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Ma Y, Dai Y, Zhao Y, Song Z, Hu C, Zhang Y. Radiomics model based on dual-energy CT can determine the source of thrombus in strokes with middle cerebral artery occlusion. Neuroradiology 2024:10.1007/s00234-024-03422-y. [PMID: 38985319 DOI: 10.1007/s00234-024-03422-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 06/29/2024] [Indexed: 07/11/2024]
Abstract
PURPOSE To develop thrombus radiomics models based on dual-energy CT (DECT) for predicting etiologic cause of stroke. METHODS We retrospectively enrolled patients with occlusion of the middle cerebral artery who underwent computed tomography (NCCT) and DECT angiography (DECTA). 70 keV virtual monoenergetic images (simulate conventional 120kVp CTA images) and iodine overlay maps (IOM) were reconstructed for analysis. Five logistic regression radiomics models for predicting cardioembolism (CE) were built based on the features extracted from NCCT, CTA and IOM images. From these, the best one was selected to integrate with clinical information for further construction of the combined model. The performance of the different models was evaluated and compared using ROC curve analysis, clinical decision curves (DCA), calibration curves and Delong test. RESULTS Among all the radiomic models, model NCCT+IOM performed the best, with AUC = 0.95 significantly higher than model NCCT, model CTA, model IOM and model NCCT+CTA in the training set (AUC = 0.88, 0.78, 0.90,0.87, respectively, P < 0.05), and AUC = 0.92 in the testing set, significantly higher than model CTA (AUC = 0.71, P < 0.05). Smoking and NIHSS score were independent predictors of CE (P < 0.05). The combined model performed similarly to the model NCCT+IOM, with no statistically significant difference in AUC either in the training or test sets. (0.96 vs. 0.95; 0.94 vs. 0.92, both P > 0.05). CONCLUSION Radiomics models constructed based on NCCT and IOM images can effectively determine the source of thrombus in stroke without relying on clinical information.
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Affiliation(s)
- Yuzhu Ma
- Department of Radiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, 215124, China
| | - Yao Dai
- Department of Radiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, 215124, China
| | - Ying Zhao
- Department of Radiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, 215124, China
| | - Ziyang Song
- Department of Radiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, 215124, China
| | - Chunhong Hu
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Yu Zhang
- Department of Radiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, 215124, China.
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2
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Cejvanovic S, Sheikh Z, Hamann S, Subramanian PS. Imaging the brain: diagnosis aided by structural features on neuroimaging studies. Eye (Lond) 2024:10.1038/s41433-024-03142-w. [PMID: 38783084 DOI: 10.1038/s41433-024-03142-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/29/2024] [Accepted: 05/08/2024] [Indexed: 05/25/2024] Open
Abstract
The use of neuroimaging allows the ophthalmologist to identify structural lesions in the orbit or along the neuroaxis that allow for more accurate diagnosis and treatment of patients with neuro-ophthalmic diseases. The primary imaging tools include computed tomography (CT) and magnetic resonance imaging (MRI), both of which can be used to evaluate the brain, spinal cord and canal, and orbits. Neurovascular structures, both arterial and venous, also can be imaged in high resolution with modern CT and MR angiography and CT and MR venography. In many cases, invasive procedures such as catheter angiography can be avoided with these studies, and angiography is often reserved for confirmation of vascular lesions combined with endovascular treatment. In this article, we illustrate how the evaluation of patients presenting with neuro-ophthalmic diseases involving the afferent and efferent visual pathways can be optimized with the use of appropriate diagnostic imaging studies. The complementary value of ophthalmic imaging is also demonstrated, and the advantages and disadvantages of both CT and MRI as well as their use in longitudinal patient follow up is demonstrated.
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Affiliation(s)
| | - Zahir Sheikh
- Department of Neurology, Sue Anschutz-Rodgers University of Colorado Eye Center and University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Steffen Hamann
- Department of Ophthalmology, Rigshospitalet, Glostrup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Prem S Subramanian
- Department of Neurology, Sue Anschutz-Rodgers University of Colorado Eye Center and University of Colorado School of Medicine, Aurora, Colorado, USA.
- Department of Ophthalmology, Sue Anschutz-Rodgers University of Colorado Eye Center and University of Colorado School of Medicine, Aurora, Colorado, USA.
- Department of Neurosurgery, Sue Anschutz-Rodgers University of Colorado Eye Center and University of Colorado School of Medicine, Aurora, Colorado, USA.
- Department of Surgery (Division of Ophthalmology), Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
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Gemmete JJ. Dual-Energy Computed Tomography in the Evaluation and Management of Subarachnoid Hemorrhage, Intracranial Hemorrhage, and Acute Ischemic Stroke. Neuroimaging Clin N Am 2024; 34:241-249. [PMID: 38604708 DOI: 10.1016/j.nic.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
Dual-energy computed tomography (DECT) has emerged as a valuable imaging modality in the diagnosis and management of various cerebrovascular pathologies, including subarachnoid hemorrhage, intracranial hemorrhage, and acute ischemic stroke. This article reviews the principles of DECT and its applications in the evaluation and management of these conditions. The authors discuss the advantages of DECT over conventional computed tomography, as well as its limitations, and provide an overview of current research and future directions in the field.
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Affiliation(s)
- Joseph J Gemmete
- Departments of Radiology, Neurosurgery, Neurology, and Otolaryngology, Michigan Medicine, UH B1D 328, 1500 E Medical Center Drive, Ann Arbor, MI 48019, USA.
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Risch F, Berlis A, Kroencke T, Schwarz F, Maurer CJ. Discrimination of Hemorrhage and Contrast Media in a Head Phantom on Photon-Counting Detector CT Data. AJNR Am J Neuroradiol 2024; 45:183-187. [PMID: 38164551 DOI: 10.3174/ajnr.a8093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/07/2023] [Indexed: 01/03/2024]
Abstract
In this anthropomorphic head phantom study, samples containing blood and contrast agent with concentrations ranging from 0 to 6 mg iodine per milliliter and another set of samples without blood for reference were scanned with a photon-counting detector CT using a standard cranial protocol. It was demonstrated that photon-counting detector CT can reliably distinguish hemorrhage and contrast media, including density determination of the latter. The technology promises to add value in several neuroimaging applications.
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Affiliation(s)
- Franka Risch
- From the Department of Diagnostic and Interventional Radiology (F.R., T.K., F.S.), University Hospital Augsburg, Augsburg, Germany
| | - Ansgar Berlis
- Department of Diagnostic and Interventional Neuroradiology (A.B., C.J.M.), University Hospital Augsburg, Augsburg, Germany
| | - Thomas Kroencke
- From the Department of Diagnostic and Interventional Radiology (F.R., T.K., F.S.), University Hospital Augsburg, Augsburg, Germany
- Centre for Advanced Analytics and Predictive Sciences (T.K.), University Augsburg, Augsburg, Germany
| | - Florian Schwarz
- From the Department of Diagnostic and Interventional Radiology (F.R., T.K., F.S.), University Hospital Augsburg, Augsburg, Germany
- Medical Faculty (F.S.), Ludwig Maximilian University Munich, Munich, Germany
| | - Christoph J Maurer
- Department of Diagnostic and Interventional Neuroradiology (A.B., C.J.M.), University Hospital Augsburg, Augsburg, Germany
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Zimmerman WD, Pergakis M, Ahmad G, Morris NA, Podell J, Chang WT, Motta M, Chen H, Jindal G, Bodanapally U, Simard JM, Badjatia N, Parikh GY. Iodine-based dual-energy CT predicts early neurological decline from cerebral edema after large hemispheric infarction. RESEARCH SQUARE 2023:rs.3.rs-3508427. [PMID: 37986926 PMCID: PMC10659527 DOI: 10.21203/rs.3.rs-3508427/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
Background & Purpose Ischemia affecting two thirds of the MCA territory predicts development of malignant cerebral edema. However, early infarcts are hard to diagnose on conventional head CT. We hypothesize that high-energy (190keV) virtual monochromatic images (VMI) from dual-energy CT (DECT) imaging enables earlier detection of secondary injury from malignant cerebral edema (MCE). Methods Consecutive LHI patients with NIHSS ≥ 15 and DECT within 10 hours of reperfusion from May 2020 to March 2022 were included. We excluded patients with parenchymal hematoma-type 2 transformation. Retrospective analysis of clinical and novel variables included VMI Alberta Stroke Program Early CT Score (ASPECTS), total iodine content, and VMI infarct volume. Primary outcome was early neurological decline (END). Secondary outcomes included hemorrhagic transformation, decompressive craniectomy (DC), and medical treatment of MCE. Fisher's exact test and Wilcoxon test were used for univariate analysis. Logistic regression was used to develop prediction models for categorical outcomes. Results Eighty-four LHI patients with a median age of 67.5 [IQR 57,78] years and NIHSS 22 [IQR 18,25] were included. Twenty-nine patients had END. VMI ASPECTS, total iodine content, and VMI infarct volume were associated with END. VMI ASPECTS, VMI infarct volume, and total iodine content were predictors of END after adjusting for age, sex, initial NIHSS, and tPA administration, with a AUROC of 0.691 [0.572,0.810], 0.877 [0.800, 0.954], and 0.845 [0.750, 0.940]. By including all three predictors, the model achieved AUROC of 0.903 [0.84,0.97] and was cross validated by leave one out method with AUROC of 0.827. Conclusion DECT with high-energy VMI and iodine quantification is superior to conventional CT ASPECTS and is a novel predictor for early neurological decline due to malignant cerebral edema after large hemispheric infarction.
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Affiliation(s)
| | | | - Ghasan Ahmad
- Hackensack Meridian Jersey Shore University Medical Center
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Meer E, Patel M, Chan D, Sheikh AM, Nicolaou S. Dual-Energy Computed Tomography and Beyond: Musculoskeletal System. Radiol Clin North Am 2023; 61:1097-1110. [PMID: 37758359 DOI: 10.1016/j.rcl.2023.05.008] [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: 10/03/2023]
Abstract
Traditional monoenergetic computed tomography (CT) scans in musculoskeletal imaging provide excellent detail of bones but are limited in the evaluation of soft tissues. Dual-energy CT (DECT) overcomes many of the traditional limitations of CT and offers anatomical details previously seen only on MR imaging. In addition, DECT has benefits in the evaluation and characterization of arthropathies, bone marrow edema, and collagen applications in the evaluation of tendons, ligaments, and vertebral discs. There is current ongoing research in the application of DECT in arthrography and bone mineral density calculation.
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Affiliation(s)
- Emtenen Meer
- Vancouver General Hospital-University of British Columbia, Vancouver, British Columbia, Canada; King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia.
| | - Mitulkumar Patel
- Vancouver General Hospital-University of British Columbia, Vancouver, British Columbia, Canada
| | - Darren Chan
- Vancouver General Hospital-University of British Columbia, Vancouver, British Columbia, Canada
| | - Adnan M Sheikh
- Vancouver General Hospital-University of British Columbia, Vancouver, British Columbia, Canada
| | - Savvas Nicolaou
- Vancouver General Hospital-University of British Columbia, Vancouver, British Columbia, Canada
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7
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Fransson V, Mellander H, Ramgren B, Andersson H, Arena F, Ydström K, Ullberg T, Wassélius J. Image quality of spectral brain computed tomography angiography using halved dose of iodine contrast medium. Neuroradiology 2023; 65:1333-1342. [PMID: 37452885 PMCID: PMC10425475 DOI: 10.1007/s00234-023-03190-1] [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: 03/13/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE Reduction in iodinated contrast medium (CM) dose is highly motivated. Our aim was to evaluate if a 50% reduction of CM, while preserving image quality, is possible in brain CT angiography (CTA) using virtual monoenergetic images (VMI) on spectral CT. As a secondary aim, we evaluated if VMI can salvage examinations with suboptimal CM timing. METHODS Consecutive patients older than 18 years without intracranial stenosis/occlusion were included. Three imaging protocols were used: group 1, full CM dose; group 2, 50% CM dose suboptimal timing; and group 3, 50% CM dose optimized timing. Attenuation, noise, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were measured in the internal carotid artery, M2 segment of the middle cerebral artery, and white matter for conventional images (CI) and VMI (40-200 keV). Qualitative image quality for CI and VMI (50 and 60 keV) was rated by 4 experienced reviewers. RESULTS Qualitatively and quantitatively, VMI (40-60 keV) improved image quality within each group. Significantly higher attenuation and CNR was found for group 3 VMI 40-50 keV, with unchanged SNR, compared to group 1 CI. Group 3 VMI 50 keV also received significantly higher rating scores than group 1 CI. Group 2 VMI (40-50 keV) had significantly higher CNR compared to group 3 CI, but the subjective image quality was similar. CONCLUSION VMI of 50 keV with 50% CM dose increases qualitative and quantitative image quality over CI with full CM dose. Using VMI reduces non-diagnostic examinations and may salvage CTA examinations deemed non-diagnostic due to suboptimal timing.
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Affiliation(s)
- Veronica Fransson
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
- Medical Radiation Physics, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Helena Mellander
- Department of Medical Imaging and Physiology, Skåne University Hospital, 22185, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Birgitta Ramgren
- Department of Medical Imaging and Physiology, Skåne University Hospital, 22185, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Henrik Andersson
- Department of Medical Imaging and Physiology, Skåne University Hospital, 22185, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Francesco Arena
- Department of Medical Imaging and Physiology, Skåne University Hospital, 22185, Lund, Sweden
| | - Kristina Ydström
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
- Medical Radiation Physics, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Teresa Ullberg
- Neurology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Johan Wassélius
- Department of Medical Imaging and Physiology, Skåne University Hospital, 22185, Lund, Sweden.
- Department of Clinical Sciences, Lund University, Lund, Sweden.
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8
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Grkovski R, Acu L, Ahmadli U, Nakhostin D, Thurner P, Wacht L, Kulcsár Z, Alkadhi H, Winklhofer S. Dual-Energy Computed Tomography in Stroke Imaging : Value of a New Image Acquisition Technique for Ischemia Detection after Mechanical Thrombectomy. Clin Neuroradiol 2023; 33:747-754. [PMID: 36862231 PMCID: PMC10450017 DOI: 10.1007/s00062-023-01270-6] [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: 10/07/2022] [Accepted: 01/24/2023] [Indexed: 03/03/2023]
Abstract
OBJECTIVE To assess if a new dual-energy computed tomography (DECT) technique enables an improved visualization of ischemic brain tissue after mechanical thrombectomy in acute stroke patients. MATERIAL AND METHODS The DECT head scans with a new sequential technique (TwinSpiral DECT) were performed in 41 patients with ischemic stroke after endovascular thrombectomy and were retrospectively included. Standard mixed and virtual non-contrast (VNC) images were reconstructed. Infarct visibility and image noise were assessed qualitatively by two readers using a 4-point Likert scale. Quantitative Hounsfield units (HU) were used to assess density differences of ischemic brain tissue versus healthy tissue on the non-affected contralateral hemisphere. RESULTS Infarct visibility was significantly better in VNC compared to mixed images for both readers R1 (VNC: median 1 (range 1-3), mixed: median 2 (range 1-4), p < 0.05) and R2 (VNC: median 2 (range 1-3), mixed: 2 (range 1-4), p < 0.05). Qualitative image noise was significantly higher in VNC compared to mixed images for both readers R1 (VNC: median 3, mixed: 2) and R2 (VNC: median 2, mixed: 1, p < 0.05, each). Mean HU were significantly different between the infarcted tissue and the reference healthy brain tissue on the contralateral hemisphere in VNC (infarct 24 ± 3) and mixed images (infarct 33 ± 5, p < 0.05, each). The mean HU difference between ischemia and reference in VNC images (mean 8 ± 3) was significantly higher (p < 0.05) compared to the mean HU difference in mixed images (mean 5 ± 4). CONCLUSION TwinSpiral DECT allows an improved qualitative and quantitative visualization of ischemic brain tissue in ischemic stroke patients after endovascular treatment.
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Affiliation(s)
- Risto Grkovski
- Department of Neuroradiology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia
- Department of Radiology, University Medical Centre Maribor, Ljubljanska ulica 5, 2000, Maribor, Slovenia
| | - Leyla Acu
- Department of Neuroradiology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Uzeyir Ahmadli
- Department of Neuroradiology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Dominik Nakhostin
- Department of Neuroradiology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Patrick Thurner
- Department of Neuroradiology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Lorenz Wacht
- Department of Neuroradiology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Zsolt Kulcsár
- Department of Neuroradiology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Hatem Alkadhi
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Sebastian Winklhofer
- Department of Neuroradiology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland.
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9
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Grkovski R, Acu L, Ahmadli U, Terziev R, Schubert T, Wegener S, Kulcsar Z, Husain S, Alkadhi H, Winklhofer S. A Novel Dual-Energy CT Method for Detection and Differentiation of Intracerebral Hemorrhage From Contrast Extravasation in Stroke Patients After Endovascular Thrombectomy : Feasibility and First Results. Clin Neuroradiol 2023; 33:171-177. [PMID: 35960327 PMCID: PMC10014653 DOI: 10.1007/s00062-022-01198-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 07/07/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Dual-energy computed tomography (DECT) has been shown to be able to differentiate between intracranial hemorrhage (ICH) and extravasation of iodinated contrast media (contrast staining [CS]). TwinSpiral DECT is a recently introduced technique, which allows image acquisition at two different energy levels in two consecutive spiral scans. The aim of this study was to evaluate the feasibility and accuracy of TwinSpiral DECT to distinguish between ICH and CS after endovascular thrombectomy (EVT) in patients with acute ischemic stroke. METHODS This retrospective single-center study conducted between November 2019 and July 2020 included non-contrast TwinSpiral DECT scans (tube voltages 80 and 150Sn kVp) of 39 ischemic stroke patients (18 females, 21 males, mean age 69 ± 11 years) within 48-72 h after endovascular thrombectomy. Parenchymal hyperdensity was assessed for the presence of ICH or/and CS by two board certified and fellowship-trained, blinded and independent neuroradiologists using standard mixed images and virtual non-contrast (VNC) images with corresponding iodine maps from TwinSpiral DECT. Follow-up examinations (FU; CT or MRI) were used as a standard of reference. Sensitivity, specificity, and accuracy for the detection of ICH as well as the inter-reader agreement were calculated. RESULTS Parenchymal hyperdensities were detected in 17/39 (44%) patients. Using DECT, they were classified by both readers as ICH in 9 (53%), CS in 8 (47%), and mixture of both in 6 (35%) cases with excellent agreement (κ = 0.81, P < 0.0001). The sensitivity, specificity, and accuracy for the detection of ICH in DECT was 90% (95% confidence interval [CI]: 84-96%), 100% (95% CI 94-100%) and 95% (95% CI 89-100%), and in mixed images 90% (95% CI 84-96%), 86% (95% CI 80-92%) and 88% (95% CI 82-94%), respectively. Inter-reader agreement for detecting ICH on DECT compared to the mixed images was κ = 1.00 (P < 0.0001) vs. κ = 0.51 (P = 0.034). CONCLUSION TwinSpiral DECT demonstrates high accuracy and excellent specificity for differentiating ICH from CS in patients after mechanical thrombectomy due to acute ischemic stroke, and improves inter-reader agreement for detecting ICH compared to the standard mixed images.
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Affiliation(s)
- Risto Grkovski
- Department of Neuroradiology, Clinical Neuroscience Cente, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Faculty of Medicine, University Of Ljubljana, Ljubljana, Slovenia.,Department of Radiology, University Medical Centre Maribor, Maribor, Slovenia
| | - Leyla Acu
- Department of Neuroradiology, Clinical Neuroscience Cente, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Uzeyir Ahmadli
- Department of Neuroradiology, Clinical Neuroscience Cente, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Robert Terziev
- Department of Neuroradiology, Clinical Neuroscience Cente, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Department of Neurology, Clinical Neuroscience Cente, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Tilman Schubert
- Department of Neuroradiology, Clinical Neuroscience Cente, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Susanne Wegener
- Department of Neurology, Clinical Neuroscience Cente, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Zsolt Kulcsar
- Department of Neuroradiology, Clinical Neuroscience Cente, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Shakir Husain
- Department of Neuroradiology, Clinical Neuroscience Cente, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Hatem Alkadhi
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Sebastian Winklhofer
- Department of Neuroradiology, Clinical Neuroscience Cente, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
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Tran NA, Sodickson AD, Gupta R, Potter CA. Clinical applications of dual-energy computed tomography in neuroradiology. Semin Ultrasound CT MR 2022; 43:280-292. [PMID: 35738814 DOI: 10.1053/j.sult.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Dual-energy computed tomography (DECT) has developed into a robust set of techniques with increasingly validated clinical applications in neuroradiology. We review some of the most common applications in neuroimaging along with demonstrative case examples that showcase the use of this technology in intracranial hemorrhage, stroke imaging, trauma imaging, artifact reduction, and tumor characterization.
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Affiliation(s)
- Ngoc-Anh Tran
- Department of Radiology, Brigham and Women's Hospital, Boston, MA.
| | - Aaron D Sodickson
- Division of Emergency Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Rajiv Gupta
- Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, MA
| | - Christopher A Potter
- Division of Emergency Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA; Division of Neuroradiology, Department of Radiology, Brigham and Women's Hospital, Boston, MA
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Santos Armentia E, Martín Noguerol T, Silva Priegue N, Delgado Sánchez-Gracián C, Trinidad López C, Prada González R. Strengths, weaknesses, opportunities, and threat analysis of dual-energy CT in head and neck imaging. RADIOLOGIA 2022; 64:333-347. [DOI: 10.1016/j.rxeng.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/19/2022] [Indexed: 11/29/2022]
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12
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Santos Armentia E, Martín-Noguerol T, Silva Priegue N, Delgado Sánchez-Gracián C, Trinidad López C, Prada González R. Análisis de las fortalezas, oportunidades, debilidades y amenazas de la tomografía computarizada de doble energía en el diagnóstico por la imagen de la cabeza y el cuello. RADIOLOGIA 2022. [DOI: 10.1016/j.rx.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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13
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Mäkelä T, Öman O, Hokkinen L, Wilppu U, Salli E, Savolainen S, Kangasniemi M. Automatic CT Angiography Lesion Segmentation Compared to CT Perfusion in Ischemic Stroke Detection: a Feasibility Study. J Digit Imaging 2022; 35:551-563. [PMID: 35211838 PMCID: PMC9156593 DOI: 10.1007/s10278-022-00611-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 12/30/2021] [Accepted: 01/12/2022] [Indexed: 12/15/2022] Open
Abstract
In stroke imaging, CT angiography (CTA) is used for detecting arterial occlusions. These images could also provide information on the extent of ischemia. The study aim was to develop and evaluate a convolutional neural network (CNN)-based algorithm for detecting and segmenting acute ischemic lesions from CTA images of patients with suspected middle cerebral artery stroke. These results were compared to volumes reported by widely used CT perfusion-based RAPID software (IschemaView). A 42-layer-deep CNN was trained on 50 CTA volumes with manually delineated targets. The lower bound for predicted lesion size to reliably discern stroke from false positives was estimated. The severity of false positives and false negatives was reviewed visually to assess the clinical applicability and to further guide the method development. The CNN model corresponded to the manual segmentations with voxel-wise sensitivity 0.54 (95% confidence interval: 0.44-0.63), precision 0.69 (0.60-0.76), and Sørensen-Dice coefficient 0.61 (0.52-0.67). Stroke/nonstroke differentiation accuracy 0.88 (0.81-0.94) was achieved when only considering the predicted lesion size (i.e., regardless of location). By visual estimation, 46% of cases showed some false findings, such as CNN highlighting chronic periventricular white matter changes or beam hardening artifacts, but only in 9% the errors were severe, translating to 0.91 accuracy. The CNN model had a moderately strong correlation to RAPID-reported Tmax > 10 s volumes (Pearson's r = 0.76 (0.58-0.86)). The results suggest that detecting anterior circulation ischemic strokes from CTA using a CNN-based algorithm can be feasible when accompanied with physiological knowledge to rule out false positives.
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Affiliation(s)
- Teemu Mäkelä
- grid.7737.40000 0004 0410 2071HUS Medical Imaging Center, Radiology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland ,grid.7737.40000 0004 0410 2071Department of Physics, University of Helsinki, P.O. Box 64, 00014 Helsinki, Finland
| | - Olli Öman
- grid.7737.40000 0004 0410 2071HUS Medical Imaging Center, Radiology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland
| | - Lasse Hokkinen
- grid.7737.40000 0004 0410 2071HUS Medical Imaging Center, Radiology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland
| | - Ulla Wilppu
- grid.7737.40000 0004 0410 2071HUS Medical Imaging Center, Radiology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland
| | - Eero Salli
- grid.7737.40000 0004 0410 2071HUS Medical Imaging Center, Radiology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland
| | - Sauli Savolainen
- grid.7737.40000 0004 0410 2071HUS Medical Imaging Center, Radiology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland ,grid.7737.40000 0004 0410 2071Department of Physics, University of Helsinki, P.O. Box 64, 00014 Helsinki, Finland
| | - Marko Kangasniemi
- grid.7737.40000 0004 0410 2071HUS Medical Imaging Center, Radiology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland
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14
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Odedra D, Narayanasamy S, Sabongui S, Priya S, Krishna S, Sheikh A. Dual Energy CT Physics-A Primer for the Emergency Radiologist. FRONTIERS IN RADIOLOGY 2022; 2:820430. [PMID: 37492677 PMCID: PMC10364985 DOI: 10.3389/fradi.2022.820430] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/17/2022] [Indexed: 07/27/2023]
Abstract
Dual energy CT (DECT) refers to the acquisition of CT images at two energy spectra and can provide information about tissue composition beyond that obtainable by conventional CT. The attenuation of a photon beam varies depends on the atomic number and density of the attenuating material and the energy of the incoming photon beam. This differential attenuation of the beam at varying energy levels forms the basis of DECT imaging and enables separation of materials with different atomic numbers but similar CT attenuation. DECT can be used to detect and quantify materials like iodine, calcium, or uric acid. Several post-processing techniques are available to generate virtual non-contrast images, iodine maps, virtual mono-chromatic images, Mixed or weighted images and material specific images. Although initially the concept of dual energy CT was introduced in 1970, it is only over the past two decades that it has been extensively used in clinical practice owing to advances in CT hardware and post-processing capabilities. There are numerous applications of DECT in Emergency radiology including stroke imaging to differentiate intracranial hemorrhage and contrast staining, diagnosis of pulmonary embolism, characterization of incidentally detected renal and adrenal lesions, to reduce beam and metal hardening artifacts, in identification of uric acid renal stones and in the diagnosis of gout. This review article aims to provide the emergency radiologist with an overview of the physics and basic principles of dual energy CT. In addition, we discuss the types of DECT acquisition and post processing techniques including newer advances such as photon-counting CT followed by a brief discussion on the applications of DECT in Emergency radiology.
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Affiliation(s)
- Devang Odedra
- Department of Radiology, University of Toronto, Toronto, ON, Canada
| | - Sabarish Narayanasamy
- Department of Radiology, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States
| | - Sandra Sabongui
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada
| | - Sarv Priya
- Department of Radiology, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States
| | - Satheesh Krishna
- Department of Medical Imaging, Mount Sinai Hospital, and Women's College Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Adnan Sheikh
- Department of Radiology, The University of British Columbia, Vancouver, BC, Canada
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15
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Gaddam DS, Dattwyler M, Fleiter TR, Bodanapally UK. Principles and Applications of Dual Energy Computed Tomography in Neuroradiology. Semin Ultrasound CT MR 2021; 42:418-433. [PMID: 34537112 DOI: 10.1053/j.sult.2021.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Dual-energy computed tomography (DE CT) is a promising tool with many current and evolving applications. Available DE CT scanners usually consist of one or two tubes, or use layered detectors for spectral separation. Most DE CT scanners can be used in single energy or dual-energy mode, except for the layered detector scanners that always acquire data in dual-energy mode. However, the layered detector scanners can retrospectively integrate the data from two layers to obtain conventional single energy images. DE CT mode enables generation of virtual monochromatic images, blended images, iodine quantification, improving conspicuity of iodinated contrast enhancement, and material decomposition maps or more sophisticated quantitative analysis not possible with conventional SE CT acquisition with an acceptable or even lower dose than the SE CT. This article reviews the basic principles of dual-energy CT and highlights many of its clinical applications in the evaluation of neurological conditions.
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Affiliation(s)
- Durga Sivacharan Gaddam
- Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD
| | - Matthew Dattwyler
- Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD
| | - Thorsten R Fleiter
- Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD
| | - Uttam K Bodanapally
- Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD.
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16
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Stanton M, Sparti G. Use of dual-energy computed tomography post endovascular treatment of cerebral aneurysm. Surg Neurol Int 2021; 12:225. [PMID: 34221556 PMCID: PMC8248007 DOI: 10.25259/sni_41_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/30/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Along with surgical clipping, endovascular management is one of the mainstay treatment options for cerebral aneurysms. However, immediate post procedural imaging is often hard to interpret due to the presence of contrast material. Dual-energy computed tomography (CT) allows differentiation between contrast extravasation and intracranial hemorrhage and this case illustrates the importance of this following endovascular treatment of an unruptured cerebral aneurysm. Case Description: A patient presented with acute ophthalmoplegia secondary to mass effect from an intracavernous ICA fusiform aneurysm. The patient underwent an endovascular flow diverting stent to treat this aneurysm. Post procedure, the patient had a reduced level of consciousness and underwent a conventional CT showing diffuse subarachnoid hyperdensity of the left hemisphere. Dual-energy CT allowed accurate differentiation and illustrated diffuse contrast material extravasation, allowing patient to continue on dual antiplatelets and therapeutic anticoagulation to reduce the risk of ischemic injury post endovascular stent. Conclusion: Use of dual-energy CT in the setting of endovascular management of intracranial aneurysms allows accurate diagnosis of any postoperative complications. Specifically, differentiating between subarachnoid hemorrhage and contrast extravasation is vital in these patients due to the significant consequences to their ongoing management in regard to continuation or cessation of antiplatelets or anticoagulation. With increasing access to this technology, its use should become standard practice in the post-operative investigation of these patients undergoing endovascular treatment.
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Affiliation(s)
- Mitchell Stanton
- Department of Neurosurgery, Gold Coast University Hospital, Southport, Qld, Australia
| | - Gian Sparti
- Department of Neurosurgery, Gold Coast University Hospital, Southport, Qld, Australia
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Abstract
The past year has been one of unprecedented challenge for the modern world and especially the medical profession. This review explores some of the most impactful topics published in the CARJ during the COVID-19 pandemic including physician wellbeing and burnout, patient safety, and technological innovations including dual energy CT, quantitative imaging and ultra-high frequency ultrasound. The impact of the COVID-19 pandemic on trainee education is discussed and evidence-based tips for providing value-added care are reviewed. Patient privacy considerations relevant to the development of artificial intelligence applications for medical imaging are explored. These publications in the CARJ demonstrate that although this year has brought adversity, it has also been a harbinger for new and exciting areas of focus in our field.
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Affiliation(s)
- Caitlin J Ward
- Department of Diagnostic Imaging, Hamilton Health Sciences, Hamilton, Ontario, Canada.,McMaster University, Hamilton, Ontario, Canada
| | - Christian B van der Pol
- Department of Diagnostic Imaging, Hamilton Health Sciences, Hamilton, Ontario, Canada.,McMaster University, Hamilton, Ontario, Canada
| | - Michael N Patlas
- Department of Diagnostic Imaging, Hamilton Health Sciences, Hamilton, Ontario, Canada.,McMaster University, Hamilton, Ontario, Canada
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18
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Mangesius S, Grams AE. Dual energy computed tomomgraphy in acute stroke, where are we and where are we going? J Neuroradiol 2021; 48:71-74. [PMID: 33607169 DOI: 10.1016/j.neurad.2021.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 02/11/2021] [Accepted: 02/13/2021] [Indexed: 12/11/2022]
Affiliation(s)
- S Mangesius
- Department of Neuroradiology, Medical University of Innsbruck, 6020 Innsbruck, Austria.
| | - A E Grams
- Department of Neuroradiology, Medical University of Innsbruck, 6020 Innsbruck, Austria.
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19
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Gandikota G, Fakuda T, Finzel S. Computed tomography in rheumatology - From DECT to high-resolution peripheral quantitative CT. Best Pract Res Clin Rheumatol 2020; 34:101641. [PMID: 33281053 DOI: 10.1016/j.berh.2020.101641] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
In this chapter, we discuss current updates and applications of Dual Energy Computed Tomography (DECT), iodine-DECT mapping, and high-resolution peripheral quantitative CT (HR-pQCT) in rheumatology. DECT provides a noninvasive diagnosis of gout and can help to differentiate gout from CPPD. Accuracy of DECT varies in various stages of gout. DECT needs specialized hardware, software, and skilled post-processing and interpretation. Sensitivity reduces significantly with deeper tissues such as hip and shoulder. Iodine map enables to delineate inflammatory lesions such as capsulitis and tenosynovitis by improving iodine contrast. Iodine quantification with an iodine map is a promising objective method to evaluate therapeutic effect of inflammatory arthritis. HR-pQCT allows for highly sensitive and specific measures of bone erosions and osteophytes in inflammatory joint diseases, documenting change over time, e.g. in cohorts undergoing immunosuppressive treatments. However, assessing the images requires trained readers, and (semi)-automated scripts to detect bone damage are still undergoing validation and further development.
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Affiliation(s)
- Girish Gandikota
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA.
| | - Takeshi Fakuda
- Department of Radiology, The Jikei University School of Medicine, Japan
| | - Stephanie Finzel
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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20
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Lukiw WJ, Vergallo A, Lista S, Hampel H, Zhao Y. Biomarkers for Alzheimer's Disease (AD) and the Application of Precision Medicine. J Pers Med 2020; 10:E138. [PMID: 32967128 PMCID: PMC7565758 DOI: 10.3390/jpm10030138] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/08/2020] [Accepted: 09/15/2020] [Indexed: 02/08/2023] Open
Abstract
An accurate diagnosis of Alzheimer's disease (AD) currently stands as one of the most difficult and challenging in all of clinical neurology. AD is typically diagnosed using an integrated knowledge and assessment of multiple biomarkers and interrelated factors. These include the patient's age, gender and lifestyle, medical and genetic history (both clinical- and family-derived), cognitive, physical, behavioral and geriatric assessment, laboratory examination of multiple AD patient biofluids, especially within the systemic circulation (blood serum) and cerebrospinal fluid (CSF), multiple neuroimaging-modalities of the brain's limbic system and/or retina, followed up in many cases by post-mortem neuropathological examination to finally corroborate the diagnosis. More often than not, prospective AD cases are accompanied by other progressive, age-related dementing neuropathologies including, predominantly, a neurovascular and/or cardiovascular component, multiple-infarct dementia (MID), frontotemporal dementia (FTD) and/or strokes or 'mini-strokes' often integrated with other age-related neurological and non-neurological disorders including cardiovascular disease and cancer. Especially over the last 40 years, enormous research efforts have been undertaken to discover, characterize, and quantify more effectual and reliable biological markers for AD, especially during the pre-clinical or prodromal stages of AD so that pre-emptive therapeutic treatment strategies may be initiated. While a wealth of genetic, neurobiological, neurochemical, neuropathological, neuroimaging and other diagnostic information obtainable for a single AD patient can be immense: (i) it is currently challenging to integrate and formulate a definitive diagnosis for AD from this multifaceted and multidimensional information; and (ii) these data are unfortunately not directly comparable with the etiopathological patterns of other AD patients even when carefully matched for age, gender, familial genetics, and drug history. Four decades of AD research have repeatedly indicated that diagnostic profiles for AD are reflective of an extremely heterogeneous neurological disorder. This commentary will illuminate the heterogeneity of biomarkers for AD, comment on emerging investigative approaches and discuss why 'precision medicine' is emerging as our best paradigm yet for the most accurate and definitive prediction, diagnosis, and prognosis of this insidious and lethal brain disorder.
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Affiliation(s)
- Walter J. Lukiw
- LSU Neuroscience Center, Louisiana State University Health Science Center, New Orleans, LA 70112, USA;
- Department of Cell Biology and Anatomy, LSU-HSC, New Orleans, LA 70112, USA
- Department of Ophthalmology, LSU Neuroscience Center, LSU-HSC, New Orleans, LA 70112, USA
- Department Neurology, LSU Neuroscience Center, LSU-HSC, New Orleans, LA 70112, USA
| | - Andrea Vergallo
- Sorbonne University, GRC no 21, Alzheimer Precision Medicine (APM), AP-HP, Pitié-Salpêtrière hospital, F-75013 Paris, France; (A.V.); (S.L.); (H.H.)
| | - Simone Lista
- Sorbonne University, GRC no 21, Alzheimer Precision Medicine (APM), AP-HP, Pitié-Salpêtrière hospital, F-75013 Paris, France; (A.V.); (S.L.); (H.H.)
- Brain & Spine Institute (ICM), INSERM U 1127, CNRS UMR 7225, Boulevard de l’Hôpital, F-75013 Paris, France
- Department of Neurology, Institute of Memory and Alzheimer’s Disease (IM2A), Pitié-Salpêtrière Hospital, AP-HP, F-75013 Paris, France
| | - Harald Hampel
- Sorbonne University, GRC no 21, Alzheimer Precision Medicine (APM), AP-HP, Pitié-Salpêtrière hospital, F-75013 Paris, France; (A.V.); (S.L.); (H.H.)
| | - Yuhai Zhao
- LSU Neuroscience Center, Louisiana State University Health Science Center, New Orleans, LA 70112, USA;
- Department of Cell Biology and Anatomy, LSU-HSC, New Orleans, LA 70112, USA
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21
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Differentiation of hemorrhage from contrast enhancement using dual-layer spectral CT in patients transferred for acute stroke. Clin Imaging 2020; 69:75-78. [PMID: 32683139 DOI: 10.1016/j.clinimag.2020.06.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/03/2020] [Accepted: 06/26/2020] [Indexed: 11/23/2022]
Abstract
Acute stroke patients transferred to thrombectomy capable centers (TCC), undergo a CT head exam upon arrival at the TCC to evaluate for ASPECTS decay and intracranial hemorrhage. In patients who received iodinated contrast prior to transfer, parenchymal enhancement may simulate hemorrhage on this post-transfer CT. We report two cases utilizing CT spectral imaging to differentiate between parenchymal contrast enhancement and hemorrhage in this setting. TCC may consider dual-energy or dual-layer (spectral) imaging for this patient cohort.
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