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Broocks G, Kniep H, McDonough R, Bechstein M, Heitkamp C, Winkelmeier L, Klapproth S, Faizy TD, Schell M, Schön G, Hanning U, Gellißen S, Kemmling A, Papanagiotou P, Fiehler J, Meyer L. Thrombectomy in ischemic stroke patients with large core but minor ischemic changes on non-enhanced computed tomography. Int J Stroke 2024; 19:764-771. [PMID: 38666480 DOI: 10.1177/17474930241249588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
PURPOSE The Alberta Stroke Program Early CT Score (ASPECTS) is regularly used to guide patient selection for mechanical thrombectomy (MT). Similarly, penumbral imaging based on computed tomography perfusion (CTP) may serve as neuroimaging tool to guide treatment. Yet, patients with a large ischemic core on CTP may show only minor ischemic changes resulting in a high ASPECTS. AIM We hypothesized twofold: (1) the treatment effect of vessel recanalization in patients with core volume > 50 mL but ASPECTS ⩾ 6 is not different compared to high ASPECTS patients with core volume < 50 mL, and (2) recanalization is associated with core overestimation. METHODS We conducted an observational study analyzing ischemic stroke patients consecutively treated with MT after triage by multimodal CT. Functional endpoint was the rate of functional independence at Day 90 defined as modified Rankin Scale (mRS) 0-2. Imaging endpoint was core overestimation, which was considered when CTP-derived core was larger than the final infarct volume assessed on follow-up imaging. Recanalization was evaluated with the extended Thrombolysis in Cerebral Infarction (eTICI) scale. Multivariable logistic regression analysis and propensity score matching (PSM) were used to assess the association of recanalization (eTICI ⩾ 2b) with functional outcome and core overestimation. RESULTS Of 630 patients with ASPECTS ⩾ 6, 91 patients (14.4%) had a large ischemic core. Following 1:1 PSM, the treatment effect of recanalization was not different in patients with large core and ASPECTS ⩾ 6 (+ 25.8%, 95% CI: 16.3-35.4, p < 0.001) compared to patients with ASPECTS ⩾ 6 and core volume < 50 mL (+ 14.9%, 95% CI: 5.7-24.1, p = 0.002). Recanalization (aOR: 3.46, 95% CI: 1.85-6.47, p < 0.001) and higher core volume (aOR: 1.03, 95% CI: 1.02-1.04, p < 0.001) were significantly associated with core overestimation. CONCLUSION In patients with ASPECTS ⩾ 6, core volumes did not significantly modify outcomes following recanalization. Reperfusion and higher core volume were significantly associated with core overestimation which may explain the treatment effect of MT for patients with a large ischemic core but minor ischemic changes on non-enhanced CT. DATA ACCESS STATEMENT The data analyzed in this study will be available and shared on reasonable request from any qualified researcher for the purpose of replicating the results after clearance by the local ethics committee.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neuroradiology, HELIOS Medical Center, Campus of MSH Medical School Hamburg, Schwerin, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Heitkamp
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susan Klapproth
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Schell
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Marburg, Marburg, Germany
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Bremen, Germany
- Department of Radiology, Areteion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Ghozy S, Amoukhteh M, Hasanzadeh A, Jannatdoust P, Shafie M, Valizadeh P, Hassankhani A, Abbas AS, Kadirvel R, Kallmes DF. Net water uptake as a predictive neuroimaging marker for acute ischemic stroke outcomes: a meta-analysis. Eur Radiol 2024; 34:5308-5316. [PMID: 38276981 DOI: 10.1007/s00330-024-10599-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 12/05/2023] [Accepted: 12/23/2023] [Indexed: 01/27/2024]
Abstract
OBJECTIVE To assess the role of net water uptake (NWU) in predicting outcomes in acute ischemic stroke (AIS) patients. METHODS A systematic review and meta-analysis were performed, adhering to established guidelines. The search covered PubMed, Scopus, Web of Science, and Embase databases until July 1, 2023. Eligible studies reporting quantitative ischemic lesion NWU in admission CT scans of AIS patients, stratified based on outcomes, were included. Data analysis was performed using R software version 4.2.1. RESULTS Incorporating 17 original studies with 2217 AIS patients, NWU was significantly higher in patients with poor outcomes compared to those with good outcomes (difference of medians: 5.06, 95% CI: 3.00-7.13, p < 0.001). Despite excluding one outlier study, considerable heterogeneity persisted among the included studies (I2 = 90.8%). The meta-regression and subgroup meta-analyses demonstrated significantly higher NWU in patients with poor functional outcome, as assessed by modified Rankin Scale (difference of medians: 3.83, 95% CI: 1.98-5.68, p < 0.001, I2 = 72.9%), malignant edema/infarct (difference of medians: 8.30, 95% CI: 4.01-12.58, p < 0.001, I2 = 95.6%), and intracranial hemorrhage (difference of medians: 5.43, 95% CI: 0.44-10.43, p = 0.03, I2 = 91.1%). CONCLUSION NWU on admission CT scans shows promise as a predictive marker for outcomes in AIS patients. Prospective, multicenter trials with standardized, automated NWU measurement are crucial for robustly predicting diverse clinical outcomes. CLINICAL RELEVANCE STATEMENT The potential of net water uptake as a biomarker for predicting outcomes in acute ischemic stroke patients holds significant promise. Further validation through additional research could lead to its integration into clinical practice, potentially improving the accuracy of clinical decision-making and allowing for the development of more precise patient care strategies. KEY POINTS • Net water uptake, a CT-based biomarker, quantifies early brain edema after acute ischemic stroke. • Net water uptake is significantly higher in poor outcome acute ischemic stroke patients. • Net water uptake on CT scans holds promise in predicting diverse acute ischemic stroke outcomes.
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Affiliation(s)
- Sherief Ghozy
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Melika Amoukhteh
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | - Alireza Hasanzadeh
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Payam Jannatdoust
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Mahan Shafie
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Parya Valizadeh
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Amir Hassankhani
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA.
| | - Alzhraa Salah Abbas
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Ramanathan Kadirvel
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
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Broocks G, Meyer L, Winkelmeier L, Kniep H, Heitkamp C, Christensen S, Lansberg MG, Thaler C, Kemmling A, Schön G, Zeleňák K, Stracke PC, Albers G, Fiehler J, Wintermark M, Heit JJ, Faizy TD, Panzer A. Overestimation of the Ischemic Core Is Associated With Higher Core Lesion Volume and Degree of Reperfusion After Thrombectomy. Radiology 2024; 312:e231750. [PMID: 39078297 PMCID: PMC11294763 DOI: 10.1148/radiol.231750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 04/17/2024] [Accepted: 04/30/2024] [Indexed: 07/31/2024]
Abstract
Background CT perfusion (CTP)-derived baseline ischemic core volume (ICV) can overestimate the true extent of infarction, which may result in exclusion of patients with ischemic stroke from endovascular treatment (EVT). Purpose To determine whether ischemic core overestimation is associated with larger ICV and degree of recanalization. Materials and Methods This retrospective multicenter cohort study included patients with acute ischemic stroke triaged at multimodal CT who underwent EVT between January 2015 and January 2022. The primary outcome was ischemic core overestimation, which was assumed when baseline CTP-derived ICV was larger than the final infarct volume at follow-up imaging. The secondary outcome was functional independence defined as modified Rankin Scale scores of 0-2 90 days after EVT. Successful vessel recanalization was defined as extended Thrombolysis in Cerebral Infarction score of 2b or higher. Categorical variables were compared between patients with ICV of 50 mL or less versus large ICV greater than 50 mL with use of the χ2 test. Adjusted multivariable logistic regression analyses were used to assess the primary and secondary outcomes. Results In total, 721 patients (median age, 76 years [IQR, 64-83 years]; 371 female) were included, of which 162 (22%) demonstrated ischemic core overestimation. Core overestimation occurred more often in patients with ICV greater than 50 mL versus 50 mL or less (48% vs 16%; P < .001) and those with successful versus unsuccessful vessel recanalization (26% vs 13%; P < .001). In an adjusted model, successful recanalization after EVT (odds ratio [OR], 3.14 [95% CI: 1.65, 5.95]; P < .001) and larger ICV (OR, 1.03 [95% CI: 1.02, 1.04]; P < .001) were independently associated with core overestimation, while the time from symptom onset to imaging showed no association (OR, 0.99; P = .96). Core overestimation was independently associated with functional independence (adjusted OR, 2.83 [95% CI: 1.66, 4.81]; P < .001) after successful recanalization. Conclusion Ischemic core overestimation occurred more frequently in patients presenting with large CTP-derived ICV and successful vessel recanalization compared with those with unsuccessful recanalization. © RSNA, 2024 Supplemental material is available for this article.
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Affiliation(s)
- Gabriel Broocks
- From the Department of Neuroradiology (G.B., L.M., L.W., H.K., C.H.,
C.T., J.F., T.D.F.) and Institute for Medical Biometry and Epidemiology (G.S.),
University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg,
Germany; Department of Neuroradiology, HELIOS Medical Center, Campus of MSH
Medical School Hamburg, Schwerin, Germany (G.B.); Departments of Neurology and
Neurologic Sciences (S.C., M.G.L., M.W.) and Radiology (G.A., J.J.H.), Stanford
University School of Medicine, Stanford, Calif; Department of Neuroradiology,
University of Marburg, Marburg, Germany (A.K.); Department of Radiology,
Comenius University’s Jessenius Faculty of Medicine and University
Hospital, Martin, Slovakia (K.Z.); and Department of Neuroradiology, University
Hospital Münster, Münster, Germany (P.C.S., T.D.F.)
| | - Lukas Meyer
- From the Department of Neuroradiology (G.B., L.M., L.W., H.K., C.H.,
C.T., J.F., T.D.F.) and Institute for Medical Biometry and Epidemiology (G.S.),
University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg,
Germany; Department of Neuroradiology, HELIOS Medical Center, Campus of MSH
Medical School Hamburg, Schwerin, Germany (G.B.); Departments of Neurology and
Neurologic Sciences (S.C., M.G.L., M.W.) and Radiology (G.A., J.J.H.), Stanford
University School of Medicine, Stanford, Calif; Department of Neuroradiology,
University of Marburg, Marburg, Germany (A.K.); Department of Radiology,
Comenius University’s Jessenius Faculty of Medicine and University
Hospital, Martin, Slovakia (K.Z.); and Department of Neuroradiology, University
Hospital Münster, Münster, Germany (P.C.S., T.D.F.)
| | - Laurens Winkelmeier
- From the Department of Neuroradiology (G.B., L.M., L.W., H.K., C.H.,
C.T., J.F., T.D.F.) and Institute for Medical Biometry and Epidemiology (G.S.),
University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg,
Germany; Department of Neuroradiology, HELIOS Medical Center, Campus of MSH
Medical School Hamburg, Schwerin, Germany (G.B.); Departments of Neurology and
Neurologic Sciences (S.C., M.G.L., M.W.) and Radiology (G.A., J.J.H.), Stanford
University School of Medicine, Stanford, Calif; Department of Neuroradiology,
University of Marburg, Marburg, Germany (A.K.); Department of Radiology,
Comenius University’s Jessenius Faculty of Medicine and University
Hospital, Martin, Slovakia (K.Z.); and Department of Neuroradiology, University
Hospital Münster, Münster, Germany (P.C.S., T.D.F.)
| | - Helge Kniep
- From the Department of Neuroradiology (G.B., L.M., L.W., H.K., C.H.,
C.T., J.F., T.D.F.) and Institute for Medical Biometry and Epidemiology (G.S.),
University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg,
Germany; Department of Neuroradiology, HELIOS Medical Center, Campus of MSH
Medical School Hamburg, Schwerin, Germany (G.B.); Departments of Neurology and
Neurologic Sciences (S.C., M.G.L., M.W.) and Radiology (G.A., J.J.H.), Stanford
University School of Medicine, Stanford, Calif; Department of Neuroradiology,
University of Marburg, Marburg, Germany (A.K.); Department of Radiology,
Comenius University’s Jessenius Faculty of Medicine and University
Hospital, Martin, Slovakia (K.Z.); and Department of Neuroradiology, University
Hospital Münster, Münster, Germany (P.C.S., T.D.F.)
| | - Christian Heitkamp
- From the Department of Neuroradiology (G.B., L.M., L.W., H.K., C.H.,
C.T., J.F., T.D.F.) and Institute for Medical Biometry and Epidemiology (G.S.),
University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg,
Germany; Department of Neuroradiology, HELIOS Medical Center, Campus of MSH
Medical School Hamburg, Schwerin, Germany (G.B.); Departments of Neurology and
Neurologic Sciences (S.C., M.G.L., M.W.) and Radiology (G.A., J.J.H.), Stanford
University School of Medicine, Stanford, Calif; Department of Neuroradiology,
University of Marburg, Marburg, Germany (A.K.); Department of Radiology,
Comenius University’s Jessenius Faculty of Medicine and University
Hospital, Martin, Slovakia (K.Z.); and Department of Neuroradiology, University
Hospital Münster, Münster, Germany (P.C.S., T.D.F.)
| | - Soren Christensen
- From the Department of Neuroradiology (G.B., L.M., L.W., H.K., C.H.,
C.T., J.F., T.D.F.) and Institute for Medical Biometry and Epidemiology (G.S.),
University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg,
Germany; Department of Neuroradiology, HELIOS Medical Center, Campus of MSH
Medical School Hamburg, Schwerin, Germany (G.B.); Departments of Neurology and
Neurologic Sciences (S.C., M.G.L., M.W.) and Radiology (G.A., J.J.H.), Stanford
University School of Medicine, Stanford, Calif; Department of Neuroradiology,
University of Marburg, Marburg, Germany (A.K.); Department of Radiology,
Comenius University’s Jessenius Faculty of Medicine and University
Hospital, Martin, Slovakia (K.Z.); and Department of Neuroradiology, University
Hospital Münster, Münster, Germany (P.C.S., T.D.F.)
| | - Maarten G. Lansberg
- From the Department of Neuroradiology (G.B., L.M., L.W., H.K., C.H.,
C.T., J.F., T.D.F.) and Institute for Medical Biometry and Epidemiology (G.S.),
University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg,
Germany; Department of Neuroradiology, HELIOS Medical Center, Campus of MSH
Medical School Hamburg, Schwerin, Germany (G.B.); Departments of Neurology and
Neurologic Sciences (S.C., M.G.L., M.W.) and Radiology (G.A., J.J.H.), Stanford
University School of Medicine, Stanford, Calif; Department of Neuroradiology,
University of Marburg, Marburg, Germany (A.K.); Department of Radiology,
Comenius University’s Jessenius Faculty of Medicine and University
Hospital, Martin, Slovakia (K.Z.); and Department of Neuroradiology, University
Hospital Münster, Münster, Germany (P.C.S., T.D.F.)
| | - Christian Thaler
- From the Department of Neuroradiology (G.B., L.M., L.W., H.K., C.H.,
C.T., J.F., T.D.F.) and Institute for Medical Biometry and Epidemiology (G.S.),
University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg,
Germany; Department of Neuroradiology, HELIOS Medical Center, Campus of MSH
Medical School Hamburg, Schwerin, Germany (G.B.); Departments of Neurology and
Neurologic Sciences (S.C., M.G.L., M.W.) and Radiology (G.A., J.J.H.), Stanford
University School of Medicine, Stanford, Calif; Department of Neuroradiology,
University of Marburg, Marburg, Germany (A.K.); Department of Radiology,
Comenius University’s Jessenius Faculty of Medicine and University
Hospital, Martin, Slovakia (K.Z.); and Department of Neuroradiology, University
Hospital Münster, Münster, Germany (P.C.S., T.D.F.)
| | - Andre Kemmling
- From the Department of Neuroradiology (G.B., L.M., L.W., H.K., C.H.,
C.T., J.F., T.D.F.) and Institute for Medical Biometry and Epidemiology (G.S.),
University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg,
Germany; Department of Neuroradiology, HELIOS Medical Center, Campus of MSH
Medical School Hamburg, Schwerin, Germany (G.B.); Departments of Neurology and
Neurologic Sciences (S.C., M.G.L., M.W.) and Radiology (G.A., J.J.H.), Stanford
University School of Medicine, Stanford, Calif; Department of Neuroradiology,
University of Marburg, Marburg, Germany (A.K.); Department of Radiology,
Comenius University’s Jessenius Faculty of Medicine and University
Hospital, Martin, Slovakia (K.Z.); and Department of Neuroradiology, University
Hospital Münster, Münster, Germany (P.C.S., T.D.F.)
| | - Gerhard Schön
- From the Department of Neuroradiology (G.B., L.M., L.W., H.K., C.H.,
C.T., J.F., T.D.F.) and Institute for Medical Biometry and Epidemiology (G.S.),
University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg,
Germany; Department of Neuroradiology, HELIOS Medical Center, Campus of MSH
Medical School Hamburg, Schwerin, Germany (G.B.); Departments of Neurology and
Neurologic Sciences (S.C., M.G.L., M.W.) and Radiology (G.A., J.J.H.), Stanford
University School of Medicine, Stanford, Calif; Department of Neuroradiology,
University of Marburg, Marburg, Germany (A.K.); Department of Radiology,
Comenius University’s Jessenius Faculty of Medicine and University
Hospital, Martin, Slovakia (K.Z.); and Department of Neuroradiology, University
Hospital Münster, Münster, Germany (P.C.S., T.D.F.)
| | - Kamil Zeleňák
- From the Department of Neuroradiology (G.B., L.M., L.W., H.K., C.H.,
C.T., J.F., T.D.F.) and Institute for Medical Biometry and Epidemiology (G.S.),
University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg,
Germany; Department of Neuroradiology, HELIOS Medical Center, Campus of MSH
Medical School Hamburg, Schwerin, Germany (G.B.); Departments of Neurology and
Neurologic Sciences (S.C., M.G.L., M.W.) and Radiology (G.A., J.J.H.), Stanford
University School of Medicine, Stanford, Calif; Department of Neuroradiology,
University of Marburg, Marburg, Germany (A.K.); Department of Radiology,
Comenius University’s Jessenius Faculty of Medicine and University
Hospital, Martin, Slovakia (K.Z.); and Department of Neuroradiology, University
Hospital Münster, Münster, Germany (P.C.S., T.D.F.)
| | - Paul C. Stracke
- From the Department of Neuroradiology (G.B., L.M., L.W., H.K., C.H.,
C.T., J.F., T.D.F.) and Institute for Medical Biometry and Epidemiology (G.S.),
University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg,
Germany; Department of Neuroradiology, HELIOS Medical Center, Campus of MSH
Medical School Hamburg, Schwerin, Germany (G.B.); Departments of Neurology and
Neurologic Sciences (S.C., M.G.L., M.W.) and Radiology (G.A., J.J.H.), Stanford
University School of Medicine, Stanford, Calif; Department of Neuroradiology,
University of Marburg, Marburg, Germany (A.K.); Department of Radiology,
Comenius University’s Jessenius Faculty of Medicine and University
Hospital, Martin, Slovakia (K.Z.); and Department of Neuroradiology, University
Hospital Münster, Münster, Germany (P.C.S., T.D.F.)
| | - Gregory Albers
- From the Department of Neuroradiology (G.B., L.M., L.W., H.K., C.H.,
C.T., J.F., T.D.F.) and Institute for Medical Biometry and Epidemiology (G.S.),
University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg,
Germany; Department of Neuroradiology, HELIOS Medical Center, Campus of MSH
Medical School Hamburg, Schwerin, Germany (G.B.); Departments of Neurology and
Neurologic Sciences (S.C., M.G.L., M.W.) and Radiology (G.A., J.J.H.), Stanford
University School of Medicine, Stanford, Calif; Department of Neuroradiology,
University of Marburg, Marburg, Germany (A.K.); Department of Radiology,
Comenius University’s Jessenius Faculty of Medicine and University
Hospital, Martin, Slovakia (K.Z.); and Department of Neuroradiology, University
Hospital Münster, Münster, Germany (P.C.S., T.D.F.)
| | - Jens Fiehler
- From the Department of Neuroradiology (G.B., L.M., L.W., H.K., C.H.,
C.T., J.F., T.D.F.) and Institute for Medical Biometry and Epidemiology (G.S.),
University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg,
Germany; Department of Neuroradiology, HELIOS Medical Center, Campus of MSH
Medical School Hamburg, Schwerin, Germany (G.B.); Departments of Neurology and
Neurologic Sciences (S.C., M.G.L., M.W.) and Radiology (G.A., J.J.H.), Stanford
University School of Medicine, Stanford, Calif; Department of Neuroradiology,
University of Marburg, Marburg, Germany (A.K.); Department of Radiology,
Comenius University’s Jessenius Faculty of Medicine and University
Hospital, Martin, Slovakia (K.Z.); and Department of Neuroradiology, University
Hospital Münster, Münster, Germany (P.C.S., T.D.F.)
| | - Max Wintermark
- From the Department of Neuroradiology (G.B., L.M., L.W., H.K., C.H.,
C.T., J.F., T.D.F.) and Institute for Medical Biometry and Epidemiology (G.S.),
University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg,
Germany; Department of Neuroradiology, HELIOS Medical Center, Campus of MSH
Medical School Hamburg, Schwerin, Germany (G.B.); Departments of Neurology and
Neurologic Sciences (S.C., M.G.L., M.W.) and Radiology (G.A., J.J.H.), Stanford
University School of Medicine, Stanford, Calif; Department of Neuroradiology,
University of Marburg, Marburg, Germany (A.K.); Department of Radiology,
Comenius University’s Jessenius Faculty of Medicine and University
Hospital, Martin, Slovakia (K.Z.); and Department of Neuroradiology, University
Hospital Münster, Münster, Germany (P.C.S., T.D.F.)
| | - Jeremy J. Heit
- From the Department of Neuroradiology (G.B., L.M., L.W., H.K., C.H.,
C.T., J.F., T.D.F.) and Institute for Medical Biometry and Epidemiology (G.S.),
University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg,
Germany; Department of Neuroradiology, HELIOS Medical Center, Campus of MSH
Medical School Hamburg, Schwerin, Germany (G.B.); Departments of Neurology and
Neurologic Sciences (S.C., M.G.L., M.W.) and Radiology (G.A., J.J.H.), Stanford
University School of Medicine, Stanford, Calif; Department of Neuroradiology,
University of Marburg, Marburg, Germany (A.K.); Department of Radiology,
Comenius University’s Jessenius Faculty of Medicine and University
Hospital, Martin, Slovakia (K.Z.); and Department of Neuroradiology, University
Hospital Münster, Münster, Germany (P.C.S., T.D.F.)
| | - Tobias D. Faizy
- From the Department of Neuroradiology (G.B., L.M., L.W., H.K., C.H.,
C.T., J.F., T.D.F.) and Institute for Medical Biometry and Epidemiology (G.S.),
University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg,
Germany; Department of Neuroradiology, HELIOS Medical Center, Campus of MSH
Medical School Hamburg, Schwerin, Germany (G.B.); Departments of Neurology and
Neurologic Sciences (S.C., M.G.L., M.W.) and Radiology (G.A., J.J.H.), Stanford
University School of Medicine, Stanford, Calif; Department of Neuroradiology,
University of Marburg, Marburg, Germany (A.K.); Department of Radiology,
Comenius University’s Jessenius Faculty of Medicine and University
Hospital, Martin, Slovakia (K.Z.); and Department of Neuroradiology, University
Hospital Münster, Münster, Germany (P.C.S., T.D.F.)
| | - Ariane Panzer
- From the Department of Neuroradiology (G.B., L.M., L.W., H.K., C.H.,
C.T., J.F., T.D.F.) and Institute for Medical Biometry and Epidemiology (G.S.),
University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg,
Germany; Department of Neuroradiology, HELIOS Medical Center, Campus of MSH
Medical School Hamburg, Schwerin, Germany (G.B.); Departments of Neurology and
Neurologic Sciences (S.C., M.G.L., M.W.) and Radiology (G.A., J.J.H.), Stanford
University School of Medicine, Stanford, Calif; Department of Neuroradiology,
University of Marburg, Marburg, Germany (A.K.); Department of Radiology,
Comenius University’s Jessenius Faculty of Medicine and University
Hospital, Martin, Slovakia (K.Z.); and Department of Neuroradiology, University
Hospital Münster, Münster, Germany (P.C.S., T.D.F.)
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4
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Sporns PB, Kemmling A, Meyer L, Krogias C, Puetz V, Thierfelder KM, Duering M, Lukas C, Kaiser D, Langner S, Brehm A, Rotkopf LT, Kunz WG, Beuker C, Heindel W, Fiehler J, Schramm P, Wiendl H, Minnerup H, Psychogios MN, Minnerup J. Computed tomography hypoperfusion-hypodensity mismatch vs. automated perfusion mismatch to identify stroke patients eligible for thrombolysis. Front Neurol 2023; 14:1320620. [PMID: 38225983 PMCID: PMC10788186 DOI: 10.3389/fneur.2023.1320620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/04/2023] [Indexed: 01/17/2024] Open
Abstract
Background and purpose Automated perfusion imaging can detect stroke patients with unknown time of symptom onset who are eligible for thrombolysis. However, the availability of this technique is limited. We, therefore, established the novel concept of computed tomography (CT) hypoperfusion-hypodensity mismatch, i.e., an ischemic core lesion visible on cerebral perfusion CT without visible hypodensity in the corresponding native cerebral CT. We compared both methods regarding their accuracy in identifying patients suitable for thrombolysis. Methods In a retrospective analysis of the MissPerfeCT observational cohort study, patients were classified as suitable or not for thrombolysis based on established time window and imaging criteria. We calculated predictive values for hypoperfusion-hypodensity mismatch and automated perfusion imaging to compare accuracy in the identification of patients suitable for thrombolysis. Results Of 247 patients, 219 (88.7%) were eligible for thrombolysis and 28 (11.3%) were not eligible for thrombolysis. Of 197 patients who were within 4.5 h of symptom onset, 190 (96.4%) were identified by hypoperfusion-hypodensity mismatch and 88 (44.7%) by automated perfusion mismatch (p < 0.001). Of 22 patients who were beyond 4.5 h of symptom onset but were eligible for thrombolysis, 5 patients (22.7%) were identified by hypoperfusion-hypodensity mismatch. Predictive values for the hypoperfusion-hypodensity mismatch vs. automated perfusion mismatch were as follows: sensitivity, 89.0% vs. 50.2%; specificity, 71.4% vs. 100.0%; positive predictive value, 96.1% vs. 100.0%; and negative predictive value, 45.5% vs. 20.4%. Conclusion The novel method of hypoperfusion-hypodensity mismatch can identify patients suitable for thrombolysis with higher sensitivity and lower specificity than established techniques. Using this simple method might therefore increase the proportion of patients treated with thrombolysis without the use of special automated software.The MissPerfeCT study is a retrospective observational multicenter cohort study and is registered with clinicaltrials.gov (NCT04277728).
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Affiliation(s)
- Peter B. Sporns
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Radiology, Westfaelische Wilhelms-University of Münster and University Hospital of Münster, Münster, Germany
| | - André Kemmling
- Department of Radiology, Westfaelische Wilhelms-University of Münster and University Hospital of Münster, Münster, Germany
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany
- Department of Neuroradiology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Lennart Meyer
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Volker Puetz
- Department of Neurology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Kolja M. Thierfelder
- Department of Radiology and Institute of Diagnostic and Interventional Radiology, University Medical Center Rostock, Rostock, Germany
| | - Marco Duering
- Medical Image Analysis Center (MIAC) and Department of Biomedical Engineering, University of Basel, Basel, Switzerland
- Institute for Stroke and Dementia Research, University Hospital, LMU Munich, Munich, Germany
| | - Carsten Lukas
- Department of Neuroradiology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Daniel Kaiser
- Department of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Sönke Langner
- Department of Radiology and Institute of Diagnostic and Interventional Radiology, University Medical Center Rostock, Rostock, Germany
| | - Alex Brehm
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Lukas T. Rotkopf
- Department of Radiology, German Cancer Research Center, Heidelberg, Germany
| | - Wolfgang G. Kunz
- Department of Radiology, University Hospital, LMU Munich, Germany
| | - Carolin Beuker
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Walter Heindel
- Department of Radiology, Westfaelische Wilhelms-University of Münster and University Hospital of Münster, Münster, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Schramm
- Department of Neuroradiology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Heike Minnerup
- Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
| | - Marios Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Jens Minnerup
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
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5
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Wu RR, Cao YZ, Xu XQ, Jia ZY, Zhao LB, Shi HB, Liu S, Wu FY, Lu SS. ASPECTS-based net water uptake outperforms target mismatch for outcome prediction in patients with acute ischemic stroke and late therapeutic window. Eur Radiol 2023; 33:9130-9138. [PMID: 37498384 DOI: 10.1007/s00330-023-09965-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 05/18/2023] [Accepted: 05/25/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVE To compare the prognostic value of net water uptake (NWU) and target mismatch (TM) on CT perfusion (CTP) in acute ischemic stroke (AIS) patients with late time window. METHODS One hundred and nine consecutive AIS patients with anterior-circulation large vessel occlusion presenting within 6-24 h from onset/last seen well were enrolled. Automated Alberta Stroke Program Early CT Score-based NWU (ASPECTS-NWU) was calculated from admission CT. The correlation between ASPECTS-NWU and CTP parameters was assessed. Predictors for favorable outcome (modified Rankin Scale score ≤ 2) at 90 days were assessed using logistic regression analysis. The ability of outcome prediction between ASPECTS-NWU and TM (an ischemic core < 70 mL, a mismatch ratio ≥ 1.8, and an absolute difference ≥ 15 mL) was compared using receiver operating characteristic (ROC) curve. RESULTS A higher level of ASPECTS-NWU was associated with a larger ischemic core (r = 0.66, p < 0.001) and a larger hypoperfusion volume (r = 0.38, p < 0.001). ASPECTS-NWU performed better than TM for outcome stratification (area under the curve [AUC], 0.738 vs 0.583, p = 0.004) and was the only independent neuroimaging marker associated with favorable outcomes compared with CTP parameters (odds ratio, 0.73; 95% confidence interval [CI] 0.62-0.87, p < 0.001). An outcome prediction model including ASPECTS-NWU and clinical variables (National Institutes of Health Stroke Scale scores and age) yielded an AUC of 0.828 (95% CI 0.744-0.893; sensitivity 65.4%; specificity 87.7%). CONCLUSION ASPECTS-NWU performed better than TM for outcome prediction in AIS patients with late time window and might be an alternative imaging biomarker to CTP for patient selection. CLINICAL RELEVANCE STATEMENT Automated Alberta Stroke Program Early CT Score-based net water uptake outperforms target mismatch on CT perfusion for the outcome prediction in patients with acute ischemic stroke and can be an alternative imaging biomarker for patient selection in late therapeutic window. KEY POINTS • A higher ASPECTS-based net water uptake was associated with larger ischemic cores and hypoperfusion volumes on CT perfusion. • ASPECTS-based net water uptake outperformed target mismatch for outcome prediction in acute ischemic stroke with extended therapeutic window. • ASPECTS-based net water uptake can be an alternative biomarker to target mismatch for selecting acute ischemic stroke patients with late therapeutic window.
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Affiliation(s)
- Rong-Rong Wu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No.300 Guangzhou Road, Gulou district, Nanjing, Jiangsu Province, China
| | - Yue-Zhou Cao
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Xiao-Quan Xu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No.300 Guangzhou Road, Gulou district, Nanjing, Jiangsu Province, China
| | - Zheng-Yu Jia
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Lin-Bo Zhao
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Hai-Bin Shi
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Fei-Yun Wu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No.300 Guangzhou Road, Gulou district, Nanjing, Jiangsu Province, China.
| | - Shan-Shan Lu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No.300 Guangzhou Road, Gulou district, Nanjing, Jiangsu Province, China.
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6
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Shen L, Lu X, Wang H, Wu G, Guo Y, Zheng S, Ren L, Zhang H, Huang L, Ren B, Zhu J, Xia S. Impaired T1 mapping and Tmax during the first 7 days after ischemic stroke. A retrospective observational study. J Stroke Cerebrovasc Dis 2023; 32:107383. [PMID: 37844455 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 10/18/2023] Open
Abstract
OBJECTIVE To measure the relative T1 (rT1) value in different hypo-perfused regions after ischemic stroke using T1 mapping derived by Strategically Acquired Gradient Echo (STAGE) and assess its relationship with onset time and severity of ischemia. MATERIALS AND METHODS Sixty-three patients with acute anterior circulation ischemic stroke from 2017 to 2022 who underwent STAGE, diffusion weighted imaging (DWI) and dynamic susceptibility contrast perfusion weighted imaging (DSC-PWI) within 7 days were retrospectively enrolled. The areas with reduced diffusion and hypo-perfusion were segmented based on apparent diffusion coefficient (ADC) value < 0.62 × 10-3mm2/s and time-to-maximum (Tmax) thresholds (4, 6, 8, and 10 seconds). We measured the T1 value in the diffusion reduced and every 2 s Tmax strata regions and calculated rT1 (T1ipsi/T1contra) to explore the relationship between rT1 value, Tmax, and onset time. RESULTS rT1 value was increased in diffusion reduced (1.42) and hypo-perfused regions (1.02, 1.06, 1.12, 1.27, Tmax 4-6 s, 6-8 s, 8-10 s, > 10 s, respectively; all different from 1, P < 0.001). rT1 value was positively correlated with Tmax (rs = 0.61, P < 0.001) and onset time in area with reduced diffusion (rs = 0.39, P = 0.014). CONCLUSIONS Increased rT1 value in different hypo-perfused brain regions using T1 mapping derived by STAGE may reflect the edema; it was associated with the severity of Tmax and showed a weak correlation with the onset time in diffusion reduced areas.
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Affiliation(s)
- Lianfang Shen
- Department of Radiology, The First Central Clinical School, Tianjin Medical University, Tianjin, China
| | - Xiudi Lu
- Department of Radiology, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Huiying Wang
- The School of Medicine, Nankai University, Tianjin, China
| | - Gemuer Wu
- Department of Radiology, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Yu Guo
- Department of Radiology, Medical Imaging Institute of Tianjin, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
| | - Shaowei Zheng
- Department of Radiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Lei Ren
- Department of Radiology, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Huanlei Zhang
- Department of Radiology, Yidu Central Hospital of Weifang, Qingzhou City, Shandong, China
| | - Lixiang Huang
- Department of Radiology, Medical Imaging Institute of Tianjin, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
| | - Bo Ren
- College of Computer Science, Nankai University, Tianjin, China
| | - Jinxia Zhu
- MR Collaboration, Siemens Healthcare Ltd, Beijing, China
| | - Shuang Xia
- Department of Radiology, Medical Imaging Institute of Tianjin, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China.
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7
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Christensen S, Demeestere J, Verhaaren B, Heit JJ, Von Stein EL, Madill ES, Loube DK, Dugue R, Rengarajan S, Mlynash M, Albers GW, Lemmens R, Lansberg MG. Semiautomated Detection of Early Infarct Signs on Noncontrast CT Improves Interrater Agreement. Stroke 2023; 54:3090-3096. [PMID: 37909206 PMCID: PMC10843172 DOI: 10.1161/strokeaha.123.044058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 10/13/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND Acute ischemic infarct identification on noncontrast computed tomography (NCCT) is highly variable between raters. A semiautomated method for segmentation of acute ischemic lesions on NCCT may improve interrater reliability. METHODS Patients with successful endovascular reperfusion from the DEFUSE 3 trial (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke) were included. We created relative NCCT (rNCCT) color-gradient overlays by comparing the density of a voxel on NCCT to the homologous region in the contralateral hemisphere. Regions with a relative hypodensity of at least 5% were visualized. We coregistered baseline and follow-up images. Two neuroradiologists and 6 nonradiologists segmented the acute ischemic lesion on the baseline scans with 2 methods: (1) manually outlining hypodense regions on the NCCT (unassisted segmentation) and (2) manually excluding areas deemed outside of the ischemic lesion on the rNCCT color map (rNCCT-assisted segmentation). Voxelwise interrater agreement was quantified using the Dice similarity coefficient and volumetric agreement between raters with the detection index (DI), defined as the true positive volume minus the false positive volume. RESULTS From a total of 92, we included 61 patients. Median age was 59 (64-77), and 57% were female. Stroke onset was known in 39%. Onset to NCCT was median, 8.5 hours (7-11) and median 10 hours (8.4-11.5) in patients with known and unknown onset, respectively. Compared with unassisted NCCT segmentation, rNCCT-assisted segmentation increased the Dice similarity coefficient by >50% for neuroradiologists (Dice similarity coefficient, 0.38 versus 0.83; P<0.001) and nonradiologists (Dice similarity coefficient, 0.14 versus 0.84; P<0.001), and improved the DI among nonradiologists (mean improvement, 5.8 mL [95% CI, 3.1-8.5] mL, P<0.001) but not among neuroradiologists. CONCLUSIONS The high variability of manual segmentations of the acute ischemic lesion on NCCT is greatly reduced using semiautomated rNCCT. The rNCCT map may therefore aid acute infarct detection and provide more reliable infarct estimates for clinicians with less experience.
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Affiliation(s)
| | - Jelle Demeestere
- KU Leuven – University of Leuven, Department of Neurosciences, Experimental Neurology, Leuven, Belgium
- University Hospitals Leuven, Department of Neurology, Leuven, Belgium
| | | | | | | | | | | | | | | | | | | | - Robin Lemmens
- KU Leuven – University of Leuven, Department of Neurosciences, Experimental Neurology, Leuven, Belgium
- University Hospitals Leuven, Department of Neurology, Leuven, Belgium
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8
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Faizy TD, Winkelmeier L, Mlynash M, Broocks G, Heitkamp C, Thaler C, van Horn N, Seners P, Kniep H, Stracke P, Zelenak K, Lansberg MG, Albers GW, Wintermark M, Fiehler J, Heit JJ. Brain edema growth after thrombectomy is associated with comprehensive collateral blood flow. J Neurointerv Surg 2023:jnis-2023-020921. [PMID: 37918909 DOI: 10.1136/jnis-2023-020921] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/13/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND We determined whether a comprehensive assessment of cerebral collateral blood flow is associated with ischemic lesion edema growth in patients successfully treated by thrombectomy. METHODS This was a multicenter retrospective study of ischemic stroke patients who underwent thrombectomy treatment of large vessel occlusions. Collateral status was determined using the cerebral collateral cascade (CCC) model, which comprises three components: arterial collaterals (Tan Scale) and venous outflow profiles (Cortical Vein Opacification Score) on CT angiography, and tissue-level collaterals (hypoperfusion intensity ratio) on CT perfusion. Quantitative ischemic lesion net water uptake (NWU) was used to determine edema growth between admission and follow-up non-contrast head CT (ΔNWU). Three groups were defined: CCC+ (good pial collaterals, tissue-level collaterals, and venous outflow), CCC- (poor pial collaterals, tissue-level collaterals, and venous outflow), and CCCmixed (remainder of patients). Primary outcome was ischemic lesion edema growth (ΔNWU). Multivariable regression models were used to assess the primary and secondary outcomes. RESULTS 538 patients were included. 157 patients had CCC+, 274 patients CCCmixed, and 107 patients CCC- profiles. Multivariable regression analysis showed that compared with patients with CCC+ profiles, CCC- (β 1.99, 95% CI 0.68 to 3.30, P=0.003) and CCC mixed (β 1.65, 95% CI 0.75 to 2.56, P<0.001) profiles were associated with greater ischemic lesion edema growth (ΔNWU) after successful thrombectomy treatment. ΔNWU (OR 0.74, 95% CI 0.68 to 0.8, P<0.001) and CCC+ (OR 13.39, 95% CI 4.88 to 36.76, P<0.001) were independently associated with functional independence. CONCLUSION A comprehensive assessment of cerebral collaterals using the CCC model is strongly associated with edema growth and functional independence in acute stroke patients successfully treated by endovascular thrombectomy.
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Affiliation(s)
- Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Mlynash
- Department of Neurology, Stanford Stroke Center, Stanford University, Stanford, California, USA
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Heitkamp
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Thaler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Paul Stracke
- Section of Interventional Neuroradiology, University Hospital Munster, Munster, Germany
| | - Kamil Zelenak
- Clinic of Radiology, Comenius University in Bratislava Jessenius Faculty of Medicine in Martin, Martin, Slovakia
- Clinic of Radiology, University Hospital Martin, Martin, Slovakia
| | - Maarten G Lansberg
- Department of Neurology, Stanford Stroke Center, Stanford University, Stanford, California, USA
| | - Gregory W Albers
- Stanford Stroke Center, Stanford Medicine, Stanford, California, USA
| | - Max Wintermark
- Department of Neuroradiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
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9
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Broocks G, Meyer L. New Advances in Diagnostic Radiology for Ischemic Stroke. J Clin Med 2023; 12:6375. [PMID: 37835019 PMCID: PMC10573123 DOI: 10.3390/jcm12196375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023] Open
Abstract
Ischemic stroke, a leading cause of disability and mortality worldwide, occurs due to the sudden interruption of blood supply to a specific region of the brain [...].
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany;
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10
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Shao Y, Chen X, Wang H, Shang Y, Xu J, Zhang J, Wang P, Geng Y. Large mismatch profile predicts rapidly progressing brain edema in acute anterior circulation large vessel occlusion patients undergoing endovascular thrombectomy. Front Neurol 2023; 13:982911. [PMID: 36686510 PMCID: PMC9846046 DOI: 10.3389/fneur.2022.982911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 12/05/2022] [Indexed: 01/05/2023] Open
Abstract
Background Brain edema is a severe complication in patients with large vessel occlusion (LVO) that can reduce the effectiveness of endovascular therapy (EVT). This study aimed to investigate the association of the perfusion profile at baseline computed tomography (CT) perfusion with rapidly progressing brain edema (RPBE) after EVT in patients with acute anterior LVO. Methods We retrospectively reviewed consecutive data collected from 149 patients with anterior LVO who underwent EVT at our center. Brain edema was measured by the swelling score (0-6 score), and RPBE was defined as the swelling score increased by more than 2 scores within 24 h after EVT. We investigated the effect of RPBE on poor outcomes [National Institute of Health Stroke Scale (NIHSS) score and modified Rankin scale (mRS) score at discharge, the occurrence of hemorrhagic transformation, and mortality rate in the hospital] using the Mann-Whitney U-test and chi-square test. A multivariate logistic regression model was used to assess the relationship between perfusion imaging parameters and RPBE occurrence. Results Overall, 39 patients (26.2%) experienced RPBE after EVT. At discharge, RPBE was associated with higher NIHSS scores (Z = 3.52, 95% CI 2.0-12.0, P < 0.001) and higher mRS scores (Z = 3.67, 95% CI 0.0-1.0, P < 0.001) including the more frequent occurrence of hemorrhagic transformation (χ2 = 22.17, 95% CI 0.29-0.59, P < 0.001) and higher mortality rates in hospital (χ2 = 9.54, 95% CI 0.06-0.36, P = 0.002). Univariate analysis showed that intravenous thrombolysis, baseline ischemic core volume, and baseline mismatch ratio correlated with RPBE (all P < 0.05). After dividing the mismatch ratio into quartiles and performing a chi-square test between quartiles, we found that the occurrence of RPBE in Q4 (mismatch ratio > 11.3) was significantly lower than that in Q1 (mismatch ratio ≤ 3.0) (P < 0.05). The result of multivariate logistic regression analysis showed that compared with baseline mismatch ratio <5.1, baseline mismatch ratio between 5.1 and 11.3 (OR:3.85, 95% CI 1.06-14.29, P = 0.040), and mismatch ratio >11.3 (OR:5.26, 95% CI 1.28-20.00, P = 0.021) were independent protective factors for RPBE. Conclusion In patients with anterior circulation LVO stroke undergoing successful EVT, a large mismatch ratio at baseline is a protective factor for RPBE, which is associated with poor outcomes.
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Affiliation(s)
- Yanqi Shao
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Xinyi Chen
- Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Huiyuan Wang
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China,Department of Clinical Medicine, Bengbu Medical College, Bengbu, China
| | - Yafei Shang
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China,Department of Clinical Medicine, Bengbu Medical College, Bengbu, China
| | - Jie Xu
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China,Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jinshi Zhang
- Department of Nephrology, Urology and Nephrology Center, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Peng Wang
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Yu Geng
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China,*Correspondence: Yu Geng ✉
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11
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Lu SS, Wu RR, Cao YZ, Xu XQ, Jia ZY, Shi HB, Liu S, Wu FY. Automated Estimation of Quantitative Lesion Water Uptake as a Prognostic Biomarker for Patients with Ischemic Stroke and Large-Vessel Occlusion. AJNR Am J Neuroradiol 2023; 44:33-39. [PMID: 36549850 PMCID: PMC9835911 DOI: 10.3174/ajnr.a7741] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/11/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Net water uptake is qualified as an imaging marker of brain edema. We aimed to investigate the ability of net water uptake to predict 90-day functional outcome in patients with acute ischemic stroke and large-vessel occlusion. MATERIALS AND METHODS A total of 295 consecutive patients were retrospectively enrolled. Automated ASPECTS-net water uptake was calculated on the admission CT. The relationship between ASPECTS-net water uptake and 90-day neurologic outcome was assessed. The independent predictors of favorable outcome (mRS score ≤2) were assessed using multivariate logistic regression analysis and receiver operating characteristic curves and stratified by the ASPECTS. RESULTS Favorable 90-day outcomes were observed in 156 (52.9%) patients. ASPECTS-net water uptake (OR, 0.79; 95% CI, 0.70-0.90), NIHSS scores (OR, 0.91; 95% CI, 0.87-0.96), age (OR, 0.96; 95% CI, 0.94-0.99), and vessel recanalization (OR, 7.78; 95% CI, 3.96-15.29) were independently associated with favorable outcomes at 90 days (all, P < .01). A lower ASPECTS-net water uptake independently predicted a good prognosis, even in the subgroup of patients with low ASPECTS (≤5) (P < .05). An outcome-prediction model based on these variables yielded an area under the receiver operating characteristic curve of 0.856 (95% CI, 0.814-0.899; sensitivity, 76.3%; specificity, 81.3%). CONCLUSIONS ASPECTS-net water uptake could independently predict 90-day neurologic outcomes in patients with acute ischemic stroke and large-vessel occlusion. Integrating ASPECTS-net water uptake with clinical models could improve the efficiency of outcome stratification.
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Affiliation(s)
- S S Lu
- From the Departments of Radiology (S.S.L., R.R.W., X.Q.X., F.Y.W.)
| | - R R Wu
- From the Departments of Radiology (S.S.L., R.R.W., X.Q.X., F.Y.W.)
| | - Y Z Cao
- Interventional Radiology (Y.Z.C., Z.Y.J., H.B.S., S.L.), The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - X Q Xu
- From the Departments of Radiology (S.S.L., R.R.W., X.Q.X., F.Y.W.)
| | - Z Y Jia
- Interventional Radiology (Y.Z.C., Z.Y.J., H.B.S., S.L.), The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - H B Shi
- Interventional Radiology (Y.Z.C., Z.Y.J., H.B.S., S.L.), The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - S Liu
- Interventional Radiology (Y.Z.C., Z.Y.J., H.B.S., S.L.), The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - F Y Wu
- From the Departments of Radiology (S.S.L., R.R.W., X.Q.X., F.Y.W.)
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McDonough R, Elsayed S, Meyer L, Ewers T, Bechstein M, Kniep H, Nawka MT, Faizy TD, Schön G, Thomalla G, Fiehler J, Hanning U, Kemmling A, Broocks G. Low baseline ischemic water uptake is directly related to overestimation of CT perfusion-derived ischemic core volume. Sci Rep 2022; 12:20567. [PMID: 36446862 PMCID: PMC9708677 DOI: 10.1038/s41598-022-19176-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 08/25/2022] [Indexed: 11/30/2022] Open
Abstract
Computed-tomography perfusion (CTP) is frequently used to screen acute ischemic stroke (AIS) patients for endovascular treatment (EVT), despite known problems with ischemic "core" overestimation. This potentially leads to the unfair exclusion of patients from EVT. We propose that net water uptake (NWU) can be used in addition to CTP to more accurately assess the extent and/or stage of tissue infarction. Patients treated for AIS between 06/2015 and 07/2020 were retrospectively analyzed. Baseline CTP-derived core volume (pCore) and NWU were determined. Logistic regression tested the relationship between baseline clinical and imaging variables and core-overestimation (primary outcome). The secondary outcomes comprised 90-day functional independence (modified Rankin score) and lesion growth. 284 patients were included. Median NWU was 7.2% (IQR 2.6-12.8). ASPECTS (RR 1.28, 95% CI 1.09-1.51), NWU (RR 0.94, 95% CI 0.89-0.98), onset to recanalization (RR 1.00, 95% CI 0.99-1.00) and imaging (RR 1.00, 95% CI 1.00-1.00) times, and pCore (RR 1.02, 95% CI 1.01-1.02) were significantly associated with core overestimation. Core-overestimation was more likely to occur in patients with large pCores and low NWU at baseline. NWU was significantly correlated with lesion growth. We conclude that NWU can be used as a supplemental tool to CTP during admission imaging to more accurately assess the extent of ischemia, particularly relevant for patients with large CTP-defined cores who would otherwise be excluded from treatment.
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Affiliation(s)
- Rosalie McDonough
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Sarah Elsayed
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Lukas Meyer
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Theresa Ewers
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Matthias Bechstein
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Helge Kniep
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Marie Teresa Nawka
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Tobias D. Faizy
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Gerhard Schön
- grid.13648.380000 0001 2180 3484Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- grid.13648.380000 0001 2180 3484Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Uta Hanning
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Andre Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - Gabriel Broocks
- grid.13648.380000 0001 2180 3484Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
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Mechtouff L, Debs N, Frindel C, Bani-Sadr A, Bochaton T, Paccalet A, Crola Da Silva C, Buisson M, Amaz C, Berthezene Y, Eker OF, Bouin M, de Bourguignon C, Mewton N, Ovize M, Bidaux G, Nighoghossian N, Cho TH. Association of Blood Biomarkers of Inflammation With Penumbra Consumption After Mechanical Thrombectomy in Patients With Acute Ischemic Stroke. Neurology 2022; 99:e2063-e2071. [PMID: 36316128 DOI: 10.1212/wnl.0000000000201038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 06/15/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The objective of this study was to assess the relationship between blood biomarkers of inflammation and lesion growth within the penumbra in acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT). METHODS The HIBISCUS-STROKE cohort enrolled patients admitted in the Lyon Stroke Center for an anterior circulation AIS treated with MT after brain MRI assessment. Lesion growth within the penumbra was assessed on day 6 MRI using a voxel-based nonlinear coregistration method and dichotomized into low and high according to the median value. C-reactive protein, interleukin (IL)-6, IL-8, IL-10, monocyte chemoattractant protein-1, soluble tumor necrosis factor receptor I, soluble form suppression of tumorigenicity 2 (sST2), soluble P-selectin, vascular cellular adhesion molecule-1, and matrix metalloproteinase-9 were measured in sera at 4 time points within the first 48 hours. Reperfusion was considered as successful if Thrombolysis in Cerebral Infarction score was 2b/2c/3. A multiple logistic regression model was performed to detect any association between area under the curve (AUC) of these biomarkers within the first 48 hours and a high lesion growth within the penumbra. RESULTS Ninety patients were included. The median lesion growth within the penumbra was 2.3 (0.7-6.2) mL. On multivariable analysis, a high sST2 AUC (OR 3.77, 95% CI 1.36-10.46), a high baseline DWI volume (OR 3.65, 95% CI 1.32-10.12), and a lack of successful reperfusion (OR 0.19, 95% CI 0.04-0.92) were associated with a high lesion growth within the penumbra. When restricting analyses to patients with successful reperfusion (n = 76), a high sST2 AUC (OR 5.03, 95% CI 1.64-15.40), a high baseline DWI volume (OR 3.74, 95% CI 1.22-11.53), and a high penumbra volume (OR 3.25, 95% CI 1.10-9.57) remained associated with a high lesion growth within the penumbra. DISCUSSION High sST2 levels within the first 48 hours are associated with a high lesion growth within the penumbra.
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Affiliation(s)
- Laura Mechtouff
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France.
| | - Noelie Debs
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Carole Frindel
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Alexandre Bani-Sadr
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Thomas Bochaton
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Alexandre Paccalet
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Claire Crola Da Silva
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Marielle Buisson
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Camille Amaz
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Yves Berthezene
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Omer Faruk Eker
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Morgane Bouin
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Charles de Bourguignon
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Nathan Mewton
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Michel Ovize
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Gabriel Bidaux
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Norbert Nighoghossian
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
| | - Tae-Hee Cho
- From the Stroke Department (L.M., N.N., T.-H.C.), Hospices Civils de Lyon; Univ Lyon (L.M., T.B., A.P., C.C.D.S., M.O., G.B., N.N., T.-H.C.), CarMeN Laboratory, INSERM, INRA, University Lyon 1; CREATIS (N.D., C.F., Y.B.), CNRS UMR 5220, INSERM U1044, University Lyon 1; Neuroradiology Department (A.B.-S., Y.B., O.F.E.), Hospices Civils de Lyon; Cardiac Intensive Care Unit (T.B.), Hospices Civils de Lyon; Clinical Investigation Center (M.B., C.A., C.d.B., N.M., M.O.), INSERM 1407, Hospices Civils de Lyon; and Cellule Recherche Imagerie (M.B.), Hospices Civils de Lyon, France
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Predictive Value of Different Computed Tomography Perfusion Software Regarding 90-Day Outcome of Acute Ischemic Stroke Patients After Endovascular Treatment: A Comparison With Magnetic Resonance Imaging. J Comput Assist Tomogr 2022; 46:945-952. [PMID: 35696312 DOI: 10.1097/rct.0000000000001342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE This study compared ischemic core and penumbra volumes obtained using different computed tomography perfusion (CTP) software and evaluated the predictive value of CTP and magnetic resonance imaging (MRI) results for 90-day outcomes. METHODS In total, 105 acute ischemic stroke patients who underwent endovascular treatment from January 2016 to December 2020 were included. Patients were divided into good and poor outcome groups by a modified Rankin Scale score. Computed tomography perfusion core and penumbra volumes were obtained using OleaSphere and Vitrea software to assess the volumetric relationship with MRI using the Spearman correlation test, intraclass correlation coefficient (ICC), and Bland-Altman plot. Three multivariable models were developed: baseline variables with MRI infarct volume, baseline variables with OleaSphere core volume, and baseline variables with Vitrea core volume. The area under the receiver operating characteristic curve of the 3 models was compared using the DeLong test. RESULTS Median core volumes were 27.5, 26.9, and 31.1 mL for OleaSphere, Vitrea, and MRI, respectively. There was substantial correlation and excellent agreement between OleaSphere and MRI core volume ( ρ = 0.84, P < 0.001; ICC = 0.84) and Vitrea and MRI core volume ( ρ = 0.80, P < 0.001; ICC = 0.83). The areas under curve for MRI volume, OleaSphere, and Vitrea were 0.86, 0.84, and 0.83, respectively. There were no significant differences ( P = 0.18) between the predictive value of the 3 models. CONCLUSIONS Computed tomography perfusion core volumes showed substantial correlation and excellent agreement with MRI. There was no significant difference in the predictive value of the 3 models, suggesting that core volumes measured using CTP software can predict patient prognosis.
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Gu Y, Zhou C, Piao Z, Yuan H, Jiang H, Wei H, Zhou Y, Nan G, Ji X. Cerebral edema after ischemic stroke: Pathophysiology and underlying mechanisms. Front Neurosci 2022; 16:988283. [PMID: 36061592 PMCID: PMC9434007 DOI: 10.3389/fnins.2022.988283] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/01/2022] [Indexed: 11/30/2022] Open
Abstract
Ischemic stroke is associated with increasing morbidity and has become the main cause of death and disability worldwide. Cerebral edema is a serious complication arising from ischemic stroke. It causes an increase in intracranial pressure, rapid deterioration of neurological symptoms, and formation of cerebral hernia, and is an important risk factor for adverse outcomes after stroke. To date, the detailed mechanism of cerebral edema after stroke remains unclear. This limits advances in prevention and treatment strategies as well as drug development. This review discusses the classification and pathological characteristics of cerebral edema, the possible relationship of the development of cerebral edema after ischemic stroke with aquaporin 4, the SUR1-TRPM4 channel, matrix metalloproteinase 9, microRNA, cerebral venous reflux, inflammatory reactions, and cerebral ischemia/reperfusion injury. It also summarizes research on new therapeutic drugs for post-stroke cerebral edema. Thus, this review provides a reference for further studies and for clinical treatment of cerebral edema after ischemic stroke.
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Affiliation(s)
- Yuhang Gu
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Chen Zhou
- Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Capital Medical University, Beijing, China
| | - Zhe Piao
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Honghua Yuan
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Huimin Jiang
- Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Capital Medical University, Beijing, China
| | - Huimin Wei
- Advanced Innovation Center for Big Data-Based Precision Medicine, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Yifan Zhou
- Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Capital Medical University, Beijing, China
| | - Guangxian Nan
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
- *Correspondence: Guangxian Nan,
| | - Xunming Ji
- Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Capital Medical University, Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Xunming Ji,
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16
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Kumar A, Chen Y, Corbin A, Hamzehloo A, Abedini A, Vardar Z, Carey G, Bhatia K, Heitsch L, Derakhshan JJ, Lee JM, Dhar R. Automated Measurement of Net Water Uptake From Baseline and Follow-Up CTs in Patients With Large Vessel Occlusion Stroke. Front Neurol 2022; 13:898728. [PMID: 35832178 PMCID: PMC9271791 DOI: 10.3389/fneur.2022.898728] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/06/2022] [Indexed: 11/13/2022] Open
Abstract
Quantifying the extent and evolution of cerebral edema developing after stroke is an important but challenging goal. Lesional net water uptake (NWU) is a promising CT-based biomarker of edema, but its measurement requires manually delineating infarcted tissue and mirrored regions in the contralateral hemisphere. We implement an imaging pipeline capable of automatically segmenting the infarct region and calculating NWU from both baseline and follow-up CTs of large-vessel occlusion (LVO) patients. Infarct core is extracted from CT perfusion images using a deconvolution algorithm while infarcts on follow-up CTs were segmented from non-contrast CT (NCCT) using a deep-learning algorithm. These infarct masks were flipped along the brain midline to generate mirrored regions in the contralateral hemisphere of NCCT; NWU was calculated as one minus the ratio of densities between regions, removing voxels segmented as CSF and with HU outside thresholds of 20-80 (normal hemisphere and baseline CT) and 0-40 (infarct region on follow-up). Automated results were compared with those obtained using manually-drawn infarcts and an ASPECTS region-of-interest based method that samples densities within the infarct and normal hemisphere, using intraclass correlation coefficient (ρ). This was tested on serial CTs from 55 patients with anterior circulation LVO (including 66 follow-up CTs). Baseline NWU using automated core was 4.3% (IQR 2.6-7.3) and correlated with manual measurement (ρ = 0.80, p < 0.0001) and ASPECTS (r = -0.60, p = 0.0001). Automatically segmented infarct volumes (median 110-ml) correlated to manually-drawn volumes (ρ = 0.96, p < 0.0001) with median Dice similarity coefficient of 0.83 (IQR 0.72-0.90). Automated NWU was 24.6% (IQR 20-27) and highly correlated to NWU from manually-drawn infarcts (ρ = 0.98) and the sampling-based method (ρ = 0.68, both p < 0.0001). We conclude that this automated imaging pipeline is able to accurately quantify region of infarction and NWU from serial CTs and could be leveraged to study the evolution and impact of edema in large cohorts of stroke patients.
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Affiliation(s)
- Atul Kumar
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Yasheng Chen
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Aaron Corbin
- Saint Louis University School of Medicine, Saint Louis, MO, United States
| | - Ali Hamzehloo
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Amin Abedini
- Department of Radiology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Zeynep Vardar
- Department of Radiology, University of Massachusetts Medical School, Worcester, MA, United States
| | - Grace Carey
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Kunal Bhatia
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Laura Heitsch
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Jamal J. Derakhshan
- Department of Radiology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Jin-Moo Lee
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Rajat Dhar
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States,*Correspondence: Rajat Dhar
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17
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Han Q, Yang J, Gao X, Li J, Wu Y, Xu Y, Shang Q, Parsons MW, Lin L. Early Edema Within the Ischemic Core Is Time-Dependent and Associated With Functional Outcomes of Acute Ischemic Stroke Patients. Front Neurol 2022; 13:861289. [PMID: 35463133 PMCID: PMC9021998 DOI: 10.3389/fneur.2022.861289] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/08/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo investigate the difference in early edema, quantified by net water uptake (NWU) based on computed tomography (CT) between ischemic core and penumbra and to explore predictors of NWU and test its predictive power for clinical outcome.MethodsRetrospective analysis was conducted on patients admitted to Ningbo First Hospital with anterior circulation stroke and multi-modal CT. In 154 included patients, NWU of the ischemic core and penumbra were calculated and compared by Mann–Whitney U test. Correlations between NWU and variables including age, infarct time (time from symptom onset to imaging), volume of ischemic core, collateral status, and National Institutes of Health Stroke Scale (NIHSS) scores were investigated by Spearman's correlation analyses. Clinical outcome was defined using the modified Rankin Scale (mRS) at 90 days. Logistic regression and receiver operating characteristic analyses were performed to test the predictive value of NWU. Summary statistics are presented as median (interquartile range), mean (standard deviation) or estimates (95% confidence interval).ResultsThe NWU within the ischemic core [6.1% (2.9–9.2%)] was significantly higher than that of the penumbra [1.8% (−0.8–4.0%)]. The only significant predictor of NWU within the ischemic core was infarct time (p = 0.004). The NWU within the ischemic core [odds ratio = 1.23 (1.10–1.39)], the volume of ischemic core [1.04, (1.02–1.06)], age [1.09 (1.01–1.17)], and admission NHISS score [1.05 (1.01–1.09)] were associated with the outcome of patients adjusted for sex and treatment. The predictive power for the outcome of the model was significantly higher when NWU was included (area under the curve 0.875 vs. 0.813, p < 0.05 by Delong test).ConclusionsEarly edema quantified by NWU is relatively limited in the ischemic core and develops in a time-dependent manner. NWU estimates within the ischemic core may help to predict clinical outcomes of patients with acute ischemic stroke.
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Affiliation(s)
- Qing Han
- Department of Neurology, Ningbo First Hospital, Ningbo, China
| | - Jianhong Yang
- Department of Neurology, Ningbo First Hospital, Ningbo, China
| | - Xiang Gao
- Department of Neurosurgery, Ningbo First Hospital, Ningbo, China
| | - Jichuan Li
- Department of Neurology, Ningbo First Hospital, Ningbo, China
| | - Yuefei Wu
- Department of Neurology, Ningbo First Hospital, Ningbo, China
| | - Yao Xu
- Department of Neurology, Ningbo First Hospital, Ningbo, China
| | - Qing Shang
- Department of Neurology, Ningbo First Hospital, Ningbo, China
| | - Mark W. Parsons
- Sydney Brain Center, University of New South Wales, Sydney, NSW, Australia
- Mark W. Parsons
| | - Longting Lin
- Department of Neurology, Ningbo First Hospital, Ningbo, China
- Sydney Brain Center, University of New South Wales, Sydney, NSW, Australia
- *Correspondence: Longting Lin
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18
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Zhang X, Huang P, Zhang R. Evaluation and Prediction of Post-stroke Cerebral Edema Based on Neuroimaging. Front Neurol 2022; 12:763018. [PMID: 35087464 PMCID: PMC8786707 DOI: 10.3389/fneur.2021.763018] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 12/06/2021] [Indexed: 11/13/2022] Open
Abstract
Cerebral edema is a common complication of acute ischemic stroke that leads to poorer functional outcomes and substantially increases the mortality rate. Given that its negative effects can be reduced by more intensive monitoring and evidence-based interventions, the early identification of patients with a high risk of severe edema is crucial. Neuroimaging is essential for the assessment and prediction of edema. Simple markers, such as midline shift and hypodensity volume on computed tomography, have been used to evaluate edema in clinical trials; however, advanced techniques can be applied to examine the underlying mechanisms. In this study, we aimed to review current imaging tools in the assessment and prediction of cerebral edema to provide guidance for using these methods in clinical practice.
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Affiliation(s)
- Xiaocheng Zhang
- Department of Radiology, School of Medicine, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Peiyu Huang
- Department of Radiology, School of Medicine, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Ruiting Zhang
- Department of Radiology, School of Medicine, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
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19
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van Horn N, Heit JJ, Kabiri R, Broocks G, Christensen S, Mlynash M, Meyer L, Schoenfeld MH, Lansberg MG, Albers GW, Fiehler J, Wintermark M, Faizy TD. Venous outflow profiles are associated with early edema progression in ischemic stroke. Int J Stroke 2022; 17:1078-1084. [PMID: 34983276 DOI: 10.1177/17474930211065635] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND In patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO), development of extensive early ischemic brain edema is associated with poor functional outcomes, despite timely treatment. Robust cortical venous outflow (VO) profiles correlate with favorable tissue perfusion. We hypothesized that favorable VO profiles (VO+) correlate with a reduced early edema progression rate (EPR) and good functional outcomes. METHODS Multicenter, retrospective analysis to investigate AIS-LVO patients treated by mechanical thrombectomy between May 2013 and December 2020. Baseline computed tomography angiography (CTA) was used to determine VO using the cortical vein opacification score (COVES); VO+ was defined as COVES ⩾ 3 and unfavorable as COVES ⩽ 2. EPR was determined as the ratio of net water uptake (NWU) on baseline non-contrast CT and time from symptom onset to admission imaging. Multivariable regression analysis was performed to assess primary (EPR) and secondary outcome (good functional outcomes defined as 0-2 points on the modified Rankin scale). RESULTS A total of 728 patients were included. Primary outcome analysis showed VO+ (β: -0.03, SE: 0.009, p = 0.002), lower presentation National Institutes of Health Stroke Scale (NIHSS; β: 0.002, SE: 0.001, p = 0.002), and decreased time from onset to admission imaging (β: -0.00002, SE: 0.00004, p < 0.001) were independently associated with reduced EPR. VO+ also predicted good functional outcomes (odds ratio (OR): 5.07, 95% CI: 2.839-9.039, p < 0.001), while controlling for presentation NIHSS, time from onset to imaging, general vessel reperfusion, baseline Alberta Stroke Program Early CT Score, infarct core volume, EPR, and favorable arterial collaterals. CONCLUSIONS Favorable VO profiles were associated with slower infarct edema progression and good long-term functional outcomes as well as better neurological status and ischemic brain alterations at admission.
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Affiliation(s)
- Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Reza Kabiri
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Soren Christensen
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Max Wintermark
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
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20
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Bala F, Ospel J, Mulpur B, Kim BJ, Yoo J, Menon BK, Goyal M, Federau C, Sohn SI, Hussain MS, Almekhlafi MA. Infarct Growth despite Successful Endovascular Reperfusion in Acute Ischemic Stroke: A Meta-analysis. AJNR Am J Neuroradiol 2021; 42:1472-1478. [PMID: 34083260 DOI: 10.3174/ajnr.a7177] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/25/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Infarct volume inversely correlates with good recovery in stroke. The magnitude and predictors of infarct growth despite successful reperfusion via endovascular treatment are not known. PURPOSE We aimed to summarize the extent of infarct growth in patients with acute stroke who achieved successful reperfusion (TICI 2b-3) after endovascular treatment. DATA SOURCES We performed a systematic review and meta-analysis by searching MEDLINE and Google Scholar for articles published up to October 31, 2020. STUDY SELECTION Studies of >10 patients reporting baseline and post-endovascular treatment infarct volumes on MR imaging were included. Only patients with TICI 2b-3 were included. We calculated infarct growth at a study level as the difference between baseline and follow-up MR imaging infarct volumes. DATA ANALYSIS Our search yielded 345 studies, and we included 10 studies reporting on 973 patients having undergone endovascular treatment who achieved successful reperfusion. DATA SYNTHESIS The mean baseline infarct volume was 19.5 mL, while the mean final infarct volume was 37.5 mL. A TICI 2b reperfusion grade was achieved in 24% of patients, and TICI 2c or 3 in 76%. The pooled mean infarct growth was 14.8 mL (95% CI, 7.9-21.7 mL). Meta-regression showed higher infarct growth in studies that reported higher baseline infarct volumes, higher rates of incomplete reperfusion (modified TICI 2b), and longer onset-to-reperfusion times. LIMITATIONS Significant heterogeneity among studies was noted and might be driven by the difference in infarct growth between early- and late-treatment studies. CONCLUSIONS These results suggest considerable infarct growth despite successful endovascular treatment reperfusion and call for a faster workflow and the need for specific therapies to limit infarct growth.
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Affiliation(s)
- F Bala
- From the Calgary Stroke Program (F.B., J.O., B.K.M., M.G., M.A.A.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (F.B., B.K.M., M.A.A.), University of Calgary, Calgary, Alberta, Canada
| | - J Ospel
- From the Calgary Stroke Program (F.B., J.O., B.K.M., M.G., M.A.A.), University of Calgary, Calgary, Alberta, Canada
- Department of Neuroradiology, Clinic of Radiology, and Nuclear Medicine (J.O.), University Hospital Basel, Basel, Switzerland
| | - B Mulpur
- Cerebrovascular Center and Department of Neurology (B.M., M.S.H.), Neurological Institute, Cleveland Clinic, Ohio
| | - B J Kim
- Department of Neurology and Cerebrovascular Center (B.J.K.), Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - J Yoo
- Yonsei University College of Medicine (J.Y.), Yongin Severance Hospital, Yongin, Korea
| | - B K Menon
- From the Calgary Stroke Program (F.B., J.O., B.K.M., M.G., M.A.A.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (F.B., B.K.M., M.A.A.), University of Calgary, Calgary, Alberta, Canada
- Department of Radiology (B.K.M., M.A.A.), University of Calgary, Calgary, Alberta, Canada
| | - M Goyal
- From the Calgary Stroke Program (F.B., J.O., B.K.M., M.G., M.A.A.), University of Calgary, Calgary, Alberta, Canada
| | - C Federau
- Institute for Biomedical Engineering (C.F.), Swiss Federal Institute of Technology in Zürich, Zürich, Switzerland
| | - S-I Sohn
- Department of Neurology (S.-I.S.), Keimyung University School of Medicine, Daegu, Korea
| | - M S Hussain
- Cerebrovascular Center and Department of Neurology (B.M., M.S.H.), Neurological Institute, Cleveland Clinic, Ohio
| | - M A Almekhlafi
- From the Calgary Stroke Program (F.B., J.O., B.K.M., M.G., M.A.A.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (F.B., B.K.M., M.A.A.), University of Calgary, Calgary, Alberta, Canada
- Department of Radiology (B.K.M., M.A.A.), University of Calgary, Calgary, Alberta, Canada
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21
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Faizy TD, Kabiri R, Christensen S, Mlynash M, Kuraitis G, Broocks G, Hanning U, Nawabi J, Lansberg MG, Marks MP, Albers GW, Fiehler J, Wintermark M, Heit JJ. Perfusion imaging-based tissue-level collaterals predict ischemic lesion net water uptake in patients with acute ischemic stroke and large vessel occlusion. J Cereb Blood Flow Metab 2021; 41:2067-2075. [PMID: 33557694 PMCID: PMC8327120 DOI: 10.1177/0271678x21992200] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Ischemic lesion Net Water Uptake (NWU) quantifies cerebral edema formation and likely correlates with the microvascular perfusion status of patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). We hypothesized that favorable tissue-level collaterals (TLC) predict less NWU and good functional outcomes. We performed a retrospective multicenter analysis of AIS-LVO patients who underwent thrombectomy triage. TLC were measured on cerebral perfusion studies using the hypoperfusion intensity ratio (HIR; volume ratio of brain tissue with [Tmax > 10 sec/Tmax > 6 sec]); favorable TLC were regarded as HIR ≤ 0.4. NWU was determined using a quantitative densitometry approach on follow-up CT. Primary outcome was NWU. Secondary outcome was a good functional outcome (modified Rankin Scale [mRS] 0-2).580 patients met inclusion criteria. Favorable TLC (β: 4.23, SE: 0.65; p < 0.001) predicted smaller NWU after treatment. Favorable TLC (OR: 2.35, [95% CI: 1.31-4.21]; p < 0.001), and decreased NWU (OR: 0.75, [95% CI: 0.70-0.79]; p < 0.001) predicted good functional outcome, while controlling for age, glucose, CTA collaterals, baseline NIHSS and good vessel reperfusion status.We conclude that favorable TLC predict less ischemic lesion NWU after treatment in AIS-LVO patients. Favorable TLC and decreased NWU were independent predictors of good functional outcome.
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Affiliation(s)
- Tobias D Faizy
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Reza Kabiri
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Soren Christensen
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Gabriella Kuraitis
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jawed Nawabi
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Radiology (CCM), Charité, Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, Freie Universität Berlin, Berlin, Germany
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael P Marks
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Max Wintermark
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
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22
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Konduri P, van Kranendonk K, Boers A, Treurniet K, Berkhemer O, Yoo AJ, van Zwam W, van Oostenbrugge R, van der Lugt A, Dippel D, Roos Y, Bot J, Majoie C, Marquering H. The Role of Edema in Subacute Lesion Progression After Treatment of Acute Ischemic Stroke. Front Neurol 2021; 12:705221. [PMID: 34354669 PMCID: PMC8329530 DOI: 10.3389/fneur.2021.705221] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/18/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Ischemic lesions commonly continue to progress even days after treatment, and this lesion growth is associated with unfavorable functional outcome in acute ischemic stroke patients. The aim of this study is to elucidate the role of edema in subacute lesion progression and its influence on unfavorable functional outcome by quantifying net water uptake. Methods: We included all 187 patients from the MR CLEAN trial who had high quality follow-up non-contrast CT at 24 h and 1 week. Using a CT densitometry-based method to calculate the net water uptake, we differentiated total ischemic lesion volume (TILV) into edema volume (EV) and edema-corrected infarct volume (ecIV). We calculated these volumes at 24 h and 1 week after stroke and determined their progression in the subacute period. We assessed the effect of 24-h lesion characteristics on EV and ecIV progression. We evaluated the influence of edema and edema-corrected infarct progression on favorable functional outcome after 90 days (modified Rankin Scale: 0-2) after correcting for potential confounders. Lastly, we compared these volumes between subgroups of patients with and without successful recanalization using the Mann-Whitney U-test. Results: Median TILV increased from 37 (IQR: 18-81) ml to 68 (IQR: 30-130) ml between 24 h and 1 week after stroke, while the net water uptake increased from 22 (IQR: 16-26)% to 27 (IQR: 22-32)%. The TILV progression of 20 (8.8-40) ml was mostly caused by ecIV with a median increase of 12 (2.4-21) ml vs. 6.5 (2.7-15) ml of EV progression. Larger TILV, EV, and ecIV volumes at 24 h were all associated with more edema and lesion progression. Edema progression was associated with unfavorable functional outcome [aOR: 0.53 (0.28-0.94) per 10 ml; p-value: 0.05], while edema-corrected infarct progression showed a similar, non-significant association [aOR: 0.80 (0.62-0.99); p-value: 0.06]. Lastly, edema progression was larger in patients without successful recanalization, whereas ecIV progression was comparable between the subgroups. Conclusion: EV increases in evolving ischemic lesions in the period between 1 day and 1 week after acute ischemic stroke. This progression is larger in patients without successful recanalization and is associated with unfavorable functional outcome. However, the extent of edema cannot explain the total expansion of ischemic lesions since edema-corrected infarct progression is larger than the edema progression.
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Affiliation(s)
- Praneeta Konduri
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Amsterdam, Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Katinka van Kranendonk
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Anna Boers
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Amsterdam, Netherlands.,Nico.lab, Amsterdam, Netherlands
| | - Kilian Treurniet
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands.,Department of Radiology and Nuclear Medicine, Haaglanden Medisch Centrum, The Hague, Netherlands
| | - Olvert Berkhemer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands.,Department of Neurology, Erasmus MC-University Medical Center, Rotterdam, Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus MC-University Medical Center, Rotterdam, Netherlands
| | - Albert J Yoo
- Department of Radiology, Texas Stroke Institute, Dallas-Fort Worth, TX, United States
| | - Wim van Zwam
- Department of Radiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Robert van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC-University Medical Center, Rotterdam, Netherlands
| | - Diederik Dippel
- Department of Neurology, Erasmus MC-University Medical Center, Rotterdam, Netherlands
| | - Yvo Roos
- Department of Neurology, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Joost Bot
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Vrije Universiteit van Amsterdam, Amsterdam, Netherlands
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Henk Marquering
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Amsterdam, Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
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Broocks G, Elsayed S, Kniep H, Kemmling A, Flottmann F, Bechstein M, Faizy TD, Meyer L, Lindner T, Sporns P, Rusche T, Schön G, Mader MM, Nawabi J, Fiehler J, Hanning U. Early Prediction of Malignant Cerebellar Edema in Posterior Circulation Stroke Using Quantitative Lesion Water Uptake. Neurosurgery 2021; 88:531-537. [PMID: 33040147 DOI: 10.1093/neuros/nyaa438] [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] [Received: 04/14/2020] [Accepted: 07/20/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Malignant cerebellar edema (MCE) is a life-threatening complication of ischemic posterior circulation stroke that requires timely diagnosis and management. Yet, there is no established imaging biomarker that may serve as predictor of MCE. Early edematous water uptake can be determined using quantitative lesion water uptake, but this biomarker has only been applied in anterior circulation strokes. OBJECTIVE To test the hypothesis that lesion water uptake in early posterior circulation stroke predicts MCE. METHODS A total 179 patients with posterior circulation stroke and multimodal admission CT were included. A total of 35 (19.5%) patients developed MCE defined by using an established 10-point scale in follow-up CT, of which ≥4 points are considered malignant. Posterior circulation net water uptake (pcNWU) was quantified in admission CT based on CT densitometry and compared with posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) as predictor of MCE using receiver operating curve (ROC) analysis and logistic regression analysis. RESULTS Acute pcNWU within the early ischemic lesion was 24.6% (±8.4) for malignant and 7.2% (±7.4) for nonmalignant infarctions, respectively (P < .0001). Based on ROC analysis, pcNWU above 14.9% identified MCE with high discriminative power (area under the curve: 0.94; 95% CI: 0.89-0.97). Early pcNWU (odds ratio [OR]: 1.28; 95% CI: 1.15-1.42, P < .0001) and pc-ASPECTS (OR: 0.71, 95% CI: 0.53-0.95, P = .02) were associated with MCE, adjusted for age and recanalization status. CONCLUSION Quantitative pcNWU in early posterior circulation stroke is an important marker for MCE. Besides pc-ASPECTS, lesion water uptake measurements may further support identifying patients at risk for MCE at an early stage indicating stricter monitoring and consideration for further therapeutic measures.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Elsayed
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany.,Department of Neuroradiology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Radiology, Stanford University, Stanford, California
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Lindner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Neuroradiology, Universitätsspital Basel, Basel, Switzerland
| | - Thilo Rusche
- Department of Neuroradiology, Universitätsspital Basel, Basel, Switzerland.,Department of Radiology, University Hospital Münster, Münster, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marius M Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jawed Nawabi
- Department of Radiology, Charité University Medical Center, Berlin, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Faizy TD, Kabiri R, Christensen S, Mlynash M, Kuraitis G, Meyer L, Marks MP, Broocks G, Flottmann F, Lansberg MG, Albers GW, Fiehler J, Wintermark M, Heit JJ. Venous Outflow Profiles Are Linked to Cerebral Edema Formation at Noncontrast Head CT after Treatment in Acute Ischemic Stroke Regardless of Collateral Vessel Status at CT Angiography. Radiology 2021; 299:682-690. [PMID: 33825511 DOI: 10.1148/radiol.2021203651] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Ischemic lesion net water uptake (NWU) at noncontrast head CT enables quantification of cerebral edema in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Purpose To assess whether favorable venous outflow (VO) profiles at CT angiography are associated with reduced NWU and good functional outcomes in patients with AIS due to LVO. Materials and Methods This multicenter retrospective cohort study evaluated consecutive patients with AIS due to LVO who underwent thrombectomy triage between January 2013 and December 2019. Arterial collateral vessel status (Tan scale) and venous output were measured at CT angiography. Venous outflow was graded with use of the cortical vein opacification score, which quantifies opacification of the vein of Labbé, sphenoparietal sinus, and superficial middle cerebral vein. Favorable VO was regarded as a score of 3-6 and unfavorable VO as a score of 0-2. NWU was determined at follow-up noncontrast CT. Multivariable regression analyses were performed to determine the association between favorable VO profiles and NWU after treatment and good functional outcome (modified Rankin Scale, ≤2). Results A total of 580 patients were included. Of the 580 patients, 231 had favorable VO (104 women; median age, 73 years [interquartile range {IQR}, 62-81 years]) and 349 had unfavorable VO (190 women; median age, 77 years [IQR, 66-84 years]). Compared with patients with unfavorable VO, those with favorable VO exhibited lower baseline National Institutes of Health Stroke Scale score (median, 12.5 [IQR, 7-17] vs 17 [IQR, 13-21]), higher Alberta Stroke Program Early CT Score (median, 9 [IQR, 7-10] vs 7 [IQR, 6-8]), and less NWU after treatment (median, 7% [IQR, 4.6%-11.5%] vs 17.9% [IQR, 12.3%-22.2%]). In a multivariable regression analysis, NWU mean difference between patients with unfavorable VO and those with favorable VO was 6.1% (95% CI: 4.9, 7.3; P < .001) regardless of arterial CT angiography collateral vessel status (b coefficient, 0.72 [95% CI: -0.59, 2.03; P = .28]). Favorable VO (odds ratio [OR]: 4.1 [95% CI: 2.2, 7.7]; P < .001) and reduced NWU after treatment (OR: 0.77 [95% CI: 0.73, 0.83]; P < .001) were independently associated with good functional outcomes. Conclusion Favorable venous outflow (VO) correlated with reduced ischemic net water uptake (NWU) after treatment. Reduced NWU and favorable VO were associated with good functional outcomes regardless of CT angiography arterial collateral vessel status. © RSNA, 2021 Online supplemental material is available for this article.
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Affiliation(s)
- Tobias D Faizy
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Reza Kabiri
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Soren Christensen
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Michael Mlynash
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Gabriella Kuraitis
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Lukas Meyer
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Michael P Marks
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Gabriel Broocks
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Fabian Flottmann
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Maarten G Lansberg
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Gregory W Albers
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Jens Fiehler
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Max Wintermark
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
| | - Jeremy J Heit
- From the Department of Radiology (T.D.F., R.K., G.K., M.P.M., M.W., J.J.H.) and Department of Neurology and Neurological Sciences (S.C., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, 300 Pasteur Dr, Room S047, Stanford, CA 94305; and Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M., G.B., F.F., J.F.)
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McDonough R, Elsayed S, Faizy TD, Austein F, Sporns PB, Meyer L, Bechstein M, van Horn N, Nawka MT, Schön G, Kniep H, Hanning U, Fiehler J, Heit JJ, Broocks G. Computed tomography-based triage of extensive baseline infarction: ASPECTS and collaterals versus perfusion imaging for outcome prediction. J Neurointerv Surg 2020; 13:869-874. [PMID: 33168659 DOI: 10.1136/neurintsurg-2020-016848] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/09/2020] [Accepted: 10/14/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Patients presenting with large baseline infarctions are often excluded from mechanical thrombectomy (MT) due to uncertainty surrounding its effect on outcome. We hypothesized that computed tomography perfusion (CTP)-based selection may be predictive of functional outcome in low Alberta Stroke Program Early CT Score (ASPECTS) patients. METHODS This was a double-center, retrospective analysis of patients presenting with ASPECTS≤5 who received multimodal admission CT imaging between May 2015 and June 2020. The predicted ischemic core (pCore) was defined as a reduction in cerebral blood flow (rCBF), while mismatch volume was defined using time to maximum (Tmax). The pCore perfusion mismatch ratio (CPMR) was also calculated. These parameters (pCore, mismatch volume, and CPMR), as well as a combined radiological score consisting of ASPECTS and collateral status (ASCO score), were tested in logistic regression and receiver operating characteristic (ROC) analyses. The primary outcome was favorable modified Rankin Scale (mRS) at discharge (≤3). RESULTS A total of 113 patients met the inclusion criteria. The median ischemic core volume was 74.1 mL (IQR 43.8-121.8). The ASCO score was associated with favorable outcome at discharge (aOR 3.7, 95% CI 1.8 to 10.7, P=0.002), while no association was observed for the CTP parameters. A model including the ASCO score also had significantly higher area under the curve (AUC) values compared with the CTP-based model (0.88 vs 0.64, P=0.018). CONCLUSIONS The ASCO score was superior to the CTP-based model for the prediction of good functional outcome and could represent a quick, practical, and easily implemented method for the selection of low ASPECTS patients most likely benefit from MT.
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Affiliation(s)
- Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Elsayed
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Friederike Austein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter B Sporns
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marie Teresa Nawka
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Radiology, Neuroradiology and Neurointervention Division, Stanford University, Stanford, California, USA
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Chen ZP, Shi ZZ, Li YG, Guo Y, Tong D. Post-processing of computed tomography perfusion in patients with acute cerebral ischemia: variability of inter-reader, inter-region of interest, inter-input model, and inter-software. Eur Radiol 2020; 30:6561-6569. [PMID: 32683549 DOI: 10.1007/s00330-020-07000-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 04/03/2020] [Accepted: 06/03/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine the reproducibility of quantitative computed tomography perfusion (CTP) parameters generated using different post-processing methods and identify the relative impact of subjective factors on the robustness of CTP parameters in acute ischemic stroke (AIS). MATERIALS AND METHODS A total of 80 CTP datasets from patients with AIS or transient ischemic attack (TIA) were retrospectively post-processed by two observers using different regions of interest (ROI) types, input models, and software. The CTP parameters were derived for 10 parenchymal ROIs. The intra-class correlation coefficients (ICCs) were used to assess the reproducibility of the CTP parameters for various post-processing methods. The Spearman correlation test was used to detect potential relationships between software and input models. RESULTS The ICCs with 95% confidence intervals (CIs) were 0.94 (0.93-0.96), 0.94 (0.92-0.96), 0.82 (0.79-0.86), and 0.87 (0.85-0.90) for inter-reader agreement by using elliptic ROI, irregular ROI, single-input model, and dual-input model, respectively. The ICCs with 95% CI were 0.98 (0.98-0.98), 0.46 (0.43-0.50), and 0.25 (0.20-0.30) for inter-ROI type, inter-input model, and inter-software agreement, respectively. CONCLUSIONS Although the CTP parameters were stable when measured using different readers with different ROI types, they varied for different input models and software. The standardization of CTP post-processing is essential to reduce variability of CTP values. KEY POINTS • The CTP parameters derived by different readers with different ROI types have agreements that range from good to excellent. • The CTP parameters derived from different input models and software programs have poor agreement but significant correlations.
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Affiliation(s)
- Zhong-Ping Chen
- Department of Radiology, The First Hospital of Jilin University, Changchun, 130021, Jilin, China
| | - Zhen-Zhen Shi
- Department of Radiology, The First Hospital of Jilin University, Changchun, 130021, Jilin, China
| | - Yun-Geng Li
- Department of Radiology, The First Hospital of Jilin University, Changchun, 130021, Jilin, China
| | - Yan Guo
- Life Sciences, GE Healthcare, Shenyang, 110000, China
| | - Dan Tong
- Department of Radiology, The First Hospital of Jilin University, Changchun, 130021, Jilin, China.
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van Horn N, Kniep H, Leischner H, McDonough R, Deb-Chatterji M, Broocks G, Thomalla G, Brekenfeld C, Fiehler J, Hanning U, Flottmann F. Predictors of poor clinical outcome despite complete reperfusion in acute ischemic stroke patients. J Neurointerv Surg 2020; 13:14-18. [PMID: 32414889 DOI: 10.1136/neurintsurg-2020-015889] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/07/2020] [Accepted: 04/07/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND In patients suffering from acute ischemic stroke from large vessel occlusion (LVO), mechanical thrombectomy (MT) often leads to successful reperfusion. Only approximately half of these patients have a favorable clinical outcome. Our aim was to determine the prognostic factors associated with poor clinical outcome following complete reperfusion. METHODS Patients treated with MT for LVO from a prospective single-center stroke registry between July 2015 and April 2019 were screened. Complete reperfusion was defined as Thrombolysis in Cerebral Infarction (TICI) grade 3. A modified Rankin scale at 90 days (mRS90) of 3-6 was defined as 'poor outcome'. A logistic regression analysis was performed with poor outcome as a dependent variable, and baseline clinical data, comorbidities, stroke severity, collateral status, and treatment information as independent variables. RESULTS 123 patients with complete reperfusion (TICI 3) were included in this study. Poor clinical outcome was observed in 67 (54.5%) of these patients. Multivariable logistic regression analysis identified greater age (adjusted OR 1.10, 95% CI 1.04 to 1.17; p=0.001), higher admission National Institutes of Health Stroke Scale (NIHSS) (OR 1.14, 95% CI 1.02 to 1.28; p=0.024), and lower Alberta Stroke Program Early CT Score (ASPECTS) (OR 0.6, 95% CI 0.4 to 0.84; p=0.007) as independent predictors of poor outcome. Poor outcome was independent of collateral score. CONCLUSION Poor clinical outcome is observed in a large proportion of acute ischemic stroke patients treated with MT, despite complete reperfusion. In this study, futile recanalization was shown to occur independently of collateral status, but was associated with increasing age and stroke severity.
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Affiliation(s)
- Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | | | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | - Goetz Thomalla
- Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
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Reply: Net water uptake: a new tool for the assessment of ischaemic stroke oedema. Brain 2019; 142:e35. [DOI: 10.1093/brain/awz148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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