reconstruction of blood velocities and arterial input functions, independent of the initial values and robust to measurement error. The two-compartmental perfusion model was not fully identifiable, showing good reconstruction of arterial velocities and input functions, but multiple valid solutions for the perfusion parameters and venous velocities, and a strong sensitivity to measurement error in these parameters.Significance.These results support the use of one-compartment spatiotemporal flow models, but two-compartment perfusion models were not sufficiently identifiable. Future studies should investigate whether this degeneracy is resolved in more realistic 2D and 3D systems, by adding physically justified constraints, or by optimizing experimental parameters such as injection duration or temporal resolution.
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Affiliation(s)
- Eve S Shalom
- School of Physics and Astronomy, The University of Leeds, United Kingdom
| | - Sven Van Loo
- Department of Applied Physics, Ghent University, Belgium
| | - Amirul Khan
- School of Civil Engineering, The University of Leeds, United Kingdom
| | - Steven P Sourbron
- Division of Clinical Medicine, University of Sheffield, United Kingdom
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15
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Marburg M, Rudolf LF, Matthis C, Neumann A, Schareck C, Schacht H, Schulz R, Machner B, Schramm P, Royl G, Koch PJ. The lesion core extent modulates the impact of early perfusion mismatch imaging on outcome variability after thrombectomy in stroke. Front Neurol 2024; 15:1366240. [PMID: 38841692 PMCID: PMC11150589 DOI: 10.3389/fneur.2024.1366240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/29/2024] [Indexed: 06/07/2024] Open
Abstract
Introduction Despite profitable group effects on functional outcomes after mechanical thrombectomy (MT) in large vessel occlusion (LVO), many patients with successful reperfusion show a non-favorable long-term outcome, highlighting the necessity to identify potential biomarkers predicting outcome variability. In this regard, the role of perfusion mismatch imaging for outcome variability in the early time window within 6 h after symptom onset is a matter of debate. We attempted to investigate under which conditions early perfusion mismatch imaging accounts for variability in functional outcomes after mechanical thrombectomy. Patients and methods In a retrospective single-center study, we examined 190 consecutive patients with LVO who were admitted to the Medical Center Lübeck within 6 h after symptom onset, all of whom underwent MT. Perfusion mismatch was quantified by applying the Alberta Stroke Program Early CT score (ASPECTS) on CT-measured cerebral blood flow (CBF-ASPECTS) and subtracting it from an ASPECTS application on cerebral blood volume (CBV-ASPECTS), i.e., ASPECTS mismatch. Using multivariate ordinal regression models, associations between ASPECTS mismatch and modified Rankin Scale (mRS) after 90 days were assessed. Furthermore, the interaction between ASPECTS mismatch and the core lesion volume was calculated to evaluate conditional associations. Results ASPECTS mismatch did not correlate with functional outcomes when corrected for multiple influencing covariables. However, interactions between ASPECTS mismatch and CBV-ASPECTS [OR: 1.12 (1.06-1.18), p-value < 0.001], as well as NCCT-ASPECTS [OR: 1.15 (1.06-1.25), p-value < 0.001], did show a significant association with functional outcomes. Model comparisons revealed that, profoundly, in patients with large core lesion volumes (CBV-ASPECTS < 6 or NCCT-ASPECTS < 6), perfusion mismatch showed a negative correlation with the mRS. Discussion and conclusion Perfusion mismatch imaging within the first 6 h of symptom onset provides valuable insights into the outcome variability of LVO stroke patients receiving thrombectomy but only in patients with large ischemic core lesions.
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Affiliation(s)
- Maria Marburg
- Department of Neurology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Linda F. Rudolf
- Department of Neuroradiology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Christine Matthis
- Department of Social Medicine and Epidemiology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Alexander Neumann
- Department of Neuroradiology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Constantin Schareck
- Department of Radiology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Hannes Schacht
- Department of Neuroradiology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Robert Schulz
- Department of Neurology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Björn Machner
- Department of Neurology, Schoen Clinic Neustadt, Neustadt in Holstein, Germany
| | - Peter Schramm
- Department of Neuroradiology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Georg Royl
- Department of Neurology, University Hospital Schleswig-Holstein, Lübeck, Germany
- Center of Brain, Behavior and Metabolism, University of Lübeck, Lübeck, Germany
| | - Philipp J. Koch
- Department of Neurology, University Hospital Schleswig-Holstein, Lübeck, Germany
- Center of Brain, Behavior and Metabolism, University of Lübeck, Lübeck, Germany
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16
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Bellomo J, Sebök M, van Niftrik CH, Stumpo V, Schubert T, Madjidyar J, Thurner P, Globas C, Wegener S, Luft AR, Kulcsár Z, Regli L, Fierstra J. The volume of steal phenomenon is associated with neurological deterioration in patients with large-vessel occlusion minor stroke not eligible for thrombectomy. Eur Stroke J 2024:23969873241251718. [PMID: 38742386 DOI: 10.1177/23969873241251718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION A significant number of patients who present with mild symptoms following large-vessel occlusion acute ischemic stroke (LVO-AIS) are currently considered ineligible for EVT. However, they frequently experience neurological deterioration during hospitalization. This study aimed to investigate the association between neurological deterioration and hemodynamic impairment by assessing steal phenomenon derived from blood oxygenation-level dependent cerebrovascular reactivity (BOLD-CVR) in this specific patient cohort. PATIENTS AND METHODS From the database of our single-center BOLD-CVR observational cohort study (June 2015-October 2023) we retrospectively identified acute ischemic stroke patients with admission NIHSS < 6, a newly detected large vessel occlusion of the anterior circulation and ineligible for EVT. Neurological deterioration during hospitalization as well as outcome at hospital discharge were rated with NIHSS score. We analyzed the association between these two outcomes and BOLD-CVR-derived steal phenomenon volume through regression analysis. Additionally, we investigated the discriminatory accuracy of steal phenomenon volume for predicting neurological deterioration. RESULTS Forty patients were included in the final analysis. Neurological deterioration occurred in 35% of patients. In the regression analysis, a strong association between steal phenomenon volume and neurological deterioration (OR 4.80, 95% CI 1.32-31.04, p = 0.04) as well as poorer NIHSS score at hospital discharge (OR 3.73, 95% CI 1.52-10.78, p = 0.007) was found. The discriminatory accuracy of steal phenomenon for neurological deterioration prediction had an AUC of 0.791 (95% CI 0.653-0.930). DISCUSSION Based on our results we may distinguish two groups of patients with minor stroke currently ineligible for EVT, however, showing hemodynamic impairment and exhibiting neurological deterioration during hospitalization: (1) patients exhibiting steal phenomenon on BOLD-CVR imaging as well as hemodynamic impairment on resting perfusion imaging; (2) patients exhibiting steal phenomenon on BOLD-CVR imaging, however, no relevant hemodynamic impairment on resting perfusion imaging. CONCLUSION The presence of BOLD-CVR derived steal phenomenon may aid to further study hemodynamic impairment in patients with minor LVO-AIS not eligible for EVT.
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Affiliation(s)
- Jacopo Bellomo
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
- Clinical Neuroscience Center (KNZ), Neuroscience Center (ZNZ), University of Zurich, Switzerland
| | - Martina Sebök
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
- Clinical Neuroscience Center (KNZ), Neuroscience Center (ZNZ), University of Zurich, Switzerland
| | - Christiaan Hb van Niftrik
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
- Clinical Neuroscience Center (KNZ), Neuroscience Center (ZNZ), University of Zurich, Switzerland
| | - Vittorio Stumpo
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
- Clinical Neuroscience Center (KNZ), Neuroscience Center (ZNZ), University of Zurich, Switzerland
| | - Tilman Schubert
- Clinical Neuroscience Center (KNZ), Neuroscience Center (ZNZ), University of Zurich, Switzerland
- Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
| | - Jawid Madjidyar
- Clinical Neuroscience Center (KNZ), Neuroscience Center (ZNZ), University of Zurich, Switzerland
- Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
| | - Patrick Thurner
- Clinical Neuroscience Center (KNZ), Neuroscience Center (ZNZ), University of Zurich, Switzerland
- Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Globas
- Clinical Neuroscience Center (KNZ), Neuroscience Center (ZNZ), University of Zurich, Switzerland
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Susanne Wegener
- Clinical Neuroscience Center (KNZ), Neuroscience Center (ZNZ), University of Zurich, Switzerland
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Andreas R Luft
- Clinical Neuroscience Center (KNZ), Neuroscience Center (ZNZ), University of Zurich, Switzerland
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
- Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Zsolt Kulcsár
- Clinical Neuroscience Center (KNZ), Neuroscience Center (ZNZ), University of Zurich, Switzerland
- Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
- Clinical Neuroscience Center (KNZ), Neuroscience Center (ZNZ), University of Zurich, Switzerland
| | - Jorn Fierstra
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
- Clinical Neuroscience Center (KNZ), Neuroscience Center (ZNZ), University of Zurich, Switzerland
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17
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Colasurdo M, Chen H, Gandhi D. MR Imaging Techniques for Acute Ischemic Stroke and Delayed Cerebral Ischemia Following Subarachnoid Hemorrhage. Neuroimaging Clin N Am 2024; 34:203-214. [PMID: 38604705 DOI: 10.1016/j.nic.2023.12.002] [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: 04/13/2024]
Abstract
Acute ischemic stroke (AIS) is a leading cause of death and disability worldwide, and its prevalence is expected to increase with global population aging and the burgeoning obesity epidemic. Clinical care for AIS has evolved during the past 3 decades, and it comprises of 3 major tenants: (1) timely recanalization of occluded vessels with intravenous thrombolysis or endovascular thrombectomy, (2) prompt initiation of antithrombotic agents to prevent stroke recurrences, and (3) poststroke supportive care and rehabilitation. In this article, we summarize commonly used MR sequences for AIS and DCI and highlight their clinical applications.
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Affiliation(s)
- Marco Colasurdo
- Division of Interventional Neuroradiology, Department of Diagnostic Radiology, University of Maryland School of Medicine, 22 South Green Street, Baltimore, MD 21201, USA; Department of Interventional Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
| | - Huanwen Chen
- Division of Interventional Neuroradiology, Department of Diagnostic Radiology, University of Maryland School of Medicine, 22 South Green Street, Baltimore, MD 21201, USA; National Institute for Neurological Disorders and Stroke, National Institutes of Health, 10 center drive, Bethesda, MD 20892, USA; Department of Neurology, MedStar Georgetown University Hospital, Washington, DC 20007, USA
| | - Dheeraj Gandhi
- Division of Interventional Neuroradiology, Department of Diagnostic Radiology, University of Maryland School of Medicine, 22 South Green Street, Baltimore, MD 21201, USA; Department of Neurology, University of Maryland School of Medicine, 22 South Green Street, Baltimore, MD 21201, USA; Department of Neurosurgery, University of Maryland School of Medicine, 22 South Green Street, Baltimore, MD 21201, USA.
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18
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Wang W, Huang XX, Jiang RH, Zhou J, Shi HB, Xu XQ, Wu FY. Gadolinium Retention and Nephrotoxicity in a Mouse Model of Acute Ischemic Stroke: Linear Versus Macrocyclic Agents. J Magn Reson Imaging 2024; 59:1852-1861. [PMID: 37548106 DOI: 10.1002/jmri.28931] [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: 04/29/2023] [Revised: 07/16/2023] [Accepted: 07/17/2023] [Indexed: 08/08/2023] Open
Abstract
BACKGROUND Gadolinium (Gd)-based contrast agents (GBCAs) have been widely used for acute ischemic stroke (AIS) patients. GBCAs or AIS alone may cause the adverse effects on kidney tissue, respectively. However, whether GBCAs and AIS would generate a synergistic negative effect remains undefined. PURPOSE To evaluate synergistic negative effects of AIS and GBCAs on renal tissues in a mouse model of AIS, and to compare the differences of these negative effects between linear and macrocyclic GBCAs. STUDY TYPE Animal study. ANIMAL MODEL Seventy-two healthy mice underwent transient middle cerebral artery occlusion (tMCAO) and sham operation to establish AIS and sham model (N = 36/model). 5.0 mmol/kg GBCAs (gadopentetate or gadobutrol) or 250 μL saline were performed at 4.5 hours and 1 day after model establishing (N = 12/group). ASSESSMENT Inductively coupled plasma mass spectrometry (ICP-MS) was performed to detect Gd concentrations. Serum biochemical analyzer was performed to measure the serum creatinine (Scr), uric acid (UA), and blood urea nitrogen (BUN). Pathological staining was performed to observe tubular injury, cell apoptosis, mesangial hyperplasia, and interstitial fibrosis. STATISTICAL TESTS Two-way analysis of variances with post hoc Sidak's tests and independent-samples t-tests were performed. A P-value <0.05 was considered statistically significant. RESULTS AIS groups showed higher Gd concentration than sham group on day 1 p.i. regardless of gadopentetate or gadobutrol used. Increased total Gd concentration was also found in AIS + gadopentetate group compared with the sham group on day 28 p.i. Significantly higher rates for renal dysfunction, higher tubular injury scores, and higher numbers of apoptotic cells on days 1 or 28 p.i. were found for AIS mice injected with GBCA. AIS + gadopentetate group displayed more severe renal damage than the AIS + gadobutrol group. DATA CONCLUSION AIS and GBCAs may cause increased total Gd accumulation and nephrotoxicity in a mouse, especially linear GBCAs were used. LEVEL OF EVIDENCE 1 TECHNICAL EFFICACY: Stage 4.
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Affiliation(s)
- Wei Wang
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xin-Xin Huang
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Run-Hao Jiang
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jiang Zhou
- 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
| | - Xiao-Quan Xu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Fei-Yun Wu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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19
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Ozkara BB, Karabacak M, Hoseinyazdi M, Dagher SA, Wang R, Karadon SY, Ucisik FE, Margetis K, Wintermark M, Yedavalli VS. Utilizing imaging parameters for functional outcome prediction in acute ischemic stroke: A machine learning study. J Neuroimaging 2024; 34:356-365. [PMID: 38430467 DOI: 10.1111/jon.13194] [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: 11/30/2023] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND AND PURPOSE We aimed to predict the functional outcome of acute ischemic stroke patients with anterior circulation large vessel occlusions (LVOs), irrespective of how they were treated or the severity of the stroke at admission, by only using imaging parameters in machine learning models. METHODS Consecutive adult patients with anterior circulation LVOs who were scanned with CT angiography (CTA) and CT perfusion were queried in this single-center, retrospective study. The favorable outcome was defined as a modified Rankin score (mRS) of 0-2 at 90 days. Predictor variables included only imaging parameters. CatBoost, XGBoost, and Random Forest were employed. Algorithms were evaluated using the area under the receiver operating characteristic curve (AUROC), the area under the precision-recall curve (AUPRC), accuracy, Brier score, recall, and precision. SHapley Additive exPlanations were implemented. RESULTS A total of 180 patients (102 female) were included, with a median age of 69.5. Ninety-two patients had an mRS between 0 and 2. The best algorithm in terms of AUROC was XGBoost (0.91). Furthermore, the XGBoost model exhibited a precision of 0.72, a recall of 0.81, an AUPRC of 0.83, an accuracy of 0.78, and a Brier score of 0.17. Multiphase CTA collateral score was the most significant feature in predicting the outcome. CONCLUSIONS Using only imaging parameters, our model had an AUROC of 0.91 which was superior to most previous studies, indicating that imaging parameters may be as accurate as conventional predictors. The multiphase CTA collateral score was the most predictive variable, highlighting the importance of collaterals.
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Affiliation(s)
- Burak B Ozkara
- Department of Neuroradiology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Mert Karabacak
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - Meisam Hoseinyazdi
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Samir A Dagher
- Department of Neuroradiology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Richard Wang
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sadik Y Karadon
- School of Medicine, Manisa Celal Bayar University, Manisa, Turkey
| | - F Eymen Ucisik
- Department of Neuroradiology, MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Max Wintermark
- Department of Neuroradiology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Vivek S Yedavalli
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, Maryland, USA
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20
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Bourguignon GH, Hupin N, Otjacques L, Schrooyen P, Forez S, Abdulkader M, Houda H, Kozyreff A. Early OCT-angiography findings lead to prompt intravenous thrombolysis and good visual recovery in central retinal artery occlusion: A case report. J Fr Ophtalmol 2024; 47:104032. [PMID: 38242740 DOI: 10.1016/j.jfo.2023.104032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 01/21/2024]
Affiliation(s)
- G-H Bourguignon
- Service d'ophtalmologie, Cliniques universitaires Saint-Luc, université catholique de Louvain, avenue Hippocrate 10, 1200 Bruxelles, Belgium
| | - N Hupin
- Service d'ophtalmologie, Cliniques universitaires Saint-Luc, université catholique de Louvain, avenue Hippocrate 10, 1200 Bruxelles, Belgium
| | - L Otjacques
- Service d'ophtalmologie, Cliniques universitaires Saint-Luc, université catholique de Louvain, avenue Hippocrate 10, 1200 Bruxelles, Belgium
| | - P Schrooyen
- Service d'ophtalmologie, Cliniques universitaires Saint-Luc, université catholique de Louvain, avenue Hippocrate 10, 1200 Bruxelles, Belgium.
| | - S Forez
- Service d'ophtalmologie, Cliniques universitaires Saint-Luc, université catholique de Louvain, avenue Hippocrate 10, 1200 Bruxelles, Belgium
| | - M Abdulkader
- Service d'ophtalmologie, Cliniques universitaires Saint-Luc, université catholique de Louvain, avenue Hippocrate 10, 1200 Bruxelles, Belgium
| | - H Houda
- Service d'ophtalmologie, Cliniques universitaires Saint-Luc, université catholique de Louvain, avenue Hippocrate 10, 1200 Bruxelles, Belgium
| | - A Kozyreff
- Service d'ophtalmologie, Cliniques universitaires Saint-Luc, université catholique de Louvain, avenue Hippocrate 10, 1200 Bruxelles, Belgium
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21
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Koneru M, Hoseinyazdi M, Wang R, Ozkara BB, Hyson NZ, Marsh EB, Llinas RH, Urrutia VC, Leigh R, Gonzalez LF, Xu R, Caplan JM, Huang J, Lu H, Luna L, Wintermark M, Dmytriw AA, Guenego A, Albers GW, Heit JJ, Nael K, Hillis AE, Yedavalli VS. Pretreatment parameters associated with hemorrhagic transformation among successfully recanalized medium vessel occlusions. J Neurol 2024; 271:1901-1909. [PMID: 38099953 DOI: 10.1007/s00415-023-12149-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 11/26/2023] [Accepted: 12/03/2023] [Indexed: 03/28/2024]
Abstract
Although pretreatment radiographic biomarkers are well established for hemorrhagic transformation (HT) following successful mechanical thrombectomy (MT) in large vessel occlusion (LVO) strokes, they are yet to be explored for medium vessel occlusion (MeVO) acute ischemic strokes. We aim to investigate pretreatment imaging biomarkers representative of collateral status, namely the hypoperfusion intensity ratio (HIR) and cerebral blood volume (CBV) index, and their association with HT in successfully recanalized MeVOs. A prospectively collected registry of acute ischemic stroke patients with MeVOs successfully recanalized with MT between 2019 and 2023 was retrospectively reviewed. A multivariate logistic regression for HT of any subtype was derived by combining significant univariate predictors into a forward stepwise regression with minimization of Akaike information criterion. Of 60 MeVO patients successfully recanalized with MT, HT occurred in 28.3% of patients. Independent factors for HT included: diabetes mellitus history (p = 0.0005), CBV index (p = 0.0071), and proximal versus distal occlusion location (p = 0.0062). A multivariate model with these factors had strong diagnostic performance for predicting HT (area under curve [AUC] 0.93, p < 0.001). Lower CBV indexes, distal occlusion location, and diabetes history are significantly associated with HT in MeVOs successfully recanalized with MT. Of note, HIR was not found to be significantly associated with HT.
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Affiliation(s)
- Manisha Koneru
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Meisam Hoseinyazdi
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Richard Wang
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | | | - Nathan Z Hyson
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | | | - Rafael H Llinas
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Victor C Urrutia
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Richard Leigh
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | | | - Risheng Xu
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Justin M Caplan
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Judy Huang
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Hanzhang Lu
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Licia Luna
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | | | | | - Adrien Guenego
- Universite Libre De Bruxelles Hospital Erasme, Anderlecht, Belgium
| | | | - Jeremy J Heit
- Stanford University School of Medicine, Stanford, CA, USA
| | - Kambiz Nael
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Argye E Hillis
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Vivek S Yedavalli
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA.
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22
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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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23
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Ladumor H, Vilanilam GK, Ameli S, Pandey I, Vattoth S. CT perfusion in stroke: Comparing conventional and RAPID automated software. Curr Probl Diagn Radiol 2024; 53:201-207. [PMID: 37891080 DOI: 10.1067/j.cpradiol.2023.10.011] [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: 06/02/2023] [Revised: 09/12/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023]
Abstract
CT perfusion (CTP) imaging is increasingly used for routine evaluation of acute ischemic stroke. Knowledge about the different types of CTP software, imaging acquisition and post-processing, and interpretation is crucial for appropriate patient selection for reperfusion therapy. Conventional vendor-provided CTP software differentiates between ischemic penumbra and core infarct using the tiebreaker of critically reduced cerebral blood volume (CBV) values within brain regions showing abnormally elevated time parameters like mean transit time (MTT) or time to peak (TTP). On the other hand, RAPID automated software differentiates between ischemic penumbra and core infarct using the tiebreaker of critically reduced cerebral blood flow (CBF) values within brain regions showing abnormally elevated time to maximum (Tmax). Additionally, RAPID calculates certain indices that confer prognostic value, such as the hypoperfusion and CBV index. In this review, we aim to familiarize the reader with the technical principles of CTP imaging, compare CTP maps generated by conventional and RAPID software, and discuss important thresholds for reperfusion and prognostic indices. Lastly, we discuss common pitfalls to help with the accurate interpretation of CTP imaging.
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Affiliation(s)
- Heta Ladumor
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W. Markham St - Slot 556, Little Rock, AR 72205, USA.
| | - George K Vilanilam
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W. Markham St - Slot 556, Little Rock, AR 72205, USA
| | - Sanaz Ameli
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W. Markham St - Slot 556, Little Rock, AR 72205, USA
| | | | - Surjith Vattoth
- Deparment of Diagnostic Radiology & Nuclear Medicine, Division of Neuroradiology, Rush University Medical Center, Chicago, IL 60612, USA
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24
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Mujanovic A, Kurmann CC, Manhart M, Piechowiak EI, Pilgram-Pastor SM, Serrallach BL, Boulouis G, Meinel TR, Seiffge DJ, Jung S, Arnold M, Nguyen TN, Fischer U, Gralla J, Dobrocky T, Mordasini P, Kaesmacher J. Value of Immediate Flat Panel Perfusion Imaging after Endovascular Therapy (AFTERMATH): A Proof of Concept Study. AJNR Am J Neuroradiol 2024; 45:163-170. [PMID: 38238089 DOI: 10.3174/ajnr.a8103] [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: 09/12/2023] [Accepted: 11/14/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND AND PURPOSE Potential utility of flat panel CT perfusion imaging (FPCT-PI) performed immediately after mechanical thrombectomy (MT) is unknown. We aimed to assess whether FPCT-PI obtained directly post-MT could provide additional potentially relevant information on tissue reperfusion status. MATERIALS AND METHODS This was a single-center analysis of all patients with consecutive acute stroke admitted between June 2019 and March 2021 who underwent MT and postinterventional FPCT-PI (n = 26). A core lab blinded to technical details and clinical data performed TICI grading on postinterventional DSA images and qualitatively assessed reperfusion on time-sensitive FPCT-PI maps. According to agreement between DSA and FPCT-PI, all patients were classified into 4 groups: hypoperfusion findings perfectly matched by location (group 1), hypoperfusion findings mismatched by location (group 2), complete reperfusion on DSA with hypoperfusion on FPCT-PI (group 3), and hypoperfusion on DSA with complete reperfusion on FPCT-PI (group 4). RESULTS Detection of hypoperfusion (present/absent) concurred in 21/26 patients. Of these, reperfusion findings showed perfect agreement on location and size in 16 patients (group 1), while in 5 patients there was a mismatch by location (group 2). Of the remaining 5 patients with disagreement regarding the presence or absence of hypoperfusion, 3 were classified into group 3 and 2 into group 4. FPCT-PI findings could have avoided TICI overestimation in all false-positive operator-rated TICI 3 cases (10/26). CONCLUSIONS FPCT-PI may provide additional clinically relevant information in a considerable proportion of patients undergoing MT. Hence, FPCT-PI may complement the evaluation of reperfusion efficacy and potentially inform decision-making in the angiography suite.
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Affiliation(s)
- Adnan Mujanovic
- From the Departments of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., E.I.P., S.M.P.-P., B.L.S., J.G., T.D., P.M., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Graduate School of Health Sciences (A.M., C.C.K.), University of Bern, Bern, Switzerland
| | - Christoph C Kurmann
- From the Departments of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., E.I.P., S.M.P.-P., B.L.S., J.G., T.D., P.M., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Department of Diagnostic, Interventional and Pediatric Radiology (C.C.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Graduate School of Health Sciences (A.M., C.C.K.), University of Bern, Bern, Switzerland
| | - Michael Manhart
- Siemens Healthineers, Advanced Therapies (M.M.), Forchheim, Germany
| | - Eike I Piechowiak
- From the Departments of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., E.I.P., S.M.P.-P., B.L.S., J.G., T.D., P.M., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Sara M Pilgram-Pastor
- From the Departments of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., E.I.P., S.M.P.-P., B.L.S., J.G., T.D., P.M., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Bettina L Serrallach
- From the Departments of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., E.I.P., S.M.P.-P., B.L.S., J.G., T.D., P.M., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Gregoire Boulouis
- Departments of Diagnostic and Interventional Neuroradiology (G.B.), University Hospital Tours (Centre Val de Loire Region), Tours, France
| | - Thomas R Meinel
- Department of Neurology (T.R.M., D.J.S., S.J., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - David J Seiffge
- Department of Neurology (T.R.M., D.J.S., S.J., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology (T.R.M., D.J.S., S.J., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology (T.R.M., D.J.S., S.J., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Thanh N Nguyen
- Department of Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Urs Fischer
- Department of Neurology (T.R.M., D.J.S., S.J., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology (U.F.), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jan Gralla
- From the Departments of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., E.I.P., S.M.P.-P., B.L.S., J.G., T.D., P.M., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- From the Departments of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., E.I.P., S.M.P.-P., B.L.S., J.G., T.D., P.M., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- From the Departments of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., E.I.P., S.M.P.-P., B.L.S., J.G., T.D., P.M., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Department of Diagnostic and Interventional Neuroradiology (P.M.), Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Johannes Kaesmacher
- From the Departments of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., E.I.P., S.M.P.-P., B.L.S., J.G., T.D., P.M., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
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25
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van der Knaap N, Franx BAA, Majoie CBLM, van der Lugt A, Dijkhuizen RM. Implications of Post-recanalization Perfusion Deficit After Acute Ischemic Stroke: a Scoping Review of Clinical and Preclinical Imaging Studies. Transl Stroke Res 2024; 15:179-194. [PMID: 36653525 PMCID: PMC10796479 DOI: 10.1007/s12975-022-01120-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 01/20/2023]
Abstract
The goal of reperfusion therapy for acute ischemic stroke (AIS) is to restore cerebral blood flow through recanalization of the occluded vessel. Unfortunately, successful recanalization does not always result in favorable clinical outcome. Post-recanalization perfusion deficits (PRPDs), constituted by cerebral hypo- or hyperperfusion, may contribute to lagging patient recovery rates, but its clinical significance remains unclear. This scoping review provides an overview of clinical and preclinical findings on post-ischemic reperfusion, aiming to elucidate the pattern and consequences of PRPD from a translational perspective. The MEDLINE database was searched for quantitative clinical and preclinical studies of AIS reporting PRPD based on cerebral circulation parameters acquired by translational tomographic imaging methods. PRPD and stroke outcome were mapped on a charting table, creating an overview of PRPD after AIS. Twenty-two clinical and twenty-two preclinical studies were included. Post-recanalization hypoperfusion is rarely reported in clinical studies (4/22) but unequivocally associated with detrimental outcome. Post-recanalization hyperperfusion is more commonly reported (18/22 clinical studies) and may be associated with positive or negative outcome. PRPD has been replicated in animal studies, offering mechanistic insights into causes and consequences of PRPD and allowing delineation of possible courses of PRPD. Complex relationships exist between PRPD and stroke outcome. Diversity in methods and lack of standardized definitions in reperfusion studies complicate the characterization of reperfusion patterns. Recommendations are made to advance the understanding of PRPD mechanisms and to further disentangle the relation between PRPD and disease outcome.
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Affiliation(s)
- Noa van der Knaap
- Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Bart A A Franx
- Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands.
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Rick M Dijkhuizen
- Biomedical MR Imaging and Spectroscopy Group, Center for Image Sciences, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands.
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26
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Guo W, Wang X, Chen Y, Wang F, Qiu J, Lu W. Effect of Menopause Status on Brain Perfusion Hemodynamics. Stroke 2024; 55:260-268. [PMID: 37850361 DOI: 10.1161/strokeaha.123.044841] [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: 06/04/2023] [Accepted: 09/26/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND The menopause transition is associated with an increasing risk of cerebrovascular disorders. However, the direct effect of menopause status on brain perfusion hemodynamics remains unclear. This study aimed to explore the influence of menopause status on cerebral blood flow (CBF) using arterial spin labeling magnetic resonance imaging. METHODS In this cross-sectional study, 185 subjects underwent arterial spin labeling magnetic resonance imaging at a hospital in China between September 2020 and December 2022, including 38 premenopausal women (mean age, 47.74±2.02 years), 42 perimenopausal women (mean age, 50.62±3.15 years), 42 postmenopausal women (mean age, 54.02±4.09 years), and 63 men (mean age, 52.70±4.33 years) of a similar age range. Mean CBF values in the whole brain, gray matter, white matter, cortical gray matter, subcortical gray matter, juxtacortical white matter, deep white matter, and periventricular white matter were extracted. ANCOVA was used to compare mean CBF among the 4 groups, controlling for confounding factors. Student t test was applied to compare mean CBF between the 3 female groups and age-matched males, respectively. Multivariable regression analysis was used to analysis the effect of age, sex, and menopause status on the CBF of the whole brain, gray matter, white matter, and subregions. RESULTS Perimenopausal and postmenopausal women showed a higher proportion of white matter hyperintensities compared with the other 2 groups (P<0.001). Premenopausal women exhibited higher CBF in the whole brain, gray matter, white matter, and subregions, compared with perimenopausal, postmenopausal women and men (P≤0.001). Multivariable regression analysis demonstrated significant effect of age and insignificant effect of sex on CBF for all participants. In addition, menopause status and the interaction between age and menopause status on CBF of whole brain, gray matter, white matter, and the subregions were observed in female participants, except for the deep and periventricular white matter regions, with premenopausal women exhibited a slight increase in CBF with age, while perimenopausal and postmenopausal women exhibited declines in CBF with age. CONCLUSIONS The current findings suggest that alterations of brain perfusion hemodynamics begin during the perimenopause period, which may be due to the increased burden of white matter hyperintensities.
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Affiliation(s)
- Wei Guo
- Department of Radiology, the Second Affiliated Hospital of Shandong First Medical University, Taian, China (W.G., Y.C., F.W., W.L.)
| | - Xiuzhu Wang
- Department of Obstetrics, Taian City Central Hospital, China (X.W.)
| | - Yinzhong Chen
- Department of Radiology, the Second Affiliated Hospital of Shandong First Medical University, Taian, China (W.G., Y.C., F.W., W.L.)
| | - Feng Wang
- Department of Radiology, the Second Affiliated Hospital of Shandong First Medical University, Taian, China (W.G., Y.C., F.W., W.L.)
| | - Jianfeng Qiu
- Department of Radiology, Shandong First Medical University and Shandong Academy of Medical Sciences, Taian, China (J.Q.)
| | - Weizhao Lu
- Department of Radiology, the Second Affiliated Hospital of Shandong First Medical University, Taian, China (W.G., Y.C., F.W., W.L.)
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27
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Fappiano C, Long B. Is the Use of Computed Tomography Perfusion Versus Noncontrast Computed Tomography Associated With Improved Outcomes in Patients Presenting 6-24 Hours After Symptom Onset With Large Vessel Occlusion Acute Ischemic Stroke Undergoing Endovascular Thrombectomy? Ann Emerg Med 2024; 83:158-161. [PMID: 37725024 DOI: 10.1016/j.annemergmed.2023.08.483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/20/2023] [Accepted: 08/21/2023] [Indexed: 09/21/2023]
Affiliation(s)
- Cayla Fappiano
- Department of Emergency Medicine, SAUSHEC, Fort Sam Houston, TX
| | - Brit Long
- Department of Emergency Medicine, SAUSHEC, Fort Sam Houston, TX
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28
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Diestro JDB, Fahed R, Benomar A, Omar AT, Pereira VM, Spears J, Marotta TR, Djiadeu P, Sharma S, Farrokhyar F. Clinical Uncertainty in Large Vessel Occlusion ischemic stroke (CULVO): Does automated perfusion scanning make a difference? Protocol of an intrarater and interrater agreement study. PLoS One 2024; 19:e0297520. [PMID: 38289912 PMCID: PMC10826946 DOI: 10.1371/journal.pone.0297520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 01/04/2024] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Guidelines recommend the use of perfusion computed tomography (CT) to identify emergent large vessel ischemic stroke (ELVIS) patients who are likely to benefit from endovascular thrombectomy (EVT) if they present within 6-24 hour (late window) of stroke onset. We aim to determine if the interrater and intrarater reliability among physicians when recommending EVT is significantly different when perfusion CT or non-perfusion CT is reviewed. METHODS A total of 30 non-consecutive patients will be selected from our institutional database comprising 3144 cranial CT scans performed for acute stroke symptoms January 2018 to August 2022. The clinical and radiologic data of the 30 patients will be presented in random order to a group of 29 physicians in two separate sessions at least three weeks apart. In each session, the physicians will evaluate each patient once with automated perfusion images and once without. We will use non-overlapping 95% confidence intervals and difference in agreement classification as criteria to suggest a difference between the Gwet AC1 statistics (κG). DISCUSSION The results obtained from this study, combined with the clinical outcomes data of patients categorized through the two imaging techniques and a cost-effectiveness analysis, will offer a comprehensive evaluation of the clinical utility of perfusion CT neuroimaging. Should there be no significant disparity in the reliability of decisions made by clinicians using the two neuroimaging protocols, it may be necessary to revise existing recommendations regarding neuroimaging in the later time window to align with these findings.
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Affiliation(s)
- Jose Danilo Bengzon Diestro
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, Unity Health- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Robert Fahed
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Anass Benomar
- Department of Radiology, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Abdelsimar T. Omar
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Harvard TH Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
| | - Vitor Mendes Pereira
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, Unity Health- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Department of Surgery, Unity Health- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Julian Spears
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, Unity Health- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Department of Surgery, Unity Health- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Thomas R. Marotta
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Medical Imaging, Unity Health- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Pascal Djiadeu
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Global Health, McMaster University, Hamilton, Ontario, Canada
| | - Sunjay Sharma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Forough Farrokhyar
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Global Health, McMaster University, Hamilton, Ontario, Canada
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Mujanovic A, Ng F, Meinel TR, Dobrocky T, Piechowiak EI, Kurmann CC, Seiffge DJ, Wegener S, Wiest R, Meyer L, Fiehler J, Olivot JM, Ribo M, Nguyen TN, Gralla J, Campbell BC, Fischer U, Kaesmacher J. No-reflow phenomenon in stroke patients: A systematic literature review and meta-analysis of clinical data. Int J Stroke 2024; 19:58-67. [PMID: 37231702 DOI: 10.1177/17474930231180434] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND The no-reflow phenomenon refers to the absence of microvascular reperfusion despite macrovascular reperfusion. AIM The aim of this analysis was to summarize the available clinical evidence on no-reflow in patients with acute ischemic stroke. METHODS A systematic literature review and a meta-analysis of clinical data on definition, rates, and impact of the no-reflow phenomenon after reperfusion therapy was carried out. A predefined research strategy was formulated according to the Population, Intervention, Comparison, and Outcome (PICO) model and was used to screen for articles in PubMed, MEDLINE, and Embase up to 8 September 2022. Whenever possible, quantitative data were summarized using a random-effects model. RESULTS Thirteen studies with a total of 719 patients were included in the final analysis. Most studies (n = 10/13) used variations of the Thrombolysis in Cerebral Infarction scale to evaluate macrovascular reperfusion, whereas microvascular reperfusion and no-reflow were mostly assessed on perfusion maps (n = 9/13). In one-third of stroke patients with successful macrovascular reperfusion (29%, 95% confidence interval (CI), 21-37%), the no-reflow phenomenon was observed. Pooled analysis showed that no-reflow was consistently associated with reduced rates of functional independence (odds ratio (OR), 0.21, 95% CI, 0.15-0.31). CONCLUSION The definition of no-reflow varied substantially across studies, but it appears to be a common phenomenon. Some of the no-reflow cases may simply represent remaining vessel occlusions, and it remains unclear whether no-reflow is an epiphenomenon of the infarcted parenchyma or causes infarction. Future studies should focus on standardizing the definition of no-reflow with more consistent definitions of successful macrovascular reperfusion and experimental set-ups that could detect the causality of the observed findings.
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Affiliation(s)
- Adnan Mujanovic
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Felix Ng
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Thomas R Meinel
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Eike I Piechowiak
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Christoph C Kurmann
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Department of Diagnostic, Interventional and Pediatric Radiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - David J Seiffge
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Roland Wiest
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jean Marc Olivot
- Department of Neurology and Clinical Investigation Center, Toulouse University Hospital, Toulouse, France
| | - Marc Ribo
- Department of Neurology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Bruce Cv Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
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30
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Fakkert RA, Koopman MS, Scheerder MJ, Beenen LFM, Weber NC, Preckel B, van Hulst RA, Weenink RP. Computer tomography perfusion patterns in iatrogenic cerebral arterial gas embolism: A retrospective cohort study. Eur J Radiol 2024; 170:111242. [PMID: 38043382 DOI: 10.1016/j.ejrad.2023.111242] [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: 11/14/2023] [Accepted: 11/26/2023] [Indexed: 12/05/2023]
Abstract
PURPOSE Cerebral arterial gas embolism (CAGE) occurs when air or medical gas enters the systemic circulation during invasive procedures and lodges in the cerebral vasculature. Non-contrast computer tomography (CT) may not always show intracerebral gas. CT perfusion (CTP) might be a useful adjunct for diagnosing CAGE in these patients. METHODS This is a retrospective single-center cohort study. We included patients who were diagnosed with iatrogenic CAGE and underwent CTP within 24 h after onset of symptoms between January 2016 and October 2022. All imaging studies were evaluated by two independent radiologists. CTP studies were scored semi-quantitatively for perfusion abnormalities (normal, minimal, moderate, severe) in the following parameters: cerebral blood flow, cerebral blood volume, time-to-drain and time-to-maximum. RESULTS Among 27 patient admitted with iatrogenic CAGE, 15 patients underwent CTP within the designated timeframe and were included for imaging analysis. CTP showed perfusion deficits in all patients except one. The affected areas on CTP scans were in general located bilaterally and frontoparietally. The typical pattern of CTP abnormalities in these areas was hypoperfusion with an increased time-to-drain and time-to-maximum, and a corresponding minimal decrease in cerebral blood flow. Cerebral blood volume was mostly unaffected. CONCLUSION CTP may show specific perfusion defects in patients with a clinical diagnosis of CAGE. This suggests that CTP may be supportive in diagnosing CAGE in cases where no intracerebral gas is seen on non-contrast CT.
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Affiliation(s)
- Raoul A Fakkert
- Anesthesiology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands; Hyperbaric Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands; Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - Miou S Koopman
- Radiology and Nuclear Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - Maeke J Scheerder
- Radiology and Nuclear Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - Ludo F M Beenen
- Radiology and Nuclear Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - Nina C Weber
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - Benedikt Preckel
- Anesthesiology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands; Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - Robert A van Hulst
- Anesthesiology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands; Hyperbaric Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - Robert P Weenink
- Anesthesiology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands; Hyperbaric Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands.
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Liu Y, Li S, Tian X, Leung TW, Liu L, Liebeskind DS, Leng X. Cerebral haemodynamics in symptomatic intracranial atherosclerotic disease: a narrative review of the assessment methods and clinical implications. Stroke Vasc Neurol 2023; 8:521-530. [PMID: 37094991 PMCID: PMC10800270 DOI: 10.1136/svn-2023-002333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/07/2023] [Indexed: 04/26/2023] Open
Abstract
Intracranial atherosclerotic disease (ICAD) is a common cause of ischaemic stroke and transient ischaemic attack (TIA) with a high recurrence rate. It is often referred to as intracranial atherosclerotic stenosis (ICAS), when the plaque has caused significant narrowing of the vessel lumen. The lesion is usually considered 'symptomatic ICAD/ICAS' (sICAD/sICAS) when it has caused an ischaemic stroke or TIA. The severity of luminal stenosis has long been established as a prognostic factor for stroke relapse in sICAS. Yet, accumulating studies have also reported the important roles of plaque vulnerability, cerebral haemodynamics, collateral circulation, cerebral autoregulation and other factors in altering the stroke risks across patients with sICAS. In this review article, we focus on cerebral haemodynamics in sICAS. We reviewed imaging modalities/methods in assessing cerebral haemodynamics, the haemodynamic metrics provided by these methods and application of these methods in research and clinical practice. More importantly, we reviewed the significance of these haemodynamic features in governing the risk of stroke recurrence in sICAS. We also discussed other clinical implications of these haemodynamic features in sICAS, such as the associations with collateral recruitment and evolution of the lesion under medical treatment, and indications for more individualised blood pressure management for secondary stroke prevention. We then put forward some knowledge gaps and future directions on these topics.
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Affiliation(s)
- Yuying Liu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Shuang Li
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Xuan Tian
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Thomas W Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - David S Liebeskind
- Department of Neurology, Neurovascular Imaging Research Core, University of California Los Angeles, Los Angeles, California, USA
| | - Xinyi Leng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
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Lim GZ, Lai JY, Seet CYH, Tham CH, Venketasubramanian N, Tan BYQ, Jing M, Yeo JYP, Myint MZ, Sia CH, Teoh HL, Sharma VK, Chan BPL, Yang C, Makmur A, Ong SJ, Yeo LLL. Revolutionizing the Management of Large-Core Ischaemic Strokes: Decoding the Success of Endovascular Therapy in the Recent Stroke Trials. J Cardiovasc Dev Dis 2023; 10:499. [PMID: 38132666 PMCID: PMC10743836 DOI: 10.3390/jcdd10120499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/02/2023] [Accepted: 12/15/2023] [Indexed: 12/23/2023] Open
Abstract
Endovascular therapy (EVT) has revolutionized the management of acute ischaemic strokes with large vessel occlusion, with emerging evidence suggesting its benefit also in large infarct core volume strokes. In the last two years, four randomised controlled trials have been published on this topic-RESCUE-Japan LIMIT, ANGEL-ASPECT, SELECT2 and TENSION, with overall results showing that EVT improves functional and neurological outcomes compared to medical management alone. This review aims to summarise the recent evidence presented by these four trials and highlight some of the limitations in our current understanding of this topic.
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Affiliation(s)
- Gareth Zigui Lim
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Jonathan Yexian Lai
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Christopher Ying Hao Seet
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Carol Huilian Tham
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | | | - Benjamin Yong Qiang Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Mingxue Jing
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Joshua Yee Peng Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - May Zin Myint
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
- Department of Cardiology, National University Heart Center, Singapore 119228, Singapore
| | - Hock Luen Teoh
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Vijay Kumar Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Bernard Poon Lap Chan
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Cunli Yang
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Department of Diagnostic Imaging, National University Health System, Singapore 119228, Singapore
| | - Andrew Makmur
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Department of Diagnostic Imaging, National University Health System, Singapore 119228, Singapore
| | - Shao Jin Ong
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Department of Diagnostic Imaging, National University Health System, Singapore 119228, Singapore
| | - Leonard Leong Litt Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore 119228, Singapore (V.K.S.); (B.P.L.C.)
- Department of Diagnostic Imaging, National University Health System, Singapore 119228, Singapore
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Zhu C, Qin W, Xu J, Hu W. Perfusion deficits in thrombolysis-treated acute ischemic stroke patients with negative or positive diffusion-weighted imaging. BMC Neurol 2023; 23:380. [PMID: 37865726 PMCID: PMC10590031 DOI: 10.1186/s12883-023-03427-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 10/05/2023] [Indexed: 10/23/2023] Open
Abstract
OBJECTIVE Magnetic resonance imaging (MRI) and CT perfusion may provide diagnostic information for intravenous tissue-type plasminogen activator (IV t-PA) administration in acute ischemic stroke (AIS) patients. We aimed to compare the clinical features and perfusion deficits of diffusion weighted imaging (DWI)-negative and DWI-positive AIS patients. METHODS This retrospective and observational study included thrombolysis-treated AIS patients undergoing multimodel CT imaging before treatment and DWI after treatment between 2021 and 2022. Two experienced neuroradiologists blindly and independently examined the images to identify perfusion deficits in AIS patients. The patients were divided into DWI-positive and DWI-negative groups based on visible hyperintense lesions on DWI. A modified Rankin scale (mRS) score of ≤ 2 indicated good functional outcomes at discharge. Sensitivity analysis was conducted to determine whether CT perfusion was an independent predictor of positive DWI imaging on follow-up. RESULTS This study included 151 patients, of whom 35 (23.2%) patients were DWI-negative on follow-up. These DWI-negative patients were less likely to have a medical history of atrial fibrillation; they had lower triglyceride levels, a shorter admission time, lower National Institutes of Health Stroke Scale (NIHSS) scores after IV t-PA and lower mRS scores at discharge, and had better functional outcomes. A total of 37.1% of DWI-positive and 25.7% of DWI-negative patients had vascular stenosis (P = 0.215). A total of 47.4% of DWI-positive and 37.1% of DWI-negative patients had CT perfusion deficits (P = 0.284). A total of 73.5% of patients with normal CT perfusion had positive DWI, while 19.1% of patients with perfusion deficits had negative DWI. The sensitivity and specificity of NCCT were 14.8% and 97.1% (Kappa = 0.061, P = 0.074), CTP was 47.4% and 62.9% for predicting DWI lesion (Kappa = 0.069, P = 0.284). CONCLUSIONS About 23.2% of AIS patients who received intravenous thrombolysis treatment did not have a relevant DWI-MRI lesion on follow-up. Over one-third of patients in the DWI-MRI negative group showed CT perfusion deficits, with a sensitivity of 47.4% for predicting DWI lesions in non-mechanical thrombectomy patients.
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Affiliation(s)
- Cuiting Zhu
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongti South Road, Chaoyang District, Beijing, 100020, P.R. China
| | - Wei Qin
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongti South Road, Chaoyang District, Beijing, 100020, P.R. China
| | - Jihua Xu
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongti South Road, Chaoyang District, Beijing, 100020, P.R. China
| | - Wenli Hu
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongti South Road, Chaoyang District, Beijing, 100020, P.R. China.
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Chen P, Pan Y, Wang J, Hui J, Gao R, Lin G, Li B, Rao J, Xia S, Ji J. The value of computed tomography perfusion deficit volumes in acute isolated brainstem infarction. Front Neurol 2023; 14:1233784. [PMID: 37928165 PMCID: PMC10620965 DOI: 10.3389/fneur.2023.1233784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/28/2023] [Indexed: 11/07/2023] Open
Abstract
Purpose Diagnosis of acute isolated brainstem infarction is challenging owing to non-specific, variable symptoms, and the effectiveness of non-contrast computed tomography (NCCT) is poor owing to limited spatial resolution and artifacts. Computed tomography perfusion (CTP) imaging parameters are significantly associated with functional outcomes in posterior circulation acute ischemic stroke; however, the role of CTP in isolated brainstem infarction remains unclear. We aimed to determine the value of CTP imaging parameters in predicting functional outcomes for affected patients. Methods In total, 116 consecutive patients with isolated pontine/midbrain hypoperfusion who underwent CTP and follow-up by magnetic resonance imaging (MRI) between January 2018 and March 2022, were retrospectively analyzed. Perfusion deficit volumes on all maps, and the final infarction volume (FIV) on MRI were quantified. "Good" functional outcome was defined as a 90-day modified Rankin Scale score of 0 and 1. Statistical analysis included uni- and multivariate regression analyses, binary logistic regressions, and receiver operating characteristics (ROC) analyses. Results In total, 113 patients had confirmed isolated pontine/midbrain infarction on follow-up MRI. Onset-to-scan time, visibility of ischemic lesions on NCCT, the baseline National Institutes of Health Stroke Scale (NIHSS) score, and perfusion deficit volumes on all CTP maps were significantly associated with FIV (p < 0.05). In a multivariate linear regression model, adjusted for age, sex, NIHSS score, onset-to-scan time, and visibility of NCCT, perfusion deficit volumes remained significantly associated with FIV. In binary logistic regression analyses, perfusion deficit volumes on all CTP maps remained independent predictors of a good functional outcome. In ROC analyses, the cerebral blood flow deficit volume showed a slightly higher discriminatory value with the largest area under the curve being 0.683 [(95% CI, 0.587-0.780), p = 0.001]. Conclusion Perfusion deficit volumes of CTP imaging could reflect the FIV and contain prognostic information on functional outcomes in patients with acute isolated brainstem infarction.
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Affiliation(s)
- Pengjun Chen
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, China
| | - Yiying Pan
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, China
| | - Jingke Wang
- Institution of Laboratory, Lishui People’s Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, Lishui, China
| | - Junguo Hui
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, China
| | - Ruijie Gao
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, China
| | - Guihan Lin
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, China
| | - Bingrong Li
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, China
| | - Jie Rao
- Department of Neurology, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, China
| | - Shuiwei Xia
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, China
| | - Jiansong Ji
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, China
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Ivanova MV, Pappas I, Inglis B, Pracar AL, Herron TJ, Baldo JV, Kayser AS, D’Esposito M, Dronkers NF. Cerebral perfusion in post-stroke aphasia and its relationship to residual language abilities. Brain Commun 2023; 6:fcad252. [PMID: 38162898 PMCID: PMC10757451 DOI: 10.1093/braincomms/fcad252] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 05/26/2023] [Accepted: 09/28/2023] [Indexed: 01/03/2024] Open
Abstract
Stroke alters blood flow to the brain resulting in damaged tissue and cell death. Moreover, the disruption of cerebral blood flow (perfusion) can be observed in areas surrounding and distal to the lesion. These structurally preserved but suboptimally perfused regions may also affect recovery. Thus, to better understand aphasia recovery, the relationship between cerebral perfusion and language needs to be systematically examined. In the current study, we aimed to evaluate (i) how stroke affects perfusion outside of lesioned areas in chronic aphasia and (ii) how perfusion in specific cortical areas and perilesional tissue relates to language outcomes in aphasia. We analysed perfusion data from a large sample of participants with chronic aphasia due to left hemisphere stroke (n = 43) and age-matched healthy controls (n = 25). We used anatomically defined regions of interest that covered the frontal, parietal, and temporal areas of the perisylvian cortex in both hemispheres, areas typically known to support language, along with several control regions not implicated in language processing. For the aphasia group, we also looked at three regions of interest in the perilesional tissue. We compared perfusion levels between the two groups and investigated the relationship between perfusion levels and language subtest scores while controlling for demographic and lesion variables. First, we observed that perfusion levels outside the lesioned areas were significantly reduced in frontal and parietal regions in the left hemisphere in people with aphasia compared to the control group, while no differences were observed for the right hemisphere regions. Second, we found that perfusion in the left temporal lobe (and most strongly in the posterior part of both superior and middle temporal gyri) and inferior parietal areas (supramarginal gyrus) was significantly related to residual expressive and receptive language abilities. In contrast, perfusion in the frontal regions did not show such a relationship; no relationship with language was also observed for perfusion levels in control areas and all right hemisphere regions. Third, perilesional perfusion was only marginally related to language production abilities. Cumulatively, the current findings demonstrate that blood flow is reduced beyond the lesion site in chronic aphasia and that hypoperfused neural tissue in critical temporoparietal language areas has a negative impact on behavioural outcomes. These results, using perfusion imaging, underscore the critical and general role that left hemisphere posterior temporal regions play in various expressive and receptive language abilities. Overall, the study highlights the importance of exploring perfusion measures in stroke.
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Affiliation(s)
- Maria V Ivanova
- Department of Psychology, University of California, Berkeley, CA 94720, USA
- Research Service, VA Northern California Health Care System, Martinez, CA 94553, USA
| | - Ioannis Pappas
- Stevens Neuroimaging and Informatics Institute, University of Southern California, Los Angeles, CA 90033, USA
| | - Ben Inglis
- Henry H. Wheeler, Jr. Brain Imaging Center, University of California, Berkeley, CA 94720, USA
| | - Alexis L Pracar
- Department of Psychology, University of California, Berkeley, CA 94720, USA
| | - Timothy J Herron
- Research Service, VA Northern California Health Care System, Martinez, CA 94553, USA
| | - Juliana V Baldo
- Research Service, VA Northern California Health Care System, Martinez, CA 94553, USA
| | - Andrew S Kayser
- Division of Neurology, San Francisco VA Health Care System, San Francisco, CA 94121, USA
- Department of Neurology, University of California San Francisco, San Francisco, CA 94158, USA
| | - Mark D’Esposito
- Department of Psychology, University of California, Berkeley, CA 94720, USA
- Neurology Service, VA Northern California Health Care System, Martinez, CA 94553, USA
| | - Nina F Dronkers
- Department of Psychology, University of California, Berkeley, CA 94720, USA
- Depertment of Neurology, University of California, Davis, CA 95817, USA
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Bani-Sadr A, Trintignac M, Mechtouff L, Hermier M, Cappucci M, Ameli R, de Bourguignon C, Derex L, Cho TH, Nighoghossian N, Eker OF, Berthezene Y. Is the optimal Tmax threshold identifying perfusion deficit volumes variable across MR perfusion software packages? A pilot study. MAGMA (NEW YORK, N.Y.) 2023; 36:815-822. [PMID: 36811716 DOI: 10.1007/s10334-023-01068-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE Accurate quantification of ischemic core and ischemic penumbra is mandatory for late-presenting acute ischemic stroke. Substantial differences between MR perfusion software packages have been reported, suggesting that the optimal Time-to-Maximum (Tmax) threshold may be variable. We performed a pilot study to assess the optimal Tmax threshold of two MR perfusion software packages (A: RAPID®; B: OleaSphere®) by comparing perfusion deficit volumes to final infarct volumes as ground truth. METHODS The HIBISCUS-STROKE cohort includes acute ischemic stroke patients treated by mechanical thrombectomy after MRI triage. Mechanical thrombectomy failure was defined as a modified thrombolysis in cerebral infarction score of 0. Admission MR perfusion were post-processed using two packages with increasing Tmax thresholds (≥ 6 s, ≥ 8 s and ≥ 10 s) and compared to final infarct volume evaluated with day-6 MRI. RESULTS Eighteen patients were included. Lengthening the threshold from ≥ 6 s to ≥ 10 s led to significantly smaller perfusion deficit volumes for both packages. For package A, Tmax ≥ 6 s and ≥ 8 s moderately overestimated final infarct volume (median absolute difference: - 9.5 mL, interquartile range (IQR) [- 17.5; 0.9] and 0.2 mL, IQR [- 8.1; 4.8], respectively). Bland-Altman analysis indicated that they were closer to final infarct volume and had narrower ranges of agreement compared with Tmax ≥ 10 s. For package B, Tmax ≥ 10 s was closer to final infarct volume (median absolute difference: - 10.1 mL, IQR: [- 17.7; - 2.9]) versus - 21.8 mL (IQR: [- 36.7; - 9.5]) for Tmax ≥ 6 s. Bland-Altman plots confirmed these findings (mean absolute difference: 2.2 mL versus 31.5 mL, respectively). CONCLUSIONS The optimal Tmax threshold for defining the ischemic penumbra appeared to be most accurate at ≥ 6 s for package A and ≥ 10 s for package B. This implies that the widely recommended Tmax threshold ≥ 6 s may not be optimal for all available MRP software package. Future validation studies are required to define the optimal Tmax threshold to use for each package.
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Affiliation(s)
- Alexandre Bani-Sadr
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France.
- CREATIS Laboratory, CNRS UMR 5220, INSERM U 5220, Claude Bernard Lyon I University, 7 Avenue Jean Capelle O, 69100, Villeurbanne, France.
| | - Mathilde Trintignac
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
| | - Laura Mechtouff
- Stroke Department, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
- CarMeN Laboratory, INSERM U1060, Claude Bernard Lyon I University, 59 Bd Pinel, 69500, Bron, France
| | - Marc Hermier
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
| | - Matteo Cappucci
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
| | - Roxana Ameli
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
| | | | - Laurent Derex
- Stroke Department, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
| | - Tae-Hee Cho
- Stroke Department, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
- CarMeN Laboratory, INSERM U1060, Claude Bernard Lyon I University, 59 Bd Pinel, 69500, Bron, France
| | - Norbert Nighoghossian
- Stroke Department, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
- CarMeN Laboratory, INSERM U1060, Claude Bernard Lyon I University, 59 Bd Pinel, 69500, Bron, France
| | - Omer Faruk Eker
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
- CREATIS Laboratory, CNRS UMR 5220, INSERM U 5220, Claude Bernard Lyon I University, 7 Avenue Jean Capelle O, 69100, Villeurbanne, France
| | - Yves Berthezene
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France
- CREATIS Laboratory, CNRS UMR 5220, INSERM U 5220, Claude Bernard Lyon I University, 7 Avenue Jean Capelle O, 69100, Villeurbanne, France
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van Stigt MN, Groenendijk EA, van de Munckhof AAGA, Marquering HA, Koopman MS, Majoie CBLM, Roos YBWEM, Koelman JHTM, Potters WV, Coutinho JM. Correlation between EEG spectral power and cerebral perfusion in patients with acute ischemic stroke. J Clin Neurosci 2023; 116:81-86. [PMID: 37657169 DOI: 10.1016/j.jocn.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/08/2023] [Accepted: 08/23/2023] [Indexed: 09/03/2023]
Abstract
Dry electrode electroencephalography (EEG) has the potential to diagnose ischemic stroke in the acute phase. In the current study we determined the correlation between EEG spectral power and ischemic stroke size and location as determined by computed tomography perfusion (CTP). Dry electrode EEG recordings were performed in patients with acute ischemic stroke in the emergency room. CTP preceded the EEG recordings as part of standard imaging protocol. Infarct core volume, total hypoperfused volume and local cerebral blood flow (CBF) were estimated with CTP. Additionally, global and local EEG spectral power were determined. We used Spearman's correlation coefficients to evaluate the correlation between variables. We included 27 patients (median age 72 [IQR:69-80] years, 15/27 [56%] men). Median CTP-to-EEG time was 32 (range:8-138) minutes. Hypoperfused volumes were estimated for 12/27 (44%) patients. Infarct core volume correlated best with global delta power (ρ = 0.76, p < 0.01), total hypoperfused volume with global alpha power (ρ = -0.58, p = 0.05), and local CBF with local alpha power (ρ = 0.43, p < 0.01). We conclude that dry electrode EEG signals slow down with increasing hypoperfused volume, which could potentially be used to discriminate between small and large ischemic strokes.
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Affiliation(s)
- M N van Stigt
- Department of Clinical Neurophysiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands; Department of Neurology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands.
| | - E A Groenendijk
- Department of Clinical Neurophysiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands; Department of Neurology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - A A G A van de Munckhof
- Department of Clinical Neurophysiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands; Department of Neurology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - H A Marquering
- Department of Biomedical Engineering and Physics, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - M S Koopman
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - C B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Y B W E M Roos
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - J H T M Koelman
- Department of Clinical Neurophysiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands; Department of Neurology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - W V Potters
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands; TrianecT, Padualaan 8, Utrecht, the Netherlands
| | - J M Coutinho
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
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Lee CH, Chung JW, Guk HS, Hong JM, Rosenson RS, Jeong SK. Cerebral artery signal intensity gradient from Time-of-Flight Magnetic Resonance Angiography and clinical outcome in lenticulostriate infarction: a retrospective cohort study. Front Neurol 2023; 14:1220840. [PMID: 37799283 PMCID: PMC10547899 DOI: 10.3389/fneur.2023.1220840] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/30/2023] [Indexed: 10/07/2023] Open
Abstract
Purpose Lenticulostriate infarction requires further research of arterial hemodynamic factors, as the disease is diagnosed in the absence of major arterial stenosis or cardioembolism. Methods In this multicenter retrospective cohort study, we included patients who were hospitalized for lenticulostriate infarction from January 2015 to March 2021 at three stroke centers in South Korea. We obtained hemodynamic information on cerebral arteries using signal intensity gradient (SIG), an in-vivo approximated wall shear stress (WSS) derived from Time-of-Flight Magnetic Resonance Angiography (TOF-MRA). A favorable outcome was defined as a modified Rankin Scale of 0 to 2 at hospital discharge. Results A total of 294 patients were included, of whom 146 (49.7%) had an unfavorable outcome. The unfavorable outcome group showed significantly lower SIG in both middle cerebral arteries (MCAs) than the favorable group (5.2 ± 1.2 SI/mm vs. 5.9 ± 1.2, p < 0.001), and similar findings were observed in other cerebral arteries. The SIGs in both MCAs were independently associated with favorable outcome, with an odds ratio of 1.42 (95% confidence interval, 1.11-1.80; p = 0.005) for the right MCA and 1.49 (95% CI, 1.15-1.93; p = 0.003) for the left MCA, after adjusting for potential confounders. Similar findings were observed in other cerebral artery SIGs. Conclusion Cerebral artery SIG from TOF-MRA was significantly associated with short-term functional outcomes in patients with lenticulostriate infarction. Further studies are needed to investigate the temporal relationships of SIG in patients with cerebral infarction.
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Affiliation(s)
- Chan-Hyuk Lee
- Department of Neurology, Asan Medical Center, Seoul, Republic of Korea
- Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Jong-Won Chung
- Department of Neurology, Samsung Medical Center, Seoul, Republic of Korea
| | - Hyung Seok Guk
- Department of Neurology, Gunsan Medical Center, Gunsan, Republic of Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Robert S. Rosenson
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Seul-Ki Jeong
- Seul-Ki Jeong Neurology Clinic, Seoul, Republic of Korea
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Piscopo A, Zanaty M, Dlouhy K. Contemporary Methods for Detection and Intervention of Distal Medium and Small Vessel Occlusions. J Clin Med 2023; 12:6071. [PMID: 37763011 PMCID: PMC10531921 DOI: 10.3390/jcm12186071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/10/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
The efficacy of using mechanical thrombectomy for proximal large vessel occlusions has been demonstrated in multiple large-scale trials and has further raised the question of its potential utility for distal medium and small vessel occlusions (DMSVOs). Their longer, more tortuous course and smaller corresponding vascular territories render a significant challenge for detection and intervention. The aim of this study is to provide a comprehensive overview of the current imaging and endovascular intervention options for DMSVOs and review the current works in the literature. Compared with traditional computed tomography angiography (CTA) and CT perfusion, recent advances such as multiphase CTA and maps derived from the time-to-maximum parameter coupled with artificial intelligence have demonstrated increased sensitivity for the detection of DMSVOs. Furthermore, newer generations of mini stent retrievers and thromboaspiration devices have allowed for the access and navigation of smaller and more fragile distal arteries. Preliminary studies have suggested that mechanical thrombectomy using this newer generation of devices is both safe and feasible in distal medium-sized vessels, such as M2. However, endovascular intervention utilizing such contemporary methods and devices must be balanced at the discretion of operator experience and favorable vascular anatomy. Further large-scale multicenter clinical trials are warranted to elucidate the indications for as well as to strengthen the safety and efficacy of this approach.
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Affiliation(s)
| | - Mario Zanaty
- Department of Neurosurgery, University of Iowa Hospital and Clinics, Iowa City, IA 52242, USA; (A.P.); (K.D.)
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Wilson SE, Ashcraft S. Stroke: Hospital Nursing Management Within the First 24 Hours. Nurs Clin North Am 2023; 58:309-324. [PMID: 37536783 DOI: 10.1016/j.cnur.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Within the United States, someone will have a stroke approximately every 40 seconds. Eighty-five percent of strokes are ischemic, with 15% classified as either intracranial or subarachnoid hemorrhage. Stroke care is complex, and nurses play a critical role in identification, assessment, management, and coordination throughout the stroke continuum of care. This article will explore the nursing care of the patient with ischemic and hemorrhagic stroke during the first 24 hours.
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Affiliation(s)
- Susan E Wilson
- Department of Neurology, University of North Carolina at Chapel Hill, CB# 7025, 170 Manning Drive, Chapel Hill, NC 27599-7025, USA.
| | - Susan Ashcraft
- Neurocritical Care Clinical Nurse Specialist, Novant Health, Inc., 1918 Randolph Road Suite LL175A, Charlotte, NC 28207, USA
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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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Sequeiros JM, Rodriguez-Calienes A, Chavez-Malpartida SS, Morán-Mariños C, Alvarado-Gamarra G, Malaga M, Quincho-Lopez A, Hernadez-Fernandez W, Pacheco-Barrios K, Ortega-Gutierrez S, Hoit D, Arthur AS, Alexandrov AV, Alva-Diaz C, Elijovich L. Stroke imaging modality for endovascular therapy in the extended window: systematic review and meta-analysis. J Neurointerv Surg 2023; 15:e46-e53. [PMID: 35725306 DOI: 10.1136/neurintsurg-2022-018896] [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: 03/07/2022] [Accepted: 06/08/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND In anterior circulation large vessel occlusion (LVO) in the extended time window, the guidelines recommend advanced imaging (ADVI) to select patients for endovascular therapy (EVT). However, questions remain regarding its availability and applicability in the real world. It is unclear whether an approach to the extended window EVT that does not use ADVI would be equivalent. METHODS In April 2022, a literature search was performed to identified randomized controlled trials (RCT) and observational studies describing 90-day outcomes. We performed a meta-analysis of the proportion of aggregate using a random effect to estimate rates of functional independence, defined as modified Rankin Scale (mRS) score ≤2 at 90 days, mean mRS, mortality and symptomatic intracranial hemorrhage (sICH) stratified by imaging modality. RESULTS Four RCTs and 28 observational studies were included. The pooled proportion of functional independence among patients selected by ADVI was 44% (95% CI 39% to 48%; I2=80%) and 48% (95% CI 41% to 55%; I2=75%) with non-contrast CT/CT angiography (NCCT/CTA) (p=0.36). Mean mRS with ADVI was 2.88 (95% CI 2.36 to 3.41; I2=0.0%) and 2.79 (95% CI 2.31 to 3.27; I2=0.0%) with NCCT (p=0.79). Mortality in patients selected by ADVI was 13% (95% CI 10% to 17%; I2=81%) and 16% (95% CI 12% to 22%; I2=69%) with NCCT (p=0.29). sICH with ADVI was 4% (95% CI 3% to 7%; I2=73%) and 6% with NCCT/CTA (95% CI 4% to 8%; I2=6%, p=0.27). CONCLUSIONS Our study suggests that, in anterior circulation LVO, the rates of functional independence may be similar when patients are selected using ADVI or NCCT for EVT in the extended time window. A simplified triage protocol does not seem to increase mortality or sICH. PROTOCOL REGISTRATION NUMBER: (PROSPERO ID: CRD42021236092).
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Affiliation(s)
- Joel M Sequeiros
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Aaron Rodriguez-Calienes
- Grupo de Investigacion Neurociencia, Efectividad Clinica y Salud Publica, Universidad Científica del Sur, Lima, Peru
| | - Sandra S Chavez-Malpartida
- Facultad de Medicina Humana, Universidad Nacional Mayor de San Marcos, Lima, Peru
- Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru
- Servicio de Neurologia, Departamento de Medicina y Oficina de Apoyo a la Docencia e Investigacion, Hospital Daniel Alcides Carrion, Callao, Peru
| | - Cristian Morán-Mariños
- Unidad de Investigacion en Bibliometria, Universidad San Ignacio de Loyola, Lima, Peru
- Servicio de Neumologia, Hospital Nacional Dos de Mayo, Lima, Peru
| | - Giancarlo Alvarado-Gamarra
- Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru
- Departamento de Pediatria, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
- Departamento de Pediatria, Instituto de Investigación Nutricional, Lima, Peru
| | - Marco Malaga
- Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru
| | - Alvaro Quincho-Lopez
- Facultad de Medicina Humana, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Wendy Hernadez-Fernandez
- Servicio de Neurologia, Departamento de Medicina y Oficina de Apoyo a la Docencia e Investigacion, Hospital Daniel Alcides Carrion, Callao, Peru
| | - Kevin Pacheco-Barrios
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
- Vicerrectorado de Investigacion, Unidad de Investigacion para la Generacion y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Daniel Hoit
- Department of Neurosurgery, University of Tennessee Health Science Center - Semmens Murphy Clinic, Memphis, TN, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center - Semmens Murphy Clinic, Memphis, TN, USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Carlos Alva-Diaz
- Grupo de Investigacion Neurociencia, Efectividad Clinica y Salud Publica, Universidad Científica del Sur, Lima, Peru
- Servicio de Neurologia, Departamento de Medicina y Oficina de Apoyo a la Docencia e Investigacion, Hospital Daniel Alcides Carrion, Callao, Peru
| | - Lucas Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of Neurosurgery, University of Tennessee Health Science Center - Semmens Murphy Clinic, Memphis, TN, USA
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Qaiser A, Lozano D, Liquigli N, Qureshi K, Farooq M. CT Perfusion Imaging Guides Clinical Decision-Making in a Case of Thalamic Stroke: A Case Report. Cureus 2023; 15:e44846. [PMID: 37809118 PMCID: PMC10560080 DOI: 10.7759/cureus.44846] [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] [Accepted: 09/06/2023] [Indexed: 10/10/2023] Open
Abstract
This case highlights a patient presenting with a stroke code in the emergency department with decreased consciousness. The patient was later found to have bilateral thalamic strokes due to ischemia of the artery of Percheron. Initial head computed tomography (CT) and CT angiogram (CTA) of the head and neck showed no abnormalities. CT perfusion (CTP) showed a perfusion deficit of 169 mL with a T-max greater than 4 s and 4 mL with a T-max greater than 6 s in the posterior circulation. The patient received IV alteplase. This case report emphasizes the importance of perfusion neuroimaging in the evaluation of acute ischemic stroke.
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Affiliation(s)
- Alisha Qaiser
- Neurology, Trinity Health Saint Mary's - Grand Rapids, Grand Rapids, USA
| | - Daniela Lozano
- Neurology, Trinity Health Saint Mary's - Grand Rapids, Grand Rapids, USA
| | - Nicholas Liquigli
- Neurology, Trinity Health Saint Mary's - Grand Rapids, Grand Rapids, USA
| | - Kasim Qureshi
- Neurology, Trinity Health Saint Mary's - Grand Rapids, Grand Rapids, USA
| | - Muhammad Farooq
- Vascular Neurology, Trinity Health Saint Mary's - Grand Rapids, Grand Rapids, USA
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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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Fernández-Rodicio S, Ferro-Costas G, Sampedro-Viana A, Bazarra-Barreiros M, Ferreirós A, López-Arias E, Pérez-Mato M, Ouro A, Pumar JM, Mosqueira AJ, Alonso-Alonso ML, Castillo J, Hervella P, Iglesias-Rey R. Perfusion-weighted software written in Python for DSC-MRI analysis. Front Neuroinform 2023; 17:1202156. [PMID: 37593674 PMCID: PMC10431979 DOI: 10.3389/fninf.2023.1202156] [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: 04/07/2023] [Accepted: 06/27/2023] [Indexed: 08/19/2023] Open
Abstract
Introduction Dynamic susceptibility-weighted contrast-enhanced (DSC) perfusion studies in magnetic resonance imaging (MRI) provide valuable data for studying vascular cerebral pathophysiology in different rodent models of brain diseases (stroke, tumor grading, and neurodegenerative models). The extraction of these hemodynamic parameters via DSC-MRI is based on tracer kinetic modeling, which can be solved using deconvolution-based methods, among others. Most of the post-processing software used in preclinical studies is home-built and custom-designed. Its use being, in most cases, limited to the institution responsible for the development. In this study, we designed a tool that performs the hemodynamic quantification process quickly and in a reliable way for research purposes. Methods The DSC-MRI quantification tool, developed as a Python project, performs the basic mathematical steps to generate the parametric maps: cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), signal recovery (SR), and percentage signal recovery (PSR). For the validation process, a data set composed of MRI rat brain scans was evaluated: i) healthy animals, ii) temporal blood-brain barrier (BBB) dysfunction, iii) cerebral chronic hypoperfusion (CCH), iv) ischemic stroke, and v) glioblastoma multiforme (GBM) models. The resulting perfusion parameters were then compared with data retrieved from the literature. Results A total of 30 animals were evaluated with our DSC-MRI quantification tool. In all the models, the hemodynamic parameters reported from the literature are reproduced and they are in the same range as our results. The Bland-Altman plot used to describe the agreement between our perfusion quantitative analyses and literature data regarding healthy rats, stroke, and GBM models, determined that the agreement for CBV and MTT is higher than for CBF. Conclusion An open-source, Python-based DSC post-processing software package that performs key quantitative perfusion parameters has been developed. Regarding the different animal models used, the results obtained are consistent and in good agreement with the physiological patterns and values reported in the literature. Our development has been built in a modular framework to allow code customization or the addition of alternative algorithms not yet implemented.
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Affiliation(s)
- Sabela Fernández-Rodicio
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | | | - Ana Sampedro-Viana
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Marcos Bazarra-Barreiros
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | | | - Esteban López-Arias
- Translational Stroke Laboratory (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - María Pérez-Mato
- Neurological Sciences and Cerebrovascular Research Laboratory, Department of Neurology and Stroke Center, La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Universidad Autónoma de Madrid, Madrid, Spain
| | - Alberto Ouro
- NeuroAging Group (NEURAL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain
| | - José M. Pumar
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
- Department of Neuroradiology, Hospital Clínico Universitario, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Antonio J. Mosqueira
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
- Department of Neuroradiology, Hospital Clínico Universitario, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - María Luz Alonso-Alonso
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - José Castillo
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Pablo Hervella
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Ramón Iglesias-Rey
- Neuroimaging and Biotechnology Laboratory (NOBEL), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
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Kishi F, Nakagawa I, Kimura S, Ogawa D, Yagi R, Yamada K, Taniguchi H. Tmax volume can predict clinical type in patients with acute ischemic stroke. Brain Behav 2023; 13:e3163. [PMID: 37469274 PMCID: PMC10454272 DOI: 10.1002/brb3.3163] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/15/2023] [Accepted: 07/06/2023] [Indexed: 07/21/2023] Open
Abstract
OBJECTIVE Endovascular therapy (EVT) is performed for acute ischemic stroke (AIS) with large vessel occlusion (LVO), however, the treatment strategies and clinical outcomes differ between cardiac embolism (CE) and intracranial arteriosclerosis-derived LVO (ICAS-LVO). We analyzed whether the time-to-max (Tmax) volume derived from perfusion imaging predicted clinical classification in AIS patients before EVT. METHODS Consecutive AIS patients with anterior circulation LVO evaluated by automated imaging software were retrospectively identified. Patients were classified into a CE group and an ICAS-LVO group, and parameters were compared between groups. RESULTS Thirty-nine patients were included and Tmax volume and Tmax > 6 s volume/Tmax > 4 s volume were significantly greater in the CE group than in the ICAS-LVO group (Tmax > 4 s volume: 261 mL vs. 149 mL, p = .01, Tmax > 6 s volume: 143 mL vs. 59 mL, p = .001, Tmax > 6 s volume/Tmax > 4 s volume: 0.59 vs. 0.40, p < .001). Multiple logistic regression analysis indicated an association between clinical classification and high Tmax > 6 s volume/Tmax > 4 s volume (p = .04). CONCLUSION The Tmax volume derived from perfusion imaging predicts the clinical classification of AIS patients before EVT.
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Affiliation(s)
- Fumihisa Kishi
- Department of NeurosurgeryYagi Neurosurgical HospitalHigashinarikuOsakaJapan
| | - Ichiro Nakagawa
- Department of NeurosurgeryNara Medical UniversityKashiharaNaraJapan
| | - Seigo Kimura
- Department of NeurosurgeryYagi Neurosurgical HospitalHigashinarikuOsakaJapan
| | - Daiji Ogawa
- Department of NeurosurgeryYagi Neurosurgical HospitalHigashinarikuOsakaJapan
| | - Ryokichi Yagi
- Department of NeurosurgeryOsaka Medical and Pharmaceutical UniversityTakatsukiOsakaJapan
| | - Keiichi Yamada
- Department of NeurosurgeryYagi Neurosurgical HospitalHigashinarikuOsakaJapan
| | - Hirokatsu Taniguchi
- Department of NeurosurgeryYagi Neurosurgical HospitalHigashinarikuOsakaJapan
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Iporre-Rivas A, Saur D, Rohr K, Scheuermann G, Gillmann C. Stroke-GFCN: ischemic stroke lesion prediction with a fully convolutional graph network. J Med Imaging (Bellingham) 2023; 10:044502. [PMID: 37465592 PMCID: PMC10350625 DOI: 10.1117/1.jmi.10.4.044502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 06/13/2023] [Accepted: 06/20/2023] [Indexed: 07/20/2023] Open
Abstract
Purpose The interpretation of image data plays a critical role during acute brain stroke diagnosis, and promptly defining the requirement of a surgical intervention will drastically impact the patient's outcome. However, determining stroke lesions purely from images can be a daunting task. Many studies proposed automatic segmentation methods for brain stroke lesions from medical images in different modalities, though heretofore results do not satisfy the requirements to be clinically reliable. We investigate the segmentation of brain stroke lesions using a geometric deep learning model that takes advantage of the intrinsic interconnected diffusion features in a set of multi-modal inputs consisting of computer tomography (CT) perfusion parameters. Approach We propose a geometric deep learning model for the segmentation of ischemic stroke brain lesions that employs spline convolutions and unpooling/pooling operators on graphs to excerpt graph-structured features in a fully convolutional network architecture. In addition, we seek to understand the underlying principles governing the different components of our model. Accordingly, we structure the experiments in two parts: an evaluation of different architecture hyperparameters and a comparison with state-of-the-art methods. Results The ablation study shows that deeper layers obtain a higher Dice coefficient score (DCS) of up to 0.3654. Comparing different pooling and unpooling methods shows that the best performing unpooling method is the proportional approach, yet it often smooths the segmentation border. Unpooling achieves segmentation results more adapted to the lesion boundary corroborated with systematic lower values of Hausdorff distance. The model performs at the level of state-of-the-art models without optimized training methods, such as augmentation or patches, with a DCS of 0.4553 ± 0.0031 . Conclusions We proposed and evaluated an end-to-end trainable fully convolutional graph network architecture using spline convolutional layers for the ischemic stroke lesion prediction. We propose a model that employs graph-based operations to predict acute stroke brain lesions from CT perfusion parameters. Our results prove the feasibility of using geometric deep learning to solve segmentation problems, and our model shows a better performance than other models evaluated. The proposed model achieves improved metric values for the DCS metric, ranging from 8.61% to 69.05%, compared with other models trained under the same conditions. Next, we compare different pooling and unpooling operations in relation to their segmentation results, and we show that the model can produce segmentation outputs that adapt to irregular segmentation boundaries when using simple heuristic unpooling operations.
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Affiliation(s)
- Ariel Iporre-Rivas
- Leipzig University, Institute for Computer Science, Faculty of Mathematics and Computer Science, Signal and Image Processing Group, Leipzig, Germany
- Max-Plank-Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
- ScaDS.AI, Leipzig, Germany
| | - Dorothee Saur
- Leipzig University, Department of Neurology, Leipzig, Germany
| | - Karl Rohr
- Heidelberg University, BioQuant Center, IPMB and DKFZ, Biomedical Computer Vision Group, Heidelberg, Germany
| | - Gerik Scheuermann
- Leipzig University, Institute for Computer Science, Faculty of Mathematics and Computer Science, Signal and Image Processing Group, Leipzig, Germany
| | - Christina Gillmann
- Leipzig University, Institute for Computer Science, Faculty of Mathematics and Computer Science, Signal and Image Processing Group, Leipzig, Germany
- ScaDS.AI, Leipzig, Germany
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Hou X, Guo P, Wang P, Liu P, Lin DDM, Fan H, Li Y, Wei Z, Lin Z, Jiang D, Jin J, Kelly C, Pillai JJ, Huang J, Pinho MC, Thomas BP, Welch BG, Park DC, Patel VM, Hillis AE, Lu H. Deep-learning-enabled brain hemodynamic mapping using resting-state fMRI. NPJ Digit Med 2023; 6:116. [PMID: 37344684 PMCID: PMC10284915 DOI: 10.1038/s41746-023-00859-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 06/09/2023] [Indexed: 06/23/2023] Open
Abstract
Cerebrovascular disease is a leading cause of death globally. Prevention and early intervention are known to be the most effective forms of its management. Non-invasive imaging methods hold great promises for early stratification, but at present lack the sensitivity for personalized prognosis. Resting-state functional magnetic resonance imaging (rs-fMRI), a powerful tool previously used for mapping neural activity, is available in most hospitals. Here we show that rs-fMRI can be used to map cerebral hemodynamic function and delineate impairment. By exploiting time variations in breathing pattern during rs-fMRI, deep learning enables reproducible mapping of cerebrovascular reactivity (CVR) and bolus arrival time (BAT) of the human brain using resting-state CO2 fluctuations as a natural "contrast media". The deep-learning network is trained with CVR and BAT maps obtained with a reference method of CO2-inhalation MRI, which includes data from young and older healthy subjects and patients with Moyamoya disease and brain tumors. We demonstrate the performance of deep-learning cerebrovascular mapping in the detection of vascular abnormalities, evaluation of revascularization effects, and vascular alterations in normal aging. In addition, cerebrovascular maps obtained with the proposed method exhibit excellent reproducibility in both healthy volunteers and stroke patients. Deep-learning resting-state vascular imaging has the potential to become a useful tool in clinical cerebrovascular imaging.
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Affiliation(s)
- Xirui Hou
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pengfei Guo
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
| | - Puyang Wang
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Peiying Liu
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Doris D M Lin
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hongli Fan
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yang Li
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Zhiliang Wei
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Zixuan Lin
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dengrong Jiang
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jin Jin
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Catherine Kelly
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jay J Pillai
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marco C Pinho
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Binu P Thomas
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Babu G Welch
- Department of Neurologic Surgery, UT Southwestern Medical Center, Dallas, TX, USA
- Center for Vital Longevity, School of Behavioral and Brain Sciences, University of Texas at Dallas, Dallas, TX, USA
| | - Denise C Park
- Center for Vital Longevity, School of Behavioral and Brain Sciences, University of Texas at Dallas, Dallas, TX, USA
| | - Vishal M Patel
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Argye E Hillis
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hanzhang Lu
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, USA.
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Ivanova MV, Pappas I. Understanding recovery of language after stroke: insights from neurovascular MRI studies. FRONTIERS IN LANGUAGE SCIENCES 2023; 2:1163547. [PMID: 38162928 PMCID: PMC10757818 DOI: 10.3389/flang.2023.1163547] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Stroke causes a disruption in blood flow to the brain that can lead to profound language impairments. Understanding the mechanisms of language recovery after stroke is crucial for the prognosis and effective rehabilitation of people with aphasia. While the role of injured brain structures and disruptions in functional connectivity have been extensively explored, the relationship between neurovascular measures and language recovery in both early and later stages has not received sufficient attention in the field. Fully functioning healthy brain tissue requires oxygen and nutrients to be delivered promptly via its blood supply. Persistent decreases in blood flow after a stroke to the remaining non-lesioned tissue have been shown to contribute to poor language recovery. The goal of the current paper is to critically examine stroke studies looking at the relationship between different neurovascular measures and language deficits and mechanisms of language recovery via changes in neurovascular metrics. Measures of perfusion or cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) provide complementary approaches to understanding neurovascular mechanisms post stroke by capturing both cerebral metabolic demands and mechanical vascular properties. While CBF measures indicate the amount of blood delivered to a certain region and serve as a proxy for metabolic demands of that area, CVR indices reflect the ability of the vasculature to recruit blood flow in response to a shortage of oxygen, such as when one is holding their breath. Increases in CBF during recovery beyond the site of the lesion have been shown to promote language gains. Similarly, CVR changes, when collateral vessels are recruited to help reorganize the flow of blood in hypoperfused regions, have been related to functional recovery post stroke. In the current review, we highlight the main findings in the literature investigating neurovascular changes in stroke recovery with a particular emphasis on how language abilities can be affected by changes in CBF and CVR. We conclude by summarizing existing methodological challenges and knowledge gaps that need to be addressed in future work in this area, outlining a promising avenue of research.
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Affiliation(s)
- Maria V. Ivanova
- Department of Psychology, University of California, Berkeley, Berkeley, CA, United States
| | - Ioannis Pappas
- USC Stevens Neuroimaging and Informatics Institute, University of Southern California, Los Angeles, CA, United States
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Aguirre C, Trillo S, Ramos C, Zapata-Wainberg G, Sanz-García A, Ximénez-Carrillo Á, Barbosa A, Caniego JL, Vivancos J. Predictive value of ischemia location on multimodal CT in thrombectomy-treated patients. Neuroradiol J 2023; 36:319-328. [PMID: 36281569 PMCID: PMC10268084 DOI: 10.1177/19714009221128658] [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: 06/04/2024] Open
Abstract
OBJECTIVE Alberta Stroke Program Early CT Score (ASPECTS) applied to CT-perfusion (CTP) and CT-angiography-source-images (CTA-SI) may improve outcome prediction in large vessel occlusion (LVO) stroke if compared to non-contrast CT (NCCT) alone. Besides, ischemia location may have enhanced capabilities, compared to ischemia volume alone, in predicting stroke outcomes. We aim to evaluate the association between ischemia location as measured by ASPECTS regions in NCCT, CTP maps and CTA-SI and 3 months outcome in patients with LVO treated with mechanical thrombectomy (MT). MATERIAL AND METHODS Consecutive patients with anterior circulation stroke treated with MT were recorded in a prospectively maintained database at a single center. Modified Rankin scale (mRS) at 3 months >2 was considered a poor outcome. Association of patients' characteristics, NCCT, CTP, and CTA-SI parameters with outcome was evaluated using single-variable analysis and binary logistic regression multivariate analysis for each imaging technique. RESULTS 177 patients were included. 115 (65%) patients reached a favorable outcome. The involvement of lenticular, caudate, M1, or M2 in all imaging techniques, insula in NCCT and CTA-SI and M5 in CBV maps and CTA-SI was related to functional outcome in bivariate analysis. However, in the multivariate analysis, none ischemia location was independently related to outcome, no matter the imaging technique studied. This finding remained unchanged when restricted to patients with good recanalization and when analyzing subpopulations according to hemisphere involvement or territories association. CONCLUSIONS Our study suggests ischemia location shouldn't be used solely for decision-making in LVO stroke patients. Its predictive value may be taken in consideration together with other clinical and radiological variables.
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Affiliation(s)
- Clara Aguirre
- Stroke Center, Neurology
Department, Instituto de Investigación Sanitaria, Hospital Universitario de La
Princesa, Madrid, Spain
| | - Santiago Trillo
- Stroke Center, Neurology
Department, Instituto de Investigación Sanitaria, Hospital Universitario de La
Princesa, Madrid, Spain
| | - Carmen Ramos
- Stroke Center, Neurology
Department, Instituto de Investigación Sanitaria, Hospital Universitario de La
Princesa, Madrid, Spain
| | - Gustavo Zapata-Wainberg
- Stroke Center, Neurology
Department, Instituto de Investigación Sanitaria, Hospital Universitario de La
Princesa, Madrid, Spain
| | - Ancor Sanz-García
- Data Analysis Unit, Instituto de
Investigación Sanitaria, Hospital Universitario de la
Princesa, Madrid, Spain
| | - Álvaro Ximénez-Carrillo
- Stroke Center, Neurology
Department, Instituto de Investigación Sanitaria, Hospital Universitario de La
Princesa, Madrid, Spain
| | - Antonio Barbosa
- Neuroradiology Department, Hospital Universitario de La
Princesa., Madrid, Spain
| | - José L Caniego
- Neuroradiology Department, Hospital Universitario de La
Princesa., Madrid, Spain
| | - José Vivancos
- Stroke Center, Neurology
Department, Instituto de Investigación Sanitaria, Hospital Universitario de La
Princesa, Madrid, Spain
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