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Wang X, Duan C, Lyu J, Han D, Cheng K, Meng Z, Wu X, Chen W, Wang G, Niu Q, Li X, Bian Y, Han D, Guo W, Yang S, Wang X, Zhang T, Bi J, Wu F, Xia S, Tong D, Duan K, Li Z, Wang R, Wang J, Lou X. Impact of the Alberta Stroke Program CT Score subregions on long-term functional outcomes in acute ischemic stroke: Results from two multicenter studies in China. J Transl Int Med 2024; 12:197-208. [PMID: 38779116 PMCID: PMC11107184 DOI: 10.2478/jtim-2022-0057] [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: 11/16/2022] Open
Abstract
Background and Objectives The Alberta Stroke Program CT Score (ASPECTS) is a widely used rating system for assessing infarct extent and location. We aimed to investigate the prognostic value of ASPECTS subregions' involvement in the long-term functional outcomes of acute ischemic stroke (AIS). Materials and Methods Consecutive patients with AIS and anterior circulation large-vessel stenosis and occlusion between January 2019 and December 2020 were included. The ASPECTS score and subregion involvement for each patient was assessed using posttreatment magnetic resonance diffusion-weighted imaging. Univariate and multivariable regression analyses were conducted to identify subregions related to 3-month poor functional outcome (modified Rankin Scale scores, 3-6) in the reperfusion and medical therapy cohorts, respectively. In addition, prognostic efficiency between the region-based ASPECTS and ASPECTS score methods were compared using receiver operating characteristic curves and DeLong's test. Results A total of 365 patients (median age, 64 years; 70% men) were included, of whom 169 had poor outcomes. In the reperfusion therapy cohort, multivariable regression analyses revealed that the involvement of the left M4 cortical region in left-hemisphere stroke (adjusted odds ratio [aOR] 5.39, 95% confidence interval [CI] 1.53-19.02) and the involvement of the right M3 cortical region in right-hemisphere stroke (aOR 4.21, 95% CI 1.05-16.78) were independently associated with poor functional outcomes. In the medical therapy cohort, left-hemisphere stroke with left M5 cortical region (aOR 2.87, 95% CI 1.08-7.59) and caudate nucleus (aOR 3.14, 95% CI 1.00-9.85) involved and right-hemisphere stroke with right M3 cortical region (aOR 4.15, 95% CI 1.29-8.18) and internal capsule (aOR 3.94, 95% CI 1.22-12.78) affected were related to the increased risks of poststroke disability. In addition, region-based ASPECTS significantly improved the prognostic efficiency compared with the conventional ASPECTS score method. Conclusion The involvement of specific ASPECTS subregions depending on the affected hemisphere was associated with worse functional outcomes 3 months after stroke, and the critical subregion distribution varied by clinical management. Therefore, region-based ASPECTS could provide additional value in guiding individual decision making and neurological recovery in patients with AIS.
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Affiliation(s)
- Xinrui Wang
- Department of Radiology, Chinese PLA General Hospital, Beijing100853, China
| | - Caohui Duan
- Department of Radiology, Chinese PLA General Hospital, Beijing100853, China
| | - Jinhao Lyu
- Department of Radiology, Chinese PLA General Hospital, Beijing100853, China
| | - Dongshan Han
- Department of Radiology, Chinese PLA General Hospital, Beijing100853, China
| | - Kun Cheng
- Department of Radiology, Chinese PLA General Hospital, Beijing100853, China
| | - Zhihua Meng
- Department of Radiology, Yuebei People’s Hospital, Shaoguan512000, Guangdong Province, China
| | - Xiaoyan Wu
- Department of Radiology, Anshan Changda Hospital, Anshan114000, Liaoning Province, China
| | - Wen Chen
- Department of Radiology, Shiyan Taihe Hospital, Shiyan442000, Hubei Province, China
| | - Guohua Wang
- Department of Radiology, Qingdao Municipal Hospital, Qingdao University, Qingdao266011, Shandong Province, China
| | - Qingliang Niu
- Department of Radiology, WeiFang Traditional Chinese Hospital, Weifang261053, Shandong Province, China
| | - Xin Li
- Department of Radiology, The Second Hospital of Jilin University, Jilin University, Changchun130014, Jilin Province, China
| | - Yitong Bian
- Department of Radiology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an710061, Shaanxi Province, China
| | - Dan Han
- Department of Radiology, The First Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming650032, Yunnan Province, China
| | - Weiting Guo
- Department of Radiology, Shanxi Provincial People’s Hospital, Taiyuan030012, Shanxi Province, China
| | - Shuai Yang
- Department of Radiology, Xiangya Hospital, Central South University, Changsha410008, Hunan Province, China
| | - Ximing Wang
- Department of Radiology, The First Affiliated Hospital of Soochow University, Soochow University, Suzhou215006, Jiangsu Province, China
| | - Tijiang Zhang
- Department of Radiology, The Affiliated Hospital of Zunyi Medical University, Zunyi Medical University, Zunyi563000, Guizhou Province, China
| | - Junying Bi
- Department of Radiology, The Third People’s Hospital of Hubei Province, Wuhan430030, Hubei Province, China
| | - Feiyun Wu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing210029, Jiangsu Province, China
| | - Shuang Xia
- Department of Radiology, Tianjin First Central Hospital, Nankai University, Tianjin300190, China
| | - Dan Tong
- Department of Radiology, The First Hospital of Jilin University, Jilin University, Changchun130021, Jilin Province, China
| | - Kai Duan
- Department of Radiology, Liangxiang Hospital, Beijing102401, China
| | - Zhi Li
- Department of Radiology, The First People’s Hospital of Yunnan Province, Kunming650034, Yunnan Province, China
| | - Rongpin Wang
- Department of Radiology, Guizhou Provincial People’s Hospital, Guiyang550499, Guizhou Province, China
| | - Jinan Wang
- Department of Radiology, Zhongshan Hospital, Xiamen University, Xiamen361004, Fujian Province, China
| | - Xin Lou
- Department of Radiology, Chinese PLA General Hospital, Beijing100853, China
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Cole TS, Rudy RF, Faridmoayer E, Gandhi S, Cavallo C, Catapano JS, Jadhav AP, Lawton MT, Albuquerque FC, Ducruet AF. Relationship between cerebral vasospasm vascular territory and functional outcome after aneurysmal subarachnoid hemorrhage. J Neurointerv Surg 2023; 15:958-963. [PMID: 36379702 DOI: 10.1136/jnis-2022-019016] [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: 04/06/2022] [Accepted: 10/17/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Vasospasm following aneurysmal subarachnoid hemorrhage (SAH) contributes significant morbidity and mortality after brain aneurysm rupture. However, the association between vascular territory of vasospasm and clinical outcome has not been studied. We present a hypothesis-generating study to determine whether the location of vasospasm within the intracranial circulation is associated with functional outcome after SAH. METHODS A retrospective analysis of a prospective, intention-to-treat trial for aneurysmal SAH was performed to supplement trial outcomes with in-hospital angiographic imaging and treatment variables regarding vasospasm. The location of vasospasm and the position on the vessel (distal vs proximal) were evaluated. Modified Rankin scale (mRS) outcomes were assessed at discharge and 6 months, and predictive models were constructed. RESULTS A total of 406 patients were included, 341 with follow-up data at 6 months. At discharge, left-sided vasospasm was associated with poor outcome (odds ratio (OR), 2.37; 95% CI, 1.25 to 4.66; P=0.01). At 6 months, anterior cerebral artery (ACA) vasospasm (OR, 3.87; 95% CI, 1.29 to 11.88; P=0.02) and basilar artery (BA) vasospasm (OR, 6.22; 95% CI, 1.54 to 27.11; P=0.01) were associated with poor outcome after adjustment. A model predicting 6-month mRS score and incorporating vasospasm variables achieved an area under the curve of 0.85 and a net improvement in reclassification of 13.2% (P<0.01) compared with a previously validated predictive model for aneurysmal SAH. CONCLUSIONS In aneurysmal SAH, left-sided vasospasm is associated with worse discharge functional status. At 6 months, both ACA and BA vasospasm are associated with unfavorable functional status.
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Affiliation(s)
- Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Robert F Rudy
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Erfan Faridmoayer
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Sirin Gandhi
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Claudio Cavallo
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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Subramaniam JC, Cheung A, Manning N, Whitley J, Cordato D, Zagami A, Cappelen-Smith C, Tian H, Levi C, Parsons M, Butcher KS. Most endovascular thrombectomy patients have Target Mismatch despite absence of formal CT perfusion selection criteria. PLoS One 2023; 18:e0285679. [PMID: 37708105 PMCID: PMC10501580 DOI: 10.1371/journal.pone.0285679] [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: 10/11/2022] [Accepted: 04/27/2023] [Indexed: 09/16/2023] Open
Abstract
Endovascular thrombectomy (EVT) is the standard of care for large vessel occlusion stroke. Use of Computed Tomographic Perfusion (CTP) to select EVT candidates is variable. The frequency of treatment and outcome in patients with unfavourable CTP patterns is unknown. A retrospective analysis of CTP utilisation prior to EVT was conducted. All CTP data were analysed centrally and a Target Mismatch was defined as an infarct core ≤70 ml, penumbral volume ≥15ml, and a total hypoperfused volume:core volume ratio >1.8. The primary outcome was good functional outcome at 90 days, defined as a modified Rankin Scale (mRS) score 0-2. follow-up infarct volume, core expansion and penumbral salvage volumes were secondary outcomes. Of 572 anterior circulation EVT patients, CTP source image data required to generate objective maps were available in 170, and a Target Mismatch was present in 151 (89%). The rate of 90-day good functional outcome was similar between Target Mismatch (53%) and Large Core Non-Mismatch groups (46%, p = 0.629). Median follow-up infarct volume in the Large Core Non-Mismatch group (104ml [IQR 25ml-189ml]) was larger than that in the Target Mismatch patients (16ml [8ml-47ml], p<0.001). Despite a lack of formal CTP selection criteria, the majority of patients treated at our centres had a Target Mismatch. Patients without Target Mismatch had larger follow-up infarct volumes, but the functional recovery rate was similar to that in Target Mismatch patients. Infarct volumes should be included as objective assessment criteria in the evaluation of the efficacy of EVT in non-Target Mismatch patients.
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Affiliation(s)
| | - Andrew Cheung
- Department of Interventional Neuroradiology, The Prince of Wales Hospital, Sydney, Australia
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, Australia
| | - Nathan Manning
- Department of Interventional Neuroradiology, The Prince of Wales Hospital, Sydney, Australia
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, Australia
| | - Justin Whitley
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, Australia
| | - Dennis Cordato
- Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, Australia
- Ingham Institute of Applied Medical Research, Sydney, Australia
| | - Alessandro Zagami
- Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia
| | - Cecilia Cappelen-Smith
- Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, Australia
- Ingham Institute of Applied Medical Research, Sydney, Australia
| | - Huiqiao Tian
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Chris Levi
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - Mark Parsons
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Ingham Institute of Applied Medical Research, Sydney, Australia
| | - Ken S. Butcher
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia
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Feyen L, Kniep H, Blockhaus C, Weinzierl M, Katoh M, Haage P, Rohde S, Münnich N. Thrombectomy in ischemic stroke patients with alberta stroke program early computed tomography score 4-5 and 0-3: Factors associated with favorable outcome. J Stroke Cerebrovasc Dis 2023; 32:107104. [PMID: 37156088 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107104] [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: 11/27/2022] [Revised: 03/04/2023] [Accepted: 03/23/2023] [Indexed: 05/10/2023] Open
Abstract
OBJECTIVES Recently published results of the ANGEL-ASPECT and SELECT2 trials suggest that stroke patients presenting with low Alberta Stroke Program Early Computed Tomography Score (ASPECTS) benefit from mechanical thrombectomy. Purpose of this retrospective study was to identify factors that are associated with a favorable outcome in patients with low ASPECTS of 4-5 and 0-3 undergoing mechanical thrombectomy. MATERIAL AND METHODS All patients reported in the quality registry of the German Society for Neuroradiology that were treated between 2018 and 2020 were analyzed. Favorable outcome was defined as a National Institute of Health Stroke Scale (NIHSS) score of less than 9 at dismissal. Successful recanalization was defined as Thrombolysis in Cerebral Infarction (mTICI) ≥ 2b. Multivariable logistic regression analyses were performed to assess the association of baseline and treatment variables with favorable outcome. RESULTS 621 patients were included in the analysis, thereof 495 with ASPECTS 4-5 and 126 with ASPECTS 0-3. In patients with ASPECTS 4-5patients with favorable outcome had less severe neurological symptoms at admission with median NIHSS of 15 vs. 18 (p<0.001), had less often wake-up strokes (44% vs. 81%, p<0.001), received more often iv-lysis (37% vs. 30%, p<0.001), had more often conscious sedation (29% vs. 16%, p<0.001), had a higher rate of successful recanalization (94% vs. 66% and lower times from groin puncture to recanalization. In multivariate regression analysis lower NIHSS at admission (aOR 0.87, CI 0.89-0.91) and successful recanalization (aOR 3.96, CI 2-8.56) were associated with favorable outcome. For ASPECTS 0-3, patients with favorable outcome had lower median NIHSS at admission (16 vs. 18 (p<0.001), lower number of passes (1 vs. 3, p=0.003) and a higher rate of successful recanalization (94% vs. 66%, p<0.001) and lower times from groin puncture to recanalization. In multivariate regression analysis lower NIHSS at admission (aOR 0.87, CI 0.81-0.94) and successful recanalization, (aOR 11.19, CI 3.19-55.53), were associated with favorable outcome. CONCLUSION Full recanalization with low groin punction to recanalization times and low number of passes were associated with favorable outcome in patients with low ASPECTS.
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Affiliation(s)
- Ludger Feyen
- Department of Diagnostic and Interventional Radiology, Helios Klinikum Krefeld, Lutherplatz 40, 47805, Krefeld, Germany; University Witten/Herdecke, Faculty of Health, School of Medicine, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany; Diagnostic and Interventional Radiology, HELIOS University Hospital Wuppertal, University Witten/Herdecke, Germany, Heusnerstraße 40, 42283, Wuppertal.
| | - Helge Kniep
- Department of Neuroradiological Diagnostics and Intervention, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany
| | - Christian Blockhaus
- Heart Centre Niederrhein, Department of Cardiology, Helios Clinic Krefeld, University Witten/Herdecke, Faculty of Health, School of Medicine, Alfred-Herrhausen-Straße 50, Witten 58448, Germany
| | - Martin Weinzierl
- Department of Neurosurgery, Helios Klinikum Krefeld, Lutherplatz 40, 47805, Krefeld, Germany
| | - Marcus Katoh
- Department of Diagnostic and Interventional Radiology, Helios Klinikum Krefeld, Lutherplatz 40, 47805, Krefeld, Germany
| | - Patrick Haage
- University Witten/Herdecke, Faculty of Health, School of Medicine, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany; Department of Diagnostic and Interventional Radiology, Helios Klinikum Wuppertal, Heusnerstraße 40, 42283, Wuppertal, Germany
| | - Stefan Rohde
- University Witten/Herdecke, Faculty of Health, School of Medicine, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany; Department of Radiology and Neuroradiology, Klinikum Dortmund, Beurhausstrasse 40, 44137, Dortmund, Germany; German Society of Interventional Radiology and Minimal Invasive Therapy, German Society of Interventional Radiology and Minimal Invasive Therapy (DeGIR) and German Society of Neuroradiology (DGNR), Ernst Reuter Platz 10, Berlin 10587, Germany
| | - Nico Münnich
- University Witten/Herdecke, Faculty of Health, School of Medicine, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany; Department of Radiology and Neuroradiology, Klinikum Dortmund, Beurhausstrasse 40, 44137, Dortmund, Germany
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5
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Neurological Functional Independence After Endovascular Thrombectomy and Different Imaging Modalities for Large Infarct Core Assessment : A Systematic Review and Meta-analysis. Clin Neuroradiol 2023; 33:21-29. [PMID: 35920865 DOI: 10.1007/s00062-022-01202-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 07/10/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE To investigate the rate of neurological functional independence (NFI) at 90 days in patients with large infarct core (LIC), which was evaluated by different imaging modalities before endovascular thrombectomy (EVT). METHODS PubMed and EMBASE were searched for original studies on clinical functional outcomes at 90 days in LIC patients who received EVT treatment from inception to 28 September 2021. The pooled NFI rates were calculated using random effects model according to different imaging modalities and criteria. RESULTS We included 34 studies enrolling 2997 LIC patients. The NFI rates were 23% (95% confidence interval, CI 15-32%) and 24% (95% CI 10-38%) when LIC was defined as core volume ≥50 ml and ≥ 70 ml separately on computed tomography perfusion, 36% (95% CI 23-48%) and 21% (95% CI 17-25%) when LIC was defined as core volume ≥ 50 ml and ≥ 70 ml separately on magnetic resonance diffusion-weighted imaging (DWI), 28% (95% CI 24-32%) and 37% (95% CI 21-53%) when LIC was defined as DWI-ASPECTS ≤ 5 and ≤ 6 separately, 23% (95% CI 19-27%) and 32% (95% CI 18-46%) when LIC was defined as NCCT-ASPECTS ≤ 5 and ≤ 6 separately. CONCLUSION Similar NFI rates could be obtained after EVT in LIC patients if proper LIC criteria were select according to the imaging modality.
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Assad RM, Al Mudhafar AM, Hadi NR. THE NEUROPROTECTIVE EFFECT OF TOCILIZUMAB IN BRAIN ISCHEMIA REPERFUSION INJURY. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2023; 75:2965-2968. [PMID: 36723311 DOI: 10.36740/wlek202212112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aim: This research was conducted to assess the possible neuroprotective effect of Tocilizumab in brain ischemic reperfusion injury in rats. PATIENTS AND METHODS Materials and methods: 24 adult Sprague-Dawley rats were divided into four groups randomly. The sham group was given anesthesia at the same time as the other groups and was in the same condition as the other groups. Control group: 1 h of ischemia followed by 4 h of reperfusion. The vehicle group was the same as the control, but they were given the vehicle intraperitoneally (1 ml/kg of 0.9 % NaCl) for 7 days before the ischemia. The treatment group as the control group, but they were given tocilizumab (8 mg/ kg) intraperitoneally for 7 days before ischemia. RESULTS Results: control group, inducing ischemia/reperfusion increased infarction size considerably (p<0.001), when comparison to the control and vehicle groups, tocilizumab at dose (8 mg/kg) showed a significantly (p<0.001) smaller infraction area. CONCLUSION Conclusions: In a cerebral ischemia/reperfusion, a reduction in infarction area in injected with Tocilizumab medication was considered neuroprotective for cerebral ischemia/reperfusion.
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Affiliation(s)
- Rashid Muhssen Assad
- DEPARTMENT OF PHARMACOLOGY, FACULTY OF MEDICINE, UNIVERSITY OF KUFA, NAJAF, IRAQ
| | - Ahmed M Al Mudhafar
- DEPARTMENT OF PHARMACOLOGY, FACULTY OF MEDICINE, UNIVERSITY OF KUFA, NAJAF, IRAQ
| | - Najah R Hadi
- DEPARTMENT OF PHARMACOLOGY & THERAPEUTICS, FACULTY OF MEDICINE, UNIVERSITY OF KUFA, NAJAF, IRAQ
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Moulton E, Valabregue R, Piotin M, Marnat G, Saleme S, Lapergue B, Lehericy S, Clarencon F, Rosso C. Interpretable deep learning for the prognosis of long-term functional outcome post-stroke using acute diffusion weighted imaging. J Cereb Blood Flow Metab 2023; 43:198-209. [PMID: 36169033 PMCID: PMC9903217 DOI: 10.1177/0271678x221129230] [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: 12/17/2021] [Revised: 08/19/2022] [Accepted: 09/04/2022] [Indexed: 01/24/2023]
Abstract
Advances in deep learning can be applied to acute stroke imaging to build powerful and explainable prediction models that could supersede traditionally used biomarkers. We aimed to evaluate the performance and interpretability of a deep learning model based on convolutional neural networks (CNN) in predicting long-term functional outcome with diffusion-weighted imaging (DWI) acquired at day 1 post-stroke. Ischemic stroke patients (n = 322) were included from the ASTER and INSULINFARCT trials as well as the Pitié-Salpêtrière registry. We trained a CNN to predict long-term functional outcome assessed at 3 months with the modified Rankin Scale (dichotomized as good [mRS ≤ 2] vs. poor [mRS ≥ 3]) and compared its performance to two logistic regression models using lesion volume and ASPECTS. The CNN contained an attention mechanism, which allowed to visualize the areas of the brain that drove prediction. The deep learning model yielded a significantly higher area under the curve (0.83 95%CI [0.78-0.87]) than lesion volume (0.78 [0.73-0.83]) and ASPECTS (0.77 [0.71-0.83]) (p < 0.05). Setting all classifiers to the specificity as the deep learning model (i.e., 0.87 [0.82-0.92]), the CNN yielded a significantly higher sensitivity (0.67 [0.59-0.73]) than lesion volume (0.48 [0.40-0.56]) and ASPECTS (0.50 [0.41-0.58]) (p = 0.002). The attention mechanism revealed that the network learned to naturally attend to the lesion to predict outcome.
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Affiliation(s)
- Eric Moulton
- Institut du Cerveau et de la Moelle épinière, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, Paris, France
| | - Romain Valabregue
- Institut du Cerveau et de la Moelle épinière, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, Paris, France
- Centre de Neuro-Imagerie de Recherche, CENIR, ICM, Paris, France
| | - Michel Piotin
- Department of Diagnostic and Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Suzana Saleme
- Diagnostic and Interventional Neuroradiology, University Hospital of Limoges, Limoges, France
| | - Bertrand Lapergue
- Department of Stroke Center and Diagnostic and Interventional Neuroradiology, University of Versailles and Saint Quentin en Yvelines, Foch Hospital, Suresnes, France
| | - Stephane Lehericy
- Institut du Cerveau et de la Moelle épinière, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, Paris, France
- Centre de Neuro-Imagerie de Recherche, CENIR, ICM, Paris, France
- AP-HP Service de Neuroradiologie diagnostique, Hôpital Pitié-Salpêtrière, Paris, France
| | - Frederic Clarencon
- Institut du Cerveau et de la Moelle épinière, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, Paris, France
- AP-HP Service de Neuroradiologie interventionelle Hôpital Pitié-Salpêtrière, Paris, France
- ICM iCRIN team: STAR (Stroke Therapy And Registries)
| | - Charlotte Rosso
- Institut du Cerveau et de la Moelle épinière, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, Paris, France
- ICM iCRIN team: STAR (Stroke Therapy And Registries)
- AP-HP, Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
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8
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Gu Y, Hang Y, Jia Z, Zhao L, Shi H, Cao Y, Liu S. Predictive value of computed tomography perfusion for acute ischemic stroke patients with ASPECTS < 6 in an early time window. Clin Neurol Neurosurg 2023; 225:107605. [PMID: 36701939 DOI: 10.1016/j.clineuro.2023.107605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The standard for computed tomography perfusion (CTP) assessment has not been well established in early acute ischemic stroke (AIS). We aimed to examine the prognostic factors for good outcomes in patients who received CTP, with an Alberta Stroke Program Early CT Score (ASPECTS) < 6 after endovascular thrombectomy (EVT) in the early time window (0-6 h). METHODS We retrospectively reviewed 59 patients who met the criteria from October 2019 to April 2021. Based on the modified Rankin Score (mRS) at 90 days, the patients were divided into a good outcome group (mRS 0-2) and a poor outcome group (mRS 3-6). Baseline and procedural characteristics were collected for unilateral and multivariate regression analyses to explore the influencing factors for good outcomes. RESULTS Of the 59 patients included, good outcomes were observed in 21 (35.6%). Multivariate logistic regression analysis showed that smaller ischemic core volume (odds ratio [OR]: 0.950; 95% CI: 0.908-0.994; P = 0.026), lower National Institutes of Health Stroke Scale (NIHSS) score (OR: 0.750; 95% CI: 0.593-0.949; P = 0.017) and shorter stroke onset to reperfusion time (ORT) (OR: 0.981; 95% CI: 0.966-0.996; P = 0.016) were independent predictors for good outcomes at 90 days. CONCLUSION Smaller ischemic core volume based on CTP, lower NIHSS score and shorter ORT were significant independent predictors of good outcomes in patients with ASPECTS < 6 in the early time window after EVT.
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Affiliation(s)
- Yiming Gu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China; Department of Intervention Radiology, Suzhou Municipal Hospital Affiliated to Nanjing Medical University, 242 Guangji Road, Gusu District, Suzhou 215008, China.
| | - Yu Hang
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China.
| | - Zhenyu Jia
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China.
| | - Linbo Zhao
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China.
| | - Haibin Shi
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China.
| | - Yuezhou Cao
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China.
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, China.
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Gkantzios A, Kokkotis C, Tsiptsios D, Moustakidis S, Gkartzonika E, Avramidis T, Aggelousis N, Vadikolias K. Evaluation of Blood Biomarkers and Parameters for the Prediction of Stroke Survivors' Functional Outcome upon Discharge Utilizing Explainable Machine Learning. Diagnostics (Basel) 2023; 13:diagnostics13030532. [PMID: 36766637 PMCID: PMC9914778 DOI: 10.3390/diagnostics13030532] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 01/25/2023] [Accepted: 01/29/2023] [Indexed: 02/04/2023] Open
Abstract
Despite therapeutic advancements, stroke remains a leading cause of death and long-term disability. The quality of current stroke prognostic models varies considerably, whereas prediction models of post-stroke disability and mortality are restricted by the sample size, the range of clinical and risk factors and the clinical applicability in general. Accurate prognostication can ease post-stroke discharge planning and help healthcare practitioners individualize aggressive treatment or palliative care, based on projected life expectancy and clinical course. In this study, we aimed to develop an explainable machine learning methodology to predict functional outcomes of stroke patients at discharge, using the Modified Rankin Scale (mRS) as a binary classification problem. We identified 35 parameters from the admission, the first 72 h, as well as the medical history of stroke patients, and used them to train the model. We divided the patients into two classes in two approaches: "Independent" vs. "Non-Independent" and "Non-Disability" vs. "Disability". Using various classifiers, we found that the best models in both approaches had an upward trend, with respect to the selected biomarkers, and achieved a maximum accuracy of 88.57% and 89.29%, respectively. The common features in both approaches included: age, hemispheric stroke localization, stroke localization based on blood supply, development of respiratory infection, National Institutes of Health Stroke Scale (NIHSS) upon admission and systolic blood pressure levels upon admission. Intubation and C-reactive protein (CRP) levels upon admission are additional features for the first approach and Erythrocyte Sedimentation Rate (ESR) levels upon admission for the second. Our results suggest that the said factors may be important predictors of functional outcomes in stroke patients.
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Affiliation(s)
- Aimilios Gkantzios
- Department of Neurology, School of Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, 68100 Alexandroupolis, Greece
- Department of Neurology, Korgialeneio—Benakeio “Hellenic Red Cross” General Hospital of Athens, 11526 Athens, Greece
- Correspondence:
| | - Christos Kokkotis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece
| | - Dimitrios Tsiptsios
- Department of Neurology, School of Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Serafeim Moustakidis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece
- AIDEAS OÜ, Narva mnt 5, 10117 Tallinn, Estonia
| | - Elena Gkartzonika
- School of Philosophy, University of Ioannina, 45110 Ioannina, Greece
| | - Theodoros Avramidis
- Department of Neurology, Korgialeneio—Benakeio “Hellenic Red Cross” General Hospital of Athens, 11526 Athens, Greece
| | - Nikolaos Aggelousis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece
| | - Konstantinos Vadikolias
- Department of Neurology, School of Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, 68100 Alexandroupolis, Greece
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Lin YH, Chen CH, Tang SC, Lee CW, Yeh SJ, Tsai LK, Jeng JS. Posterior Limb of Internal Capsule Infarct Predicts Functional Outcome in Acute Terminal Internal Carotid Artery Occlusion After Thrombectomy. Clin Neuroradiol 2022; 32:951-959. [PMID: 35238949 DOI: 10.1007/s00062-022-01148-z] [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: 11/01/2021] [Accepted: 01/31/2022] [Indexed: 12/15/2022]
Abstract
PURPOSES This study investigated the impact of posterior limb of internal capsule (PLIC) infarct on outcomes of acute internal carotid artery (ICA) occlusion after endovascular thrombectomy (EVT) and the diagnostic accuracy of pretreatment noncontrast computerized tomography (NCCT) and computerized tomography angiography (CTA) findings. METHODS Patients who underwent EVT for acute ICA occlusion between September 2014 and August 2020 were included in the study. The patients were dichotomized as PLIC infarct or spared. The risk factors for PLIC infarct were investigated, and the association between infarct patterns and clinical outcomes were assessed using logistic regression analysis. Pretreatment NCCT and CTA findings, including PLIC hypodensity, choroid plexus enhancement (CPE), and posterior cerebral artery (PCA) flow status, were calculated for diagnosis of PLIC infarct. RESULTS Among 72 patients, the mean age was 70.9 years, and the mean stroke scale was 19.4. PLIC infarct was identified in 15 patients (20.8%). PLIC infarct was associated with worse 90-day functional outcome (P = 0.01, shift test). Lack of CPE is the only independent predictor of PLIC infarct (odds ratio: 127.48, P = 0.001). Lack of CPE and impaired PCA flow produce greater diagnostic accuracy for PLIC infarct than does NCCT hypodensity (area under the receiver operating characteristics curve: 0.85 and 0.76, P = 0.0005 and 0.02, respectively). CONCLUSIONS In acute ICA occlusion, PLIC infarct is an independent risk factor for worse clinical outcome at 90 days. The lack of CPE was associated with PLIC infarct, and pretreatment CTA can be useful for early diagnosis.
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Affiliation(s)
- Yen-Heng Lin
- Department of Medical Imaging, National Taiwan University Hospital, No. 7, Chung-Shan South Road, 10055, Taipei, Taiwan
| | - Chih-Hao Chen
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, No. 7, Chung-Shan South Road, 10055, Taipei, Taiwan.
| | - Shin-Joe Yeh
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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11
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Pressman E, Sands V, Flores G, Chen L, Mhaskar R, Guerrero WR, Ren Z, Mokin M. Eloquence-based reperfusion scoring and its ability to predict post-thrombectomy disability and functional status. Interv Neuroradiol 2022; 28:538-546. [PMID: 34647489 PMCID: PMC9511628 DOI: 10.1177/15910199211046424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/20/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Angiographic reperfusion after endovascular thrombectomy in acute ischemic stroke is commonly graded using volume-based reperfusion scores such as the modified thrombolysis in cerebral infarct score. The location of non-reperfused regions is not included in modified thrombolysis in cerebral infarct score. We studied the predictive ability of an eloquence-based reperfusion score. METHODS Consecutive cases of endovascular thrombectomy for anterior circulation strokes performed between January 2018 and April 2020 were included. Digital subtraction angiograms were reviewed by two blinded neurointerventionalist operators. Incomplete reperfusion was further classified by lobar regions lacking reperfusion to create various cohorts. Outcomes were graded four to seven days post-procedure with the National Institute of Health Stroke Scale (NIHSS) and 90 days post-procedure with the modified Rankin Scale. RESULTS One hundred patients were identified. Via multivariate analysis, we found that frontal lobe non-reperfusion (mean difference (MD) = -1.60, p = 0.002) and occipital lobe non-reperfusion (MD = -1.68, p = 0.001) were associated with worse mental status improvement while left-sided stroke (MD = 2.02, p < 0.001) featured better improvement post-thrombectomy. Occipital lobe non-reperfusion (MD = -0.734, p = 0.009) was associated with the worse improvement of visual fields. The non-reperfusion of the frontal lobe was associated with a 1.732-worse NIHSS hemibody strength score (95% confidence interval (95%CI) = -3.39 to -0.072, p = 0.041). Worse improvement in NIHSS scores was found to be associated with frontal lobe non-reperfusion (MD = -5.34, 95%CI = -9.52 to -1.18, p = 0.013) and occipital lobe non-reperfusion (MD = -6.35, 95%CI = -10.4 to -2.31, p = 0.002). Odds of achieving modified Rankin Scale of 0-2 at 90 days were decreased with frontal lobe non-reperfusion (odds ratio (OR) = 0.279, 95%CI = 0.090-0.869, p = 0.028) and left laterality (OR = 0.376, 95%CI = 0.153-0.922, p = 0.033). CONCLUSIONS Eloquence-based reperfusion assessment is an important predictor for functional outcomes after thrombectomy.
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Affiliation(s)
- Elliot Pressman
- Department of Neurosurgery, University of South Florida, USA
| | - Victoria Sands
- Department of Neurosurgery, University of South Florida, USA
| | - Gabriel Flores
- Department of Neurosurgery, University of South Florida, USA
| | - Liwei Chen
- Department of Internal Medicine, University of South Florida, USA
| | - Rahul Mhaskar
- Department of Internal Medicine, University of South Florida, USA
| | | | - Zeguang Ren
- Department of Neurosurgery, University of South Florida, USA
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, USA
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12
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Astrakas LG, Li S, Elbach S, Tzika AA. The Severity of Sensorimotor Tracts Degeneration May Predict Motor Performance in Chronic Stroke Patients, While Brain Structural Network Dysfunction May Not. Front Neurol 2022; 13:813763. [PMID: 35432180 PMCID: PMC9008887 DOI: 10.3389/fneur.2022.813763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/11/2022] [Indexed: 11/13/2022] Open
Abstract
Although the relationship between corticospinal tract (CST) fiber degeneration and motor outcome after stroke has been established, the relationship of sensorimotor cortical areas with CST fibers has not been clarified. Also limited research has been conducted on how abnormalities in brain structural networks are related to motor recovery. To address these gaps in knowledge, we conducted a diffusion tensor imaging (DTI) study with 12 chronic stroke patients (CSPs) and 12 age-matched healthy controls (HCs). We compared fractional anisotropy (FA) and mean diffusivity (MD) in 60 CST segments using the probabilistic sensorimotor area tract template (SMATT). Least Absolute Shrinkage and Selection Operator (LASSO) regressions were used to select independent predictors of Fugl-Meyer upper extremity (FM-UE) scores among FA and MD values of SMATT regions. The Graph Theoretical Network Analysis Toolbox was used to assess the structural network of each subject's brain. Global and nodal metrics were calculated, compared between the groups, and correlated with FM-UE scores. Mann–Whitney U-tests revealed reduced FA values in CSPs, compared to HCs, in many ipsilesional SMATT regions and in two contralesional regions. Mean FA value of the left (L.) primary motor cortex (M1)/supplementary motor area (SMA) region was predictive of FM-UE score (P = 0.004). Mean MD values for the L. M1/ventral premotor cortex (PMv) region (P = 0.001) and L. PMv/SMA region (P = 0.001) were found to be significant predictors of FM-UE scores. Network efficiency was the only global metric found to be reduced in CSPs (P = 0.006 vs. HCs). Nodal efficiency of the L. hippocampus, L. parahippocampal gyrus, L. fusiform gyrus (P = 0.001), and nodal local efficiency of the L. supramarginal gyrus (P < 0.001) were reduced in CSPs relative to HCs. No graph metric was associated with FM-UE scores. In conclusion, the integrity of CSTs connected to M1, SMA, and PMv were shown to be independent predictors of motor performance in CSPs, while stroke-induced topological changes in the brain's structural connectome may not be. A sensorimotor cortex-specific tract template can refine CST degeneration data and the relationship of CST degeneration with motor performance.
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Affiliation(s)
- Loukas G. Astrakas
- Department of Medical Physics, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Shasha Li
- Department of Radiology, Athinoula A. Martinos Center of Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- NMR Surgical Laboratory, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Sabrina Elbach
- Department of Radiology, Athinoula A. Martinos Center of Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- NMR Surgical Laboratory, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - A. Aria Tzika
- Department of Radiology, Athinoula A. Martinos Center of Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- NMR Surgical Laboratory, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- *Correspondence: A. Aria Tzika
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Arfianti L, Rochman F, Hidayati HB, Subadi I. The addition of mirror therapy improved upper limb motor recovery and level of independence after stroke: a randomized controlled trial. CADERNOS BRASILEIROS DE TERAPIA OCUPACIONAL 2022. [DOI: 10.1590/2526-8910.ctoao245932182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Introduction In stroke survivors, the prevalence of upper motor disability remains high. There has not been much report on the success of post-stroke mirror therapy, especially in developing countries. Objective The focus of this research is to see how mirror therapy, in addition to standard rehabilitation for hand paresis, affects upper limb motor recovery and level of independence in self-care after stroke at an Indonesian teaching hospital. Method This was a randomized controlled trial with no assessor blinding. The study included 18 subacute stroke patients who did not have cognitive or visual impairment. The mirror group received a 20-minute mirror therapy session in addition to conventional rehabilitation, while the control group received only the standard program for 5 weeks (2 times per week). The Brunnstrom score and self-care level of independence elements of the Functional Independence Measure (FIM) were used as outcome measures. Results Baseline comparisons of lesion type and Brunnstrom score showed significant between-group differences. The ANACOVA test showed the difference had no effect on the FIM change in scores (P > 0.05). One patient (mirror group) was dropped out from the study. After 5 weeks (n=17), the mirror group showed improvement in both the Brunnstrom and FIM scores (P < 0.05) compared to the control group. Conclusions Mirror treatment improves upper limb motor recovery and level of independence in self-care after stroke when combined with standard hand paresis rehabilitation 2 times a week for 5 weeks.
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Nayak RR, Narayanaswamy S. Association of serum calcium levels with infarct volume and stroke scores in acute ischemic stroke patients: An observational study. CASPIAN JOURNAL OF INTERNAL MEDICINE 2022; 13:780-785. [PMID: 36420322 PMCID: PMC9659820 DOI: 10.22088/cjim.13.4.779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Stroke vastly contributes to death and disability worldwide. Acute ischemic stroke (AIS) is caused by a reduction in supply of blood to the brain. Accumulation of unnecessary intracellular serum calcium in AIS induces the cytotoxic actions that activates enzymes involved in cell death. The present investigation assessed the relationship of total serum calcium level (at admission) and initial diffusion weighted imaging (DWI) infarct volume and correlated with National Institute of Health Stroke Scale (NIHSS) scores. METHODS A hospital-based observational study was conducted on 74 consecutive patients identified with AIS fulfilling the inclusion criteria. NIHSS scores and serum ionized calcium were calculated in every patient and compared with DWI infarct volume for assessing correlation between these three. Statistical software R Version 4.0.2 and Microsoft Excel were used for statistical analysis. RESULTS Out of the 74 patients, most of them were in age group of 50-69 years, with a male preponderance (68.9%). A significant association was noticed between diabetes and dyslipidemia with age (P=0.01499). A strong negative correlation was observed between NIHSS scores (at admission & discharge) with ionized calcium, while a strong positive correlation was noticed between stroke scores with infarct volume. A statistically significant negative correlation was recorded between serum calcium (on admission) and infarct size (r=-0.851755, P=0.0001). The mean of NIHSS scores on admission (8.24±5.19) has been remarkably higher when compared with NIHSS scores at discharge (5.25±3.89). CONCLUSION In patients with AIS examined within 6-24 hours of symptoms onset, serum ionized calcium and volume of infarct on DWI showed inverse association. Serum calcium serves as a marker of severity and acts as prognostic factor in AIS.
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Affiliation(s)
- Ramya R Nayak
- Department of General Medicine, Ramaiah Medical College and Hospital, Bengaluru 560 054, Karnataka, India
| | - Srikanth Narayanaswamy
- Department of General Medicine, Ramaiah Medical College and Hospital, Bengaluru 560 054, Karnataka, India
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15
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Werdiger F, Bivard A, Parsons M. Artificial Intelligence in Acute Ischemic Stroke. Artif Intell Med 2022. [DOI: 10.1007/978-3-030-64573-1_287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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16
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Luger S, Koerbel K, Martinez Oeckel A, Schneider H, Maurer CJ, Hintereder G, Wagner M, Hattingen E, Foerch C. Role of S100B Serum Concentration as a Surrogate Outcome Parameter After Mechanical Thrombectomy. Neurology 2021; 97:e2185-e2194. [PMID: 34635559 PMCID: PMC8641970 DOI: 10.1212/wnl.0000000000012918] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 09/20/2021] [Indexed: 11/24/2022] Open
Abstract
Background and Objectives To establish serum concentration of protein S100B as an objective biomarker surrogate for astroglial tissue damage after mechanical thrombectomy in patients with acute ischemic stroke. Methods This prospective 2-center study recruited patients with acute middle cerebral artery infarctions caused by large vessel occlusion treated with mechanical thrombectomy. Blood samples were collected at day 2 after intervention and analyzed for S100B serum concentrations using ELISA techniques. Infarct size was determined on follow-up brain imaging and functional outcome according to modified Rankin Scale (mRS) was assessed at 90 days. Results A total of 171 patients were included (mean age ± SD: 70 ± 14 years, 42% female). S100B levels correlated with infarct size. Median S100B concentrations at day 2 after intervention were lower in patients with favorable outcome (mRS score 0–1) at 90 days compared to patients with unfavorable outcome (mRS score 2–6) (median 0.10 µg/L [interquartile range 0.07–0.14] vs 0.20 µg/L [0.11–0.48], p < 0.001). Younger age (odds ratio [OR] 1.120 [confidence interval (CI) 1.068–1.174]; p < 0.001), lower National Institutes of Health Stroke Scale score 24 hours after symptom onset (OR 1.232 [CI 1.106–1.372]; p < 0.001), and lower S100B serum concentrations (OR 1.364 [CI 1.105–1.683]; p = 0.004) were independently associated with a favorable outcome. S100B was able to eliminate the lateralization bias associated with the use of mRS for functional outcome assessment at 90 days after stroke. Discussion S100B serum concentrations after mechanical thrombectomy indicate the extent of ischemic tissue damage. This can be assessed rapidly, independent of brain imaging and clinical outcome scales. Following prospective validation in further studies, this may provide an objective surrogate outcome measure both in clinical routine and interventional trials. Classification of Evidence This study provides Class I evidence that S100B 2 days following mechanical thrombectomy for acute ischemic stroke accurately distinguishes favorable from unfavorable functional outcome.
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Affiliation(s)
- Sebastian Luger
- From the Department of Neurology (S.L., K.K., A.M.O., C.F.), Central Laboratory (G.H.), and Institute of Neuroradiology (M.W., E.H.), University Hospital Frankfurt / Goethe University Frankfurt; and Departments of Neurology (H.S.) and Diagnostic and Interventional Radiology and Neuroradiology (C.J.M.), University Hospital Augsburg, Germany.
| | - Kimberly Koerbel
- From the Department of Neurology (S.L., K.K., A.M.O., C.F.), Central Laboratory (G.H.), and Institute of Neuroradiology (M.W., E.H.), University Hospital Frankfurt / Goethe University Frankfurt; and Departments of Neurology (H.S.) and Diagnostic and Interventional Radiology and Neuroradiology (C.J.M.), University Hospital Augsburg, Germany
| | - Ariane Martinez Oeckel
- From the Department of Neurology (S.L., K.K., A.M.O., C.F.), Central Laboratory (G.H.), and Institute of Neuroradiology (M.W., E.H.), University Hospital Frankfurt / Goethe University Frankfurt; and Departments of Neurology (H.S.) and Diagnostic and Interventional Radiology and Neuroradiology (C.J.M.), University Hospital Augsburg, Germany
| | - Hauke Schneider
- From the Department of Neurology (S.L., K.K., A.M.O., C.F.), Central Laboratory (G.H.), and Institute of Neuroradiology (M.W., E.H.), University Hospital Frankfurt / Goethe University Frankfurt; and Departments of Neurology (H.S.) and Diagnostic and Interventional Radiology and Neuroradiology (C.J.M.), University Hospital Augsburg, Germany
| | - Christoph J Maurer
- From the Department of Neurology (S.L., K.K., A.M.O., C.F.), Central Laboratory (G.H.), and Institute of Neuroradiology (M.W., E.H.), University Hospital Frankfurt / Goethe University Frankfurt; and Departments of Neurology (H.S.) and Diagnostic and Interventional Radiology and Neuroradiology (C.J.M.), University Hospital Augsburg, Germany
| | - Gudrun Hintereder
- From the Department of Neurology (S.L., K.K., A.M.O., C.F.), Central Laboratory (G.H.), and Institute of Neuroradiology (M.W., E.H.), University Hospital Frankfurt / Goethe University Frankfurt; and Departments of Neurology (H.S.) and Diagnostic and Interventional Radiology and Neuroradiology (C.J.M.), University Hospital Augsburg, Germany
| | - Marlies Wagner
- From the Department of Neurology (S.L., K.K., A.M.O., C.F.), Central Laboratory (G.H.), and Institute of Neuroradiology (M.W., E.H.), University Hospital Frankfurt / Goethe University Frankfurt; and Departments of Neurology (H.S.) and Diagnostic and Interventional Radiology and Neuroradiology (C.J.M.), University Hospital Augsburg, Germany
| | - Elke Hattingen
- From the Department of Neurology (S.L., K.K., A.M.O., C.F.), Central Laboratory (G.H.), and Institute of Neuroradiology (M.W., E.H.), University Hospital Frankfurt / Goethe University Frankfurt; and Departments of Neurology (H.S.) and Diagnostic and Interventional Radiology and Neuroradiology (C.J.M.), University Hospital Augsburg, Germany
| | - Christian Foerch
- From the Department of Neurology (S.L., K.K., A.M.O., C.F.), Central Laboratory (G.H.), and Institute of Neuroradiology (M.W., E.H.), University Hospital Frankfurt / Goethe University Frankfurt; and Departments of Neurology (H.S.) and Diagnostic and Interventional Radiology and Neuroradiology (C.J.M.), University Hospital Augsburg, Germany
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Liu C, Song JX, Guo ZB, Chen LM, Zhao CH, Zi WJ, Yang QW. Prognostic Structural Neural Markers of MRI in Response to Mechanical Thrombectomy for Basilar Artery Occlusion. Front Neurol 2021; 12:593914. [PMID: 34177752 PMCID: PMC8220209 DOI: 10.3389/fneur.2021.593914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 04/19/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Mechanical thrombectomy (MT) has been an effective first-line therapeutic strategy for ischemic stroke. With impairment characteristics separating it from anterior circulation stroke, we aimed to explore prognostic structural neural markers for basilar artery occlusion (BAO) after MT. Methods: Fifty-four BAO patients with multi-modal magnetic resonance imaging at admission from the multicenter real-world designed BASILAR research were enrolled in this study. Features including volumes for cortical structures and subcortical regions, locations and volumes of infarctions, and white matter hyperintensity (WMH) volumes were recorded from all individuals. The impact features were identified using ANCOVA and logistic analysis. Another cohort (n = 21) was further recruited to verify the prognostic roles of screened prognostic structures. Results: For the primary clinical outcome, decreased brainstem volume and total infarction volumes from mesencephalon and midbrain were significantly related to reduced 90-day modified Rankin score (mRS) after MT treatment. WMH volume, WMH grade, average cortex thickness, white matter volume, and gray matter volume did not exhibit a remarkable relationship with the prognosis of BAO. The increased left caudate volume was obviously associated with early symptomatic recovery after MT. The prognostic role of the ratio of pons and midbrain infarct volume in brainstem was further confirmed in another cohort with area under the curve (AUC) = 0.77. Conclusions: This study was the first to provide comprehensive structural markers for the prognostic evaluation of BAO. The fully automatic and semiautomatic segmentation approaches in our study supported that the proportion of mesencephalon and midbrain infarct volume in brainstem was a crucial prognostic structural neural marker for BAO.
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Affiliation(s)
- Chang Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jia-Xin Song
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhang-Bao Guo
- Department of Neurology, Wuhan No. 1 Hospital, Chongqing, China
| | - Lu-Ming Chen
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Chen-Hao Zhao
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Wen-Jie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Qing-Wu Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
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Liu Y, Gebrezgiabhier D, Reddy AS, Davis E, Zheng Y, Arturo Larco JL, Shih AJ, Pandey AS, Savastano LE. Failure modes and effects analysis of mechanical thrombectomy for stroke discovered in human brains. J Neurosurg 2021; 136:197-204. [PMID: 34087793 DOI: 10.3171/2020.11.jns203684] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite advancement of thrombectomy technologies for large-vessel occlusion (LVO) stroke and increased user experience, complete recanalization rates linger around 50%, and one-third of patients who have undergone successful recanalization still experience poor neurological outcomes. To enhance the understanding of the biomechanics and failure modes, the authors conducted an experimental analysis of the interaction of emboli/artery/devices in the first human brain test platform for LVO stroke described to date. METHODS In 12 fresh human brains, 105 LVOs were recreated by embolizing engineered emboli analogs and recanalization was attempted using aspiration catheters and/or stent retrievers. The complex mechanical interaction between diverse emboli (elastic, stiff, and fragment prone), arteries (anterior and posterior circulation), and thrombectomy devices were observed, analyzed, and categorized. The authors systematically evaluated the recanalization process through failure modes and effects analysis, and they identified where and how thrombectomy devices fail and the impact of device failure. RESULTS The first-pass effect (34%), successful (71%), and complete (60%) recanalization rates in this model were consistent with those in the literature. Failure mode analysis of 184 passes with thrombectomy devices revealed the following. 1) Devices loaded the emboli with tensile forces leading to elongation and intravascular fragmentation. 2) In the presence of anterograde flow, small fragments embolize to the microcirculation and large fragments result in recurrent vessel occlusion. 3) Multiple passes are required due to recurrent (15%) and residual (73%) occlusions, or both (12%). 4) Residual emboli remained in small branching and perforating arteries in cases of alleged complete recanalization (28%). 5) Vacuum caused arterial collapse at physiological pressures (27%). 6) Device withdrawal caused arterial traction (41%), and severe traction provoked avulsion of perforating and small branching arteries. CONCLUSIONS Biomechanically superior thrombectomy technologies should prevent unrestrained tensional load on emboli, minimize intraluminal embolus fragmentation and release, improve device/embolus integration, recanalize small branching and perforating arteries, prevent arterial collapse, and minimize traction.
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Affiliation(s)
- Yang Liu
- Departments of1Mechanical Engineering and.,Departments of2Radiology and
| | - Daniel Gebrezgiabhier
- 3Neurosurgery, University of Michigan, Ann Arbor, Michigan.,4UC Berkeley-UCSF Graduate Program in Bioengineering, San Francisco, California; and
| | | | - Evan Davis
- Departments of1Mechanical Engineering and
| | - Yihao Zheng
- Departments of1Mechanical Engineering and.,5Department of Mechanical Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts
| | | | | | | | - Luis E Savastano
- 3Neurosurgery, University of Michigan, Ann Arbor, Michigan.,6Neurosurgery, Mayo Clinic, Rochester, Minnesota
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19
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Oki Y, Sakakibara F, Uchida K, Kageyama H, Yasaka M, Toyoda K, Mori E, Hirano T, Hamasaki T, Yamagami H, Nagao T, Uchiyama S, Minematsu K, Yoshimura S. ASPECTS-Region-Dependent Functional Outcomes after Endovascular Therapy in Patients with Cardioembolic Stroke. J Stroke Cerebrovasc Dis 2021; 30:105814. [PMID: 33915390 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 04/02/2021] [Accepted: 04/05/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Cardioembolic stroke has a poor prognosis. We evaluated the region-dependent efficacy of endovascular therapy (EVT) based on diffusion-weighted imaging-Alberta Stroke Program Early CT Score (DWI-ASPECTS). METHODS This post-hoc analysis of the RELAXED study, which investigated the optimal timing of rivaroxaban to prevent nonvalvular atrial fibrillation (NVAF) recurrence in patients with acute ischemic stroke (AIS), included NVAF patients admitted with AIS or transient ischemic attack in the middle cerebral artery (MCA), with internal carotid artery (ICA), M1, or M2-MCA occlusion. Relationships between DWI-ASPECTS region and functional outcome (modified Rankin Scale [mRS]), mortality, recurrence, and hemorrhagic stroke were compared between patients with and without EVT, and adjusted odds ratios for age, pre-stroke mRS, National Institutes of Health Stroke Scale (NIHSS), ICA occlusion, infarct size, recombinant tissue plasminogen activator (rt-PA) use, and onset-to-hospitalization time were estimated. RESULTS EVT patients had significantly lower hemoglobin levels, higher median NIHSS scores, more lentiform nucleus infarcts, ICA or M1-MCA occlusions, treatment with rt-PA, and fewer M3, M5, or M6 infarcts and M2-MCA occlusions than no-EVT patients. EVT patients had shorter onset-to-hospitalization times and more frequent favorable functional outcomes (p=0.007). Mortality, recurrent ischemic stroke, and hemorrhagic infarction were similar in both groups. EVT was associated with significantly better functional outcomes among patients with insular ribbon (p=0.043) and M3 (p=0.0008) infarcts. M3 patients had significantly fewer rt-PA and EVT, and longer onset-to-hospitalization times. CONCLUSIONS An occlusion in the insular ribbon or M3 region was associated with favorable functional outcomes in patients treated with EVT after cardioembolic stroke.
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Affiliation(s)
- Yoshiharu Oki
- Department of Neurosurgery, Goushi Hospital, Amagasaki, Japan
| | | | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroto Kageyama
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Etsuro Mori
- Department of Behavioral Neurology and Neuropsychiatry, United Graduate School of Child Development, Osaka University, Suita, Japan
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Tokyo, Japan
| | | | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Takehiko Nagao
- Department of Neurology, Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan
| | - Shinichiro Uchiyama
- Clinical Research Center for Medicine, International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Medical Center, Tokyo, Japan
| | - Kazuo Minematsu
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.
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20
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Stueckelschweiger L, Tiedt S, Puhr-Westerheide D, Fabritius MP, Mueller F, Kellert L, Maurus S, Grosu S, Rueckel J, Herzberg M, Liebig T, Ricke J, Dimitriadis K, Kunz WG, Reidler P. Decomposing Acute Symptom Severity in Large Vessel Occlusion Stroke: Association With Multiparametric CT Imaging and Clinical Parameters. Front Neurol 2021; 12:651387. [PMID: 33776900 PMCID: PMC7991695 DOI: 10.3389/fneur.2021.651387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 02/15/2021] [Indexed: 12/11/2022] Open
Abstract
Background and Purpose: Acute ischemic stroke of the anterior circulation due to large vessel occlusion (LVO) is a multifactorial process, which causes neurologic symptoms of different degree. Our aim was to examine the impact of neuromorphologic and vascular correlates as well as clinical factors on acute symptom severity in LVO stroke. Methods: We selected LVO stroke patients with known onset time from a consecutive cohort which underwent multiparametric CT including non-contrast CT, CT angiography and CT perfusion (CTP) before thrombectomy. Software-based quantification was used to calculate CTP total ischemic and ischemic core volume. Symptom severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) upon admission. Multivariable regression analysis was performed to determine independent associations of admission NIHSS with imaging and clinical parameters. Receiver operating characteristics (ROC) analyses were used to examine performance of imaging parameters to classify symptom severity. Results: We included 142 patients. Linear and ordinal regression analyses for NIHSS and NIHSS severity groups identified significant associations for total ischemic volume [β = 0.31, p = 0.01; Odds ratio (OR) = 1.11, 95%-confidence-interval (CI): 1.02-1.19], clot burden score (β = -0.28, p = 0.01; OR = 0.76, 95%-CI: 0.64-0.90) and age (β = 0.17, p = 0.04). No association was found for ischemic core volume, stroke side, collaterals and time from onset. Stroke topography according to the Alberta Stroke Program CT Score template did not display significant influence after correction for multiple comparisons. AUC for classification of the NIHSS threshold ≥6 by total ischemic volume was 0.81 (p < 0.001). Conclusions: We determined total ischemic volume, clot burden and age as relevant drivers for baseline NIHSS in acute LVO stroke. This suggests that not only mere volume but also degree of occlusion influences symptom severity. Use of imaging parameters as surrogate for baseline NIHSS reached limited performance underlining the need for combined clinical and imaging assessment in acute stroke management.
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Affiliation(s)
- Lena Stueckelschweiger
- Department of Radiology, University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Daniel Puhr-Westerheide
- Department of Radiology, University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Matthias P Fabritius
- Department of Radiology, University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Franziska Mueller
- Department of Radiology, University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Stefan Maurus
- Department of Radiology, University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Sergio Grosu
- Department of Radiology, University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Johannes Rueckel
- Department of Radiology, University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Moriz Herzberg
- Institute of Neuroradiology, University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany.,Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Würzburg, Germany
| | - Thomas Liebig
- Institute of Neuroradiology, University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Konstantinos Dimitriadis
- Institute for Stroke and Dementia Research, University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany.,Department of Neurology, University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Paul Reidler
- Department of Radiology, University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany
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21
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Peng Y, Li Q, Qin L, He Y, Luo X, Lan Y, Chen X, Wang X, Wang QM. Combination of Serum Neurofilament Light Chain Levels and MRI Markers to Predict Cognitive Function in Ischemic Stroke. Neurorehabil Neural Repair 2021; 35:247-255. [PMID: 33522401 DOI: 10.1177/1545968321989354] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND It is important to predict poststroke cognitive outcome to guide individualized treatment and prevention strategy. We aimed to evaluate the predictive value of the combination of a serum biomarker for axonal damage (neurofilament light chain [NfL]) and neuroimaging markers (volume of infarction and white matter hyperintensities [WMH]) for neuronal abnormality in poststroke cognitive outcome. METHODS A total of 1028 patients were screened; among them, 144 patients with acute ischemic stroke (stroke group) and 30 patients without stroke (control group) were enrolled. Serum NfL levels of samples obtained from both groups were measured through single molecule array assay. Neuroimaging markers of neuroaxonal injury, including infarct volume and WMH in the stroke group were quantified on magnetic resonance images using an in-house MATLAB code (MATLAB 2017; MathWorks). The primary outcome was the functional independence measure (FIM) cognitive subscores on discharge. We assessed the association of serum NfL levels and neuroimaging markers with cognitive outcome. The prognosis value of the combination of serum NfL levels and imaging markers for predicting FIM cognitive subscores on discharge was calculated using the area under curve (AUC) of the receiver operating characteristic. RESULTS Serum NfL levels of the stroke group were 9-fold higher than those of the control group (1449.7 vs 157.2 pg/mL, n = 144/30, P < .001). There was a correlation of serum NfL levels with infarct volume (r = 0.530, P < .001) and functional outcome, including FIM cognitive subscores (r = -0.387, P < .001) and FIM motor subscores on admission (r = -0.306, P < .001), but not with WMH volume after adjusting for infarct volume (r = -0.196, P = .245). Serum NfL levels on admission independently predicted poststroke FIM cognitive subscores on discharge (AUC = 0.672, P < .001). The predictive value for poststroke cognitive outcome was improved by combining serum NfL levels with infarct and WMH volume (AUC = 0.760, P < .001). CONCLUSION The combination of serum NfL levels with volume of infarct and WMH shows an improved predictive value for cognitive function during acute rehabilitation phase after stroke, providing a promising panel of biomarkers for prognosis and guidance of treatment.
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Affiliation(s)
- Yuan Peng
- Spaulding Rehabilitation Hospital, the teaching affiliate of Harvard Medical School, Charlestown, MA, USA.,Guangzhou First People's Hospital, Second Affiliated Hospital of South China University of Technology, Guangzhou, Guangdong, China
| | - Qianfeng Li
- Spaulding Rehabilitation Hospital, the teaching affiliate of Harvard Medical School, Charlestown, MA, USA.,Shenzhen Dapeng New District Nan'ao People's Hospital, Shenzhen, China
| | - Lei Qin
- Dana-Farber Cancer Institute, Boston, MA, USA
| | - Yating He
- Spaulding Rehabilitation Hospital, the teaching affiliate of Harvard Medical School, Charlestown, MA, USA.,Tianjin Medical University General Hospital, Tianjin, China
| | - Xun Luo
- Shenzhen Dapeng New District Nan'ao People's Hospital, Shenzhen, China.,Kerry Rehabilitation Medicine Research Institute, Shenzhen, Guangdong, China
| | - Yue Lan
- Guangzhou First People's Hospital, Second Affiliated Hospital of South China University of Technology, Guangzhou, Guangdong, China
| | - Xin Chen
- Guangzhou First People's Hospital, Second Affiliated Hospital of South China University of Technology, Guangzhou, Guangdong, China
| | - Xin Wang
- Spaulding Rehabilitation Hospital, the teaching affiliate of Harvard Medical School, Charlestown, MA, USA.,Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Qing Mei Wang
- Spaulding Rehabilitation Hospital, the teaching affiliate of Harvard Medical School, Charlestown, MA, USA
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22
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Artificial Intelligence in Acute Ischemic Stroke. Artif Intell Med 2021. [DOI: 10.1007/978-3-030-58080-3_287-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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23
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Regenhardt RW, Etherton MR, Das AS, Schirmer MD, Hirsch JA, Stapleton CJ, Patel AB, Leslie-Mazwi TM, Rost NS. White Matter Acute Infarct Volume After Thrombectomy for Anterior Circulation Large Vessel Occlusion Stroke is Associated with Long Term Outcomes. J Stroke Cerebrovasc Dis 2020; 30:105567. [PMID: 33385939 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105567] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/15/2020] [Accepted: 12/17/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES Despite the proven efficacy of endovascular thrombectomy (EVT) for large vessel occlusion stroke, over half treated remain functionally disabled or die. Infarct topography may have implications for prognostication, patient selection, and the development of tissue-specific neuroprotective agents. We sought to quantify white matter injury in anterior circulation acute infarcts post-EVT to understand its significance and identify its determinants. MATERIALS AND METHODS Demographics, history, presentations, and outcomes for consecutive patients treated with EVT were recorded in a prospectively maintained database at a single center. Acute infarct masks were coregistered to standard space. Standard atlases of white matter, cortex, and basal ganglia were used to determine region-specific infarct volumes. RESULTS 167 individuals were identified with median age 69 years and 53% women. 85% achieved adequate reperfusion (TICI 2b-3) after EVT; 43% achieved 90-day functional independence (mRS 0-2). Median infarct volumes were 45cc (IQR 18-122) for total, 17cc (6-49) for white matter, 21cc (4-53) for cortex, and 5cc (1-8) for basal ganglia. The odds of 90-day mRS 0-2 were reduced in patients with larger white matter infarct volume (cc, OR=0.89, 95%CI=0.81-0.96), independent of cortex infarct volume, basal ganglia infarct volume, age, NIHSS, and TICI 2b-3 reperfusion. Reperfusion-to-MRI time was associated with white matter infarct volume (hr, β=0.119, p=0.017), but not cortical or basal ganglia infarct volume. CONCLUSIONS These data quantitatively describe region-specific infarct volumes after EVT and suggest the clinical relevance of white matter infarct volume as a predictor of long-term outcomes. Further study is warranted to examine delayed white matter infarction and the significance of specific white matter tracts.
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Affiliation(s)
- Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA; Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, USA.
| | - Mark R Etherton
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA
| | - Alvin S Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA
| | - Markus D Schirmer
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, USA
| | | | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, USA
| | - Thabele M Leslie-Mazwi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA; Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, USA
| | - Natalia S Rost
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA
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24
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Cognitive declines after perioperative covert stroke: Recent advances and perspectives. Curr Opin Anaesthesiol 2020; 33:651-654. [PMID: 32796168 DOI: 10.1097/aco.0000000000000903] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW With the aging of the population, there are increasing number of aged patients who require surgical interventions. Perioperative covert stroke is emerging as an important health threat and social burden that could affect patients' long-term neurological outcomes. RECENT FINDINGS Recent findings of the association between perioperative covert stroke with long-term cognitive declines of surgical patients highlighted the significance of the silent cognitive function killer-perioperative covert stroke. Considering the devastating long-term consequence of the asymptomatic covert stroke, early diagnosis and prevention are turning out as crucial problems to tackle. The evolving brain imaging techniques, such as multimodel MRI sequences are not only able to detect early, small and subtle injuries of the acute ischemic lesions, but also quite advantageous in capturing the preexisting brain vascular diseases that are considered as important risk factors of covert stroke. However, effective predictive markers are still lacking to identify high risk patients for perioperative covert stroke, rendering an unmet need of investigations in this regard. SUMMARY The present review will summarize recent findings in perioperative covert stroke and highlight future perspectives of its early diagnosis and the impact of postoperative cognitive impairments.
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25
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Grønning Hansen M, Laterza C, Palma-Tortosa S, Kvist G, Monni E, Tsupykov O, Tornero D, Uoshima N, Soriano J, Bengzon J, Martino G, Skibo G, Lindvall O, Kokaia Z. Grafted human pluripotent stem cell-derived cortical neurons integrate into adult human cortical neural circuitry. Stem Cells Transl Med 2020; 9:1365-1377. [PMID: 32602201 PMCID: PMC7581452 DOI: 10.1002/sctm.20-0134] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/27/2020] [Accepted: 06/10/2020] [Indexed: 12/13/2022] Open
Abstract
Several neurodegenerative diseases cause loss of cortical neurons, leading to sensory, motor, and cognitive impairments. Studies in different animal models have raised the possibility that transplantation of human cortical neuronal progenitors, generated from pluripotent stem cells, might be developed into a novel therapeutic strategy for disorders affecting cerebral cortex. For example, we have shown that human long‐term neuroepithelial‐like stem (lt‐NES) cell‐derived cortical neurons, produced from induced pluripotent stem cells and transplanted into stroke‐injured adult rat cortex, improve neurological deficits and establish both afferent and efferent morphological and functional connections with host cortical neurons. So far, all studies with human pluripotent stem cell‐derived neurons have been carried out using xenotransplantation in animal models. Whether these neurons can integrate also into adult human brain circuitry is unknown. Here, we show that cortically fated lt‐NES cells, which are able to form functional synaptic networks in cell culture, differentiate to mature, layer‐specific cortical neurons when transplanted ex vivo onto organotypic cultures of adult human cortex. The grafted neurons are functional and establish both afferent and efferent synapses with adult human cortical neurons in the slices as evidenced by immuno‐electron microscopy, rabies virus retrograde monosynaptic tracing, and whole‐cell patch‐clamp recordings. Our findings provide the first evidence that pluripotent stem cell‐derived neurons can integrate into adult host neural networks also in a human‐to‐human grafting situation, thereby supporting their potential future clinical use to promote recovery by neuronal replacement in the patient's diseased brain.
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Affiliation(s)
| | - Cecilia Laterza
- Lund Stem Cell Center, Lund University, Lund, Sweden.,Laboratory of Stem Cells and Restorative Neurology, Lund Stem Cell Center, Lund University, Lund, Sweden
| | - Sara Palma-Tortosa
- Lund Stem Cell Center, Lund University, Lund, Sweden.,Laboratory of Stem Cells and Restorative Neurology, Lund Stem Cell Center, Lund University, Lund, Sweden
| | - Giedre Kvist
- Lund Stem Cell Center, Lund University, Lund, Sweden.,Laboratory of Stem Cells and Restorative Neurology, Lund Stem Cell Center, Lund University, Lund, Sweden
| | - Emanuela Monni
- Lund Stem Cell Center, Lund University, Lund, Sweden.,Laboratory of Stem Cells and Restorative Neurology, Lund Stem Cell Center, Lund University, Lund, Sweden
| | - Oleg Tsupykov
- Bogomoletz Institute of Physiology and State Institute of Genetic and Regenerative Medicine, Kyiv, Ukraine
| | - Daniel Tornero
- Laboratory of Stem Cells and Regenerative Medicine, Institute of Neurosciences, University of Barcelona, Barcelona, Spain
| | - Naomi Uoshima
- Lund Stem Cell Center, Lund University, Lund, Sweden.,Laboratory of Stem Cells and Restorative Neurology, Lund Stem Cell Center, Lund University, Lund, Sweden
| | - Jordi Soriano
- Departament de Física de la Matèria Condensada, Institute of Complex Systems (UBICS), Universitat de Barcelona, Barcelona, Spain
| | - Johan Bengzon
- Lund Stem Cell Center, Lund University, Lund, Sweden.,Division of Neurosurgery, Department of Clinical Sciences Lund, University Hospital, Lund, Sweden
| | - Gianvito Martino
- Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy
| | - Galyna Skibo
- Bogomoletz Institute of Physiology and State Institute of Genetic and Regenerative Medicine, Kyiv, Ukraine
| | - Olle Lindvall
- Lund Stem Cell Center, Lund University, Lund, Sweden.,Laboratory of Stem Cells and Restorative Neurology, Lund Stem Cell Center, Lund University, Lund, Sweden
| | - Zaal Kokaia
- Lund Stem Cell Center, Lund University, Lund, Sweden.,Laboratory of Stem Cells and Restorative Neurology, Lund Stem Cell Center, Lund University, Lund, Sweden
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26
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Abstract
Despite advances in understanding the cause of ischemic stroke, cryptogenic stroke remains a diagnostic and therapeutic challenge for clinicians. Approximately 15% to 40% of all ischemic strokes have no identifiable cause. CS is a diagnosis of exclusion after completing the standard stroke work-up. Further investigation needs to be tailored individually according to results of the clinical evaluation so appropriate secondary prevention strategies can be applied.
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Affiliation(s)
- Mary P Amatangelo
- Neurology, Stroke, Neurocritical Care, Brigham and Women's Hospital, 15 Francis Street, BB 335, Boston, MA 02115, USA.
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27
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Kaesmacher J, Chaloulos-Iakovidis P, Panos L, Mordasini P, Michel P, Hajdu SD, Ribo M, Requena M, Maegerlein C, Friedrich B, Costalat V, Benali A, Pierot L, Gawlitza M, Schaafsma J, Mendes Pereira V, Gralla J, Fischer U. Mechanical Thrombectomy in Ischemic Stroke Patients With Alberta Stroke Program Early Computed Tomography Score 0-5. Stroke 2020; 50:880-888. [PMID: 30827193 PMCID: PMC6430594 DOI: 10.1161/strokeaha.118.023465] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— If anterior circulation large vessel occlusion acute ischemic stroke patients presenting with ASPECTS 0–5 (Alberta Stroke Program Early CT Score) should be treated with mechanical thrombectomy remains unclear. Purpose of this study was to report on the outcome of patients with ASPECTS 0–5 treated with mechanical thrombectomy and to provide data regarding the effect of successful reperfusion on clinical outcomes and safety measures in these patients. Methods— Multicenter, pooled analysis of 7 institutional prospective registries: Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the SOLITAIRE FR With the Intention for Thrombectomy (Clinical Trial Registration—URL: https://www.clinicaltrials.gov. Unique identifier: NCT03496064). Primary outcome was defined as modified Rankin Scale 0–3 at day 90 (favorable outcome). Secondary outcomes included rates of day 90 modified Rankin Scale 0–2 (functional independence), day 90 mortality and occurrence of symptomatic intracerebral hemorrhage. Multivariable logistic regression analyses were performed to assess the association of successful reperfusion with clinical outcomes. Outputs are displayed as adjusted Odds Ratios (aOR) and 95% CI. Results— Two hundred thirty-seven of 2046 patients included in this registry presented with anterior circulation large vessel occlusion and ASPECTS 0–5. In this subgroup, the overall rates of favorable outcome and mortality at day 90 were 40.1% and 40.9%. Achieving successful reperfusion was independently associated with favorable outcome (aOR, 5.534; 95% CI, 2.363–12.961), functional independence (aOR, 5.583; 95% CI, 1.964–15.873), reduced mortality (aOR, 0.180; 95% CI, 0.083–0.390), and lower rates of symptomatic intracerebral hemorrhage (aOR, 0.235; 95% CI, 0.062–0.887). The mortality-reducing effect remained in patients with ASPECTS 0–4 (aOR, 0.167; 95% CI, 0.056–0.499). Sensitivity analyses did not change the primary results. Conclusions— In patients presenting with ASPECTS 0–5, who were treated with mechanical thrombectomy, successful reperfusion was beneficial without increasing the risk of symptomatic intracerebral hemorrhage. Although the results do not allow for general treatment recommendations, formal testing of mechanical thrombectomy versus best medical treatment in these patients in a randomized controlled trial is warranted.
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Affiliation(s)
- Johannes Kaesmacher
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., P. Mordasini, J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland.,Department of Neurology (J.K., P.C.-I., L.P., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland.,University Institute of Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Panagiotis Chaloulos-Iakovidis
- Department of Neurology (J.K., P.C.-I., L.P., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Leonidas Panos
- Department of Neurology (J.K., P.C.-I., L.P., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Pasquale Mordasini
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., P. Mordasini, J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Patrik Michel
- Department of Neurology (P. Michel) and Department of Radiology (S.D.H.), CHUV Lausanne, Switzerland
| | - Steven D Hajdu
- Department of Neurology (P. Michel) and Department of Radiology (S.D.H.), CHUV Lausanne, Switzerland
| | - Marc Ribo
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain (M. Ribo, M. Requena)
| | - Manuel Requena
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain (M. Ribo, M. Requena)
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Germany (C.M., B.F.)
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Germany (C.M., B.F.)
| | - Vincent Costalat
- Department of Neuroradiology, CHU Montpellier, France (V.C., A.B.), Toronto Western Hospital, ON
| | - Amel Benali
- Department of Neuroradiology, CHU Montpellier, France (V.C., A.B.), Toronto Western Hospital, ON
| | - Laurent Pierot
- Department of Neuroradiology, CHU Reims, France (L.P., M.G.), Toronto Western Hospital, ON
| | - Matthias Gawlitza
- Department of Neuroradiology, CHU Reims, France (L.P., M.G.), Toronto Western Hospital, ON
| | | | | | - Jan Gralla
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., P. Mordasini, J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Urs Fischer
- Department of Neurology (J.K., P.C.-I., L.P., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
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28
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Schirmer MD, Ktena SI, Nardin MJ, Donahue KL, Giese AK, Etherton MR, Wu O, Rost NS. Rich-Club Organization: An Important Determinant of Functional Outcome After Acute Ischemic Stroke. Front Neurol 2019; 10:956. [PMID: 31551913 PMCID: PMC6748157 DOI: 10.3389/fneur.2019.00956] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 08/20/2019] [Indexed: 12/21/2022] Open
Abstract
Objective: To determine whether the rich-club organization, essential for information transport in the human connectome, is an important biomarker of functional outcome after acute ischemic stroke (AIS). Methods: Consecutive AIS patients (N = 344) with acute brain magnetic resonance imaging (MRI) (<48 h) were eligible for this study. Each patient underwent a clinical MRI protocol, which included diffusion weighted imaging (DWI). All DWIs were registered to a template on which rich-club regions have been defined. Using manual outlines of stroke lesions, we automatically counted the number of affected rich-club regions and assessed its effect on the National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS; obtained at 90 days post-stroke) scores through ordinal regression. Results: Of 344 patients (median age 65, inter-quartile range 54-76 years) with a median DWI lesion volume (DWIv) of 3cc, 64% were male. We established that an increase in number of rich-club regions affected by a stroke increases the odds of poor stroke outcome, measured by NIHSS (OR: 1.77, 95%CI 1.41-2.21) and mRS (OR: 1.38, 95%CI 1.11-1.73). Additionally, we demonstrated that the OR exceeds traditional markers, such as DWIv (ORNIHSS 1.08, 95%CI 1.06-1.11; ORmRS 1.05, 95%CI 1.03-1.07) and age (ORNIHSS 1.03, 95%CI 1.01-1.05; ORmRS 1.05, 95%CI 1.03-1.07). Conclusion: In this proof-of-concept study, the number of rich-club nodes affected by a stroke lesion presents a translational biomarker of stroke outcome, which can be readily assessed using standard clinical AIS imaging protocols and considered in functional outcome prediction models beyond traditional factors.
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Affiliation(s)
- Markus D Schirmer
- Department of Neurology, J. Philip Kistler Stroke Research Center, Harvard Medical School, Boston, MA, United States.,Computer Science and Artificial Intelligence Lab, Massachusetts Institute of Technology, Cambridge, MA, United States.,Department of Population Health Sciences, German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Sofia Ira Ktena
- Biomedical Image Analysis Group, Imperial College London, London, United Kingdom
| | - Marco J Nardin
- Department of Neurology, J. Philip Kistler Stroke Research Center, Harvard Medical School, Boston, MA, United States
| | - Kathleen L Donahue
- Department of Neurology, J. Philip Kistler Stroke Research Center, Harvard Medical School, Boston, MA, United States
| | - Anne-Katrin Giese
- Department of Neurology, J. Philip Kistler Stroke Research Center, Harvard Medical School, Boston, MA, United States
| | - Mark R Etherton
- Department of Neurology, J. Philip Kistler Stroke Research Center, Harvard Medical School, Boston, MA, United States
| | - Ona Wu
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, United States
| | - Natalia S Rost
- Department of Neurology, J. Philip Kistler Stroke Research Center, Harvard Medical School, Boston, MA, United States
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29
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Oxidative stress and DNA damage after cerebral ischemia: Potential therapeutic targets to repair the genome and improve stroke recovery. Neuropharmacology 2017; 134:208-217. [PMID: 29128308 DOI: 10.1016/j.neuropharm.2017.11.011] [Citation(s) in RCA: 184] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 11/02/2017] [Accepted: 11/05/2017] [Indexed: 12/12/2022]
Abstract
The past two decades have witnessed remarkable advances in oxidative stress research, particularly in the context of ischemic brain injury. Oxidative stress in ischemic tissues compromises the integrity of the genome, resulting in DNA lesions, cell death in neurons, glial cells, and vascular cells, and impairments in neurological recovery after stroke. As DNA is particularly vulnerable to oxidative attack, cells have evolved the ability to induce multiple DNA repair mechanisms, including base excision repair (BER), nucleotide excision repair (NER) and non-homogenous endpoint jointing (NHEJ). Defective DNA repair is tightly correlated with worse neurological outcomes after stroke, whereas upregulation of DNA repair enzymes, such as APE1, OGG1, and XRCC1, improves long-term functional recovery following stroke. Indeed, DNA damage and repair are now known to play critical roles in fundamental aspects of stroke recovery, such as neurogenesis, white matter recovery, and neurovascular unit remodeling. Several DNA repair enzymes are essential for comprehensive neural repair mechanisms after stroke, including Polβ and NEIL3 for neurogenesis, APE1 for white matter repair, Gadd45b for axonal regeneration, and DNA-PKs for neurovascular remodeling. This review discusses the emerging role of DNA damage and repair in functional recovery after stroke and highlights the contribution of DNA repair to regenerative elements after stroke. This article is part of the Special Issue entitled 'Cerebral Ischemia'.
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