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Parsons MW, Yogendrakumar V, Churilov L, Garcia-Esperon C, Campbell BCV, Russell ML, Sharma G, Chen C, Lin L, Chew BL, Ng FC, Deepak A, Choi PMC, Kleinig TJ, Cordato DJ, Wu TY, Fink JN, Ma H, Phan TG, Markus HS, Molina CA, Tsai CH, Lee JT, Jeng JS, Strbian D, Meretoja A, Arenillas JF, Buck BH, Devlin MJ, Brown H, Butcher KS, O'Brien B, Sabet A, Wijeratne T, Bivard A, Grimley RS, Agarwal S, Munshi SK, Donnan GA, Davis SM, Miteff F, Spratt NJ, Levi CR. Tenecteplase versus alteplase for thrombolysis in patients selected by use of perfusion imaging within 4·5 h of onset of ischaemic stroke (TASTE): a multicentre, randomised, controlled, phase 3 non-inferiority trial. Lancet Neurol 2024; 23:775-786. [PMID: 38880118 DOI: 10.1016/s1474-4422(24)00206-0] [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: 04/17/2024] [Revised: 05/05/2024] [Accepted: 05/07/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Intravenous tenecteplase increases reperfusion in patients with salvageable brain tissue on perfusion imaging and might have advantages over alteplase as a thrombolytic for ischaemic stroke. We aimed to assess the non-inferiority of tenecteplase versus alteplase on clinical outcomes in patients selected by use of perfusion imaging. METHODS This international, multicentre, open-label, parallel-group, randomised, clinical non-inferiority trial enrolled patients from 35 hospitals in eight countries. Participants were aged 18 years or older, within 4·5 h of ischaemic stroke onset or last known well, were not being considered for endovascular thrombectomy, and met target mismatch criteria on brain perfusion imaging. Patients were randomly assigned (1:1) by use of a centralised web server with randomly permuted blocks to intravenous tenecteplase (0·25 mg/kg) or alteplase (0·90 mg/kg). The primary outcome was the proportion of patients without disability (modified Rankin Scale 0-1) at 3 months, assessed via masked review in both the intention-to-treat and per-protocol populations. We aimed to recruit 832 participants to yield 90% power (one-sided alpha=0·025) to detect a risk difference of 0·08, with an absolute non-inferiority margin of -0·03. The trial was registered with the Australian New Zealand Clinical Trials Registry, ACTRN12613000243718, and the European Union Clinical Trials Register, EudraCT Number 2015-002657-36, and it is completed. FINDINGS Recruitment ceased early following the announcement of other trial results showing non-inferiority of tenecteplase versus alteplase. Between March 21, 2014, and Oct 20, 2023, 680 patients were enrolled and randomly assigned to tenecteplase (n=339) and alteplase (n=341), all of whom were included in the intention-to-treat analysis (multiple imputation was used to account for missing primary outcome data for five patients). Protocol violations occurred in 74 participants, thus the per-protocol population comprised 601 people (295 in the tenecteplase group and 306 in the alteplase group). Participants had a median age of 74 years (IQR 63-82), baseline National Institutes of Health Stroke Scale score of 7 (4-11), and 260 (38%) were female. In the intention-to-treat analysis, the primary outcome occurred in 191 (57%) of 335 participants allocated to tenecteplase and 188 (55%) of 340 participants allocated to alteplase (standardised risk difference [SRD]=0·03 [95% CI -0·033 to 0·10], one-tailed pnon-inferiority=0·031). In the per-protocol analysis, the primary outcome occurred in 173 (59%) of 295 participants allocated to tenecteplase and 171 (56%) of 306 participants allocated to alteplase (SRD 0·05 [-0·02 to 0·12], one-tailed pnon-inferiority=0·01). Nine (3%) of 337 patients in the tenecteplase group and six (2%) of 340 in the alteplase group had symptomatic intracranial haemorrhage (unadjusted risk difference=0·01 [95% CI -0·01 to 0·03]) and 23 (7%) of 335 and 15 (4%) of 340 died within 90 days of starting treatment (SRD 0·02 [95% CI -0·02 to 0·05]). INTERPRETATION The findings in our study provide further evidence to strengthen the assertion of the non-inferiority of tenecteplase to alteplase, specifically when perfusion imaging has been used to identify reperfusion-eligible stroke patients. Although non-inferiority was achieved in the per-protocol population, it was not reached in the intention-to-treat analysis, possibly due to sample size limtations. Nonetheless, large-scale implementation of perfusion CT to assist in patient selection for intravenous thrombolysis in the early time window was shown to be feasible. FUNDING Australian National Health Medical Research Council; Boehringer Ingelheim.
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Affiliation(s)
- Mark W Parsons
- Department of Neurology, Liverpool Hospital, University of New South Wales, Ingham Institute, Liverpool, NSW, Australia; Melbourne Brain Centre, Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia; Hunter New England Local Health District, New Lambton Heights, NSW, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Faculty of Medicine, University of Newcastle, Newcastle, NSW, Australia.
| | - Vignan Yogendrakumar
- Melbourne Brain Centre, Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Leonid Churilov
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Carlos Garcia-Esperon
- Hunter New England Local Health District, New Lambton Heights, NSW, Australia; Faculty of Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Bruce C V Campbell
- Melbourne Brain Centre, Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Michelle L Russell
- Hunter New England Local Health District, New Lambton Heights, NSW, Australia
| | - Gagan Sharma
- Department of Neurology, Liverpool Hospital, University of New South Wales, Ingham Institute, Liverpool, NSW, Australia; Melbourne Brain Centre, Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Chushuang Chen
- Department of Neurology, Liverpool Hospital, University of New South Wales, Ingham Institute, Liverpool, NSW, Australia; Faculty of Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Longting Lin
- Department of Neurology, Liverpool Hospital, University of New South Wales, Ingham Institute, Liverpool, NSW, Australia; Faculty of Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Beng Lim Chew
- Hunter New England Local Health District, New Lambton Heights, NSW, Australia
| | - Felix C Ng
- Melbourne Brain Centre, Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Austin Health, Melbourne, VIC, Australia
| | | | - Philip M C Choi
- Department of Neuroscience, Box Hill Hospital, Eastern Health, Melbourne, VIC, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Dennis J Cordato
- Department of Neurology, Liverpool Hospital, University of New South Wales, Ingham Institute, Liverpool, NSW, Australia
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - John N Fink
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Henry Ma
- Schools of Clinical Science at Monash Health, Department of Medicine and Neurology, Monash University, Melbourne, VIC, Australia
| | - Thanh G Phan
- Schools of Clinical Science at Monash Health, Department of Medicine and Neurology, Monash University, Melbourne, VIC, Australia
| | - Hugh S Markus
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Carlos A Molina
- Vall d'Hebron Stroke Center, Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Chon-Haw Tsai
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan
| | - Jiunn-Tay Lee
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Juan F Arenillas
- Department of Neurology, Hospital Clínico Universitario, Valladolid Health Research Institute, University of Valladolid, Valladolid, Spain
| | - Brian H Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Michael J Devlin
- Department of Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Helen Brown
- Department of Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Ken S Butcher
- School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | | | - Arman Sabet
- Gold Coast University Hospital, Southport, Queensland, Australia
| | - Tissa Wijeratne
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Department of Neurology, Western Health, Sunshine Hospital, St Albans, VIC, Australia
| | - Andrew Bivard
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Rohan S Grimley
- Sunshine Coast University Hospital, School of Medicine and Dentistry, Griffith University, Birtinya, QLD, Australia
| | - Smriti Agarwal
- Department of Clinical Neurosciences, Addenbrooke's Hospital, Cambridge, UK
| | - Sunil K Munshi
- Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Geoffrey A Donnan
- Melbourne Brain Centre, Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Stephen M Davis
- Melbourne Brain Centre, Department of Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Ferdinand Miteff
- Hunter New England Local Health District, New Lambton Heights, NSW, Australia; Faculty of Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Neil J Spratt
- Hunter New England Local Health District, New Lambton Heights, NSW, Australia; Faculty of Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Christopher R Levi
- Hunter New England Local Health District, New Lambton Heights, NSW, Australia; Faculty of Medicine, University of Newcastle, Newcastle, NSW, Australia
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Herpe G, Platon A, Poletti PA, Lövblad KO, Machi P, Becker M, Muster M, Perneger T, Guillevin R. Dual-Energy CT in Acute Stroke: Could Non-Contrast CT Be Replaced by Virtual Non-Contrast CT? A Feasibility Study. J Clin Med 2024; 13:3647. [PMID: 38999213 PMCID: PMC11242297 DOI: 10.3390/jcm13133647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 06/18/2024] [Accepted: 06/20/2024] [Indexed: 07/14/2024] Open
Abstract
Purpose: We aimed to evaluate whether virtual non-contrast cerebral computed tomography (VNCCT) reconstructed from intravenous contrast-enhanced dual-energy CT (iv-DECT) could replace non-contrast CT (NCCT) in patients with suspected acute cerebral ischemia. Method: This retrospective study included all consecutive patients in whom NCCT followed by iv-DECT were performed for suspected acute ischemia in our emergency department over a 1-month period. The Alberta Stroke Program Early CT Score (ASPECTS) was used to determine signs of acute ischemia in the anterior and posterior circulation, the presence of hemorrhage, and alternative findings, which were randomly evaluated via the consensus reading of NCCT and VNCCT by two readers blinded to the final diagnosis. An intraclass correlation between VNCCT and NCCT was calculated for the ASPECTS values. Both techniques were evaluated for their ability to detect ischemic lesions (ASPECTS <10) when compared with the final discharge diagnosis (reference standard). Results: Overall, 148 patients (80 men, mean age 64 years) were included, of whom 46 (30%) presented with acute ischemia, 6 (4%) presented with intracerebral hemorrhage, 11 (7%) had an alternative diagnosis, and 85 (59%) had no pathological findings. The intraclass correlation coefficients of the two modalities were 0.97 (0.96-0.98) for the anterior circulation and 0.77 (0.69-0.83) for the posterior circulation. The VNCCT's sensitivity for detecting acute ischemia was higher (41%, 19/46) than that of NCCT (33%, 15/46). Specificity was similar between the two techniques, at 94% (97/103) and 98% (101/103), respectively. Conclusions: Our results show that VNCCT achieved a similar diagnostic performance as NCCT and could, thus, replace NCCT in assessing patients with suspected acute cerebral ischemia.
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Affiliation(s)
- Guillaume Herpe
- Emergency Radiology Unit, Division of Radiology, University Hospital of Geneva, 4 Rue Gabrielle-Perret-Gentil, 1205 Geneva, Switzerland;
- DACTIM-MIS Lab, I3M, Poitiers University, 86021 Poitiers, France;
| | - Alexandra Platon
- Emergency Radiology Unit, Division of Radiology, University Hospital of Geneva, 4 Rue Gabrielle-Perret-Gentil, 1205 Geneva, Switzerland;
| | - Pierre-Alexandre Poletti
- Division of Radiology, University Hospital of Geneva, 4 Rue Gabrielle-Perret-Gentil, 1205 Geneva, Switzerland; (P.-A.P.); (M.B.)
| | - Karl O. Lövblad
- Division of Neuroradiology, University Hospital of Geneva, 4 Rue Gabrielle-Perret-Gentil, 1205 Geneva, Switzerland; (K.O.L.); (P.M.); (M.M.)
| | - Paolo Machi
- Division of Neuroradiology, University Hospital of Geneva, 4 Rue Gabrielle-Perret-Gentil, 1205 Geneva, Switzerland; (K.O.L.); (P.M.); (M.M.)
| | - Minerva Becker
- Division of Radiology, University Hospital of Geneva, 4 Rue Gabrielle-Perret-Gentil, 1205 Geneva, Switzerland; (P.-A.P.); (M.B.)
| | - Michel Muster
- Division of Neuroradiology, University Hospital of Geneva, 4 Rue Gabrielle-Perret-Gentil, 1205 Geneva, Switzerland; (K.O.L.); (P.M.); (M.M.)
| | - Thomas Perneger
- Division of Clinical Epidemiology, University Hospital of Geneva, 4 Rue Gabrielle-Perret-Gentil, 1205 Geneva, Switzerland;
| | - Rémy Guillevin
- DACTIM-MIS Lab, I3M, Poitiers University, 86021 Poitiers, France;
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Zhiqiang P, Junchen C, Wenying C, Dongqing Z, Mi M, Qiaowei L, Zhenzhen Z, Wanyi H, Biqing Y, Minqi C. Aspiration thrombectomy versus stent retriever thrombectomy as a first-line approach for cardiogenic cerebral embolism and cryptogenic stroke in large vessels of the anterior circulation. Front Neurol 2024; 14:1324725. [PMID: 38288331 PMCID: PMC10824241 DOI: 10.3389/fneur.2023.1324725] [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: 10/24/2023] [Accepted: 12/26/2023] [Indexed: 01/31/2024] Open
Abstract
Subject This study aims to compare the clinical efficacy of aspiration thrombectomy and stent retriever thrombectomy as first-line approaches for anterior circulation large vessel cardiogenic cerebral embolism and cryptogenic stroke. Method This retrospective observational study included patients with anterior circulation large vessel cardiogenic cerebral embolism and cryptogenic stroke treated with endovascular therapy. Patients were grouped according to the first-line approach they received: aspiration thrombectomy or stent retriever thrombectomy. The primary outcome measure was the change in the National Institute of Health Stroke Scale (NIHSS) score from preoperative to immediate postoperative and from preoperative to discharge. Secondary indicators included the rate of favorable prognosis at discharge [Modified Rankin Scale (mRS) score ≤ 2], successful vessel recanalization rate [modified Treatment in Cerebral Ischemia (mTICI) score ≥ 2b], time from successful femoral artery puncture to successful vessel recanalization, and perioperative complications. Result The study included 127 cases, with 1 case withdrawal after enrollment due to a stroke of another determined cause, with 83 in the aspiration thrombectomy group and 43 cases in the stent retriever thrombectomy group. The change in NIHSS score from preoperative to immediate postoperative was 5 (1, 8) in the aspiration thrombectomy group and 1 (0, 4.5) in the stent retriever thrombectomy group. The change from preoperative to discharge was 8 (5, 12) in the aspiration thrombectomy group and 4 (0, 9) in the stent retriever thrombectomy group. The aspiration thrombectomy group exhibited significantly better prognosis rates and shorter time from successful femoral artery puncture to successful vessel recanalization. There were no significant differences between the two groups in terms of successful vessel recanalization rates and perioperative complications. Conclusion As a first-line approach for anterior circulation large vessel cardiogenic cerebral embolism and cryptogenic stroke, aspiration thrombectomy leads to better improvement in neurological functional deficits and prognosis rates compared to stent retriever thrombectomy.
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Affiliation(s)
- Peng Zhiqiang
- Department of Stroke Center, Guangzhou Panyu Central Hospital, Guangzhou, Guangdong, China
| | - Chen Junchen
- Department of Neurosurgery, Zhongshan Hospital of Traditional Chinese Medicine, Zhongshan, Guangdong, China
| | - Cao Wenying
- Department of Stroke Center, Guangzhou Panyu Central Hospital, Guangzhou, Guangdong, China
| | - Zhao Dongqing
- Department of Stroke Center, Guangzhou Panyu Central Hospital, Guangzhou, Guangdong, China
| | - Ma Mi
- Department of Stroke Center, Guangzhou Panyu Central Hospital, Guangzhou, Guangdong, China
| | - Li Qiaowei
- Department of Stroke Center, Guangzhou Panyu Central Hospital, Guangzhou, Guangdong, China
| | - Zhu Zhenzhen
- Department of Stroke Center, Guangzhou Panyu Central Hospital, Guangzhou, Guangdong, China
| | - He Wanyi
- Department of Stroke Center, Guangzhou Panyu Central Hospital, Guangzhou, Guangdong, China
| | - Yang Biqing
- Department of Stroke Center, Guangzhou Panyu Central Hospital, Guangzhou, Guangdong, China
| | - Cao Minqi
- Department of Intensive Care Unit, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
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Fainardi E, Busto G, Morotti A. Automated advanced imaging in acute ischemic stroke. Certainties and uncertainties. Eur J Radiol Open 2023; 11:100524. [PMID: 37771657 PMCID: PMC10523426 DOI: 10.1016/j.ejro.2023.100524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/12/2023] [Accepted: 09/13/2023] [Indexed: 09/30/2023] Open
Abstract
The purpose of this is study was to review pearls and pitfalls of advanced imaging, such as computed tomography perfusion and diffusion-weighed imaging and perfusion-weighted imaging in the selection of acute ischemic stroke (AIS) patients suitable for endovascular treatment (EVT) in the late time window (6-24 h from symptom onset). Advanced imaging can quantify infarct core and ischemic penumbra using specific threshold values and provides optimal selection parameters, collectively called target mismatch. More precisely, target mismatch criteria consist of core volume and/or penumbra volume and mismatch ratio (the ratio between total hypoperfusion and core volumes) with precise cut-off values. The parameters of target mismatch are automatically calculated with dedicated software packages that allow a quick and standardized interpretation of advanced imaging. However, this approach has several limitations leading to a misclassification of core and penumbra volumes. In fact, automatic software platforms are affected by technical artifacts and are not interchangeable due to a remarkable vendor-dependent variability, resulting in different estimate of target mismatch parameters. In addition, advanced imaging is not completely accurate in detecting infarct core, that can be under- or overestimated. Finally, the selection of candidates for EVT remains currently suboptimal due to the high rates of futile reperfusion and overselection caused by the use of very stringent inclusion criteria. For these reasons, some investigators recently proposed to replace advanced with conventional imaging in the selection for EVT, after the demonstration that non-contrast CT ASPECTS and computed tomography angiography collateral evaluation are not inferior to advanced images in predicting outcome in AIS patients treated with EVT. However, other authors confirmed that CTP and PWI/DWI postprocessed images are superior to conventional imaging in establishing the eligibility of patients for EVT. Therefore, the routine application of automatic assessment of advanced imaging remains a matter of debate. Recent findings suggest that the combination of conventional and advanced imaging might improving our selection criteria.
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Affiliation(s)
- Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Italy
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Giorgio Busto
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Andrea Morotti
- Department of Neurological and Vision Sciences, Neurology Unit, ASST Spedali Civili, Brescia, Italy
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Kimberly WT, Sorby-Adams AJ, Webb AG, Wu EX, Beekman R, Bowry R, Schiff SJ, de Havenon A, Shen FX, Sze G, Schaefer P, Iglesias JE, Rosen MS, Sheth KN. Brain imaging with portable low-field MRI. NATURE REVIEWS BIOENGINEERING 2023; 1:617-630. [PMID: 37705717 PMCID: PMC10497072 DOI: 10.1038/s44222-023-00086-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/06/2023] [Indexed: 09/15/2023]
Abstract
The advent of portable, low-field MRI (LF-MRI) heralds new opportunities in neuroimaging. Low power requirements and transportability have enabled scanning outside the controlled environment of a conventional MRI suite, enhancing access to neuroimaging for indications that are not well suited to existing technologies. Maximizing the information extracted from the reduced signal-to-noise ratio of LF-MRI is crucial to developing clinically useful diagnostic images. Progress in electromagnetic noise cancellation and machine learning reconstruction algorithms from sparse k-space data as well as new approaches to image enhancement have now enabled these advancements. Coupling technological innovation with bedside imaging creates new prospects in visualizing the healthy brain and detecting acute and chronic pathological changes. Ongoing development of hardware, improvements in pulse sequences and image reconstruction, and validation of clinical utility will continue to accelerate this field. As further innovation occurs, portable LF-MRI will facilitate the democratization of MRI and create new applications not previously feasible with conventional systems.
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Affiliation(s)
- W Taylor Kimberly
- Department of Neurology and the Center for Genomic Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Annabel J Sorby-Adams
- Department of Neurology and the Center for Genomic Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew G Webb
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ed X Wu
- Laboratory of Biomedical Imaging and Signal Processing, Department of Electrical and Electronic Engineering, The University of Hong Kong, Hong Kong SAR, China
| | - Rachel Beekman
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale New Haven Hospital and Yale School of Medicine, Yale Center for Brain & Mind Health, New Haven, CT, USA
| | - Ritvij Bowry
- Departments of Neurosurgery and Neurology, McGovern Medical School, University of Texas Health Neurosciences, Houston, TX, USA
| | - Steven J Schiff
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Adam de Havenon
- Division of Vascular Neurology, Department of Neurology, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Francis X Shen
- Harvard Medical School Center for Bioethics, Harvard law School, Boston, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Gordon Sze
- Department of Radiology, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Pamela Schaefer
- Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Juan Eugenio Iglesias
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Centre for Medical Image Computing, University College London, London, UK
- Computer Science and AI Laboratory, Massachusetts Institute of Technology, Boston, MA, USA
| | - Matthew S Rosen
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale New Haven Hospital and Yale School of Medicine, Yale Center for Brain & Mind Health, New Haven, CT, USA
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Abel F, Schubert T, Winklhofer S. Advanced Neuroimaging With Photon-Counting Detector CT. Invest Radiol 2023; 58:472-481. [PMID: 37158466 DOI: 10.1097/rli.0000000000000984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
ABSTRACT Photon-counting detector computed tomography (PCD-CT) is an emerging technology and promises the next step in CT evolution. Photon-counting detectors count the number of individual incoming photons and assess the energy level of each of them. These mechanisms differ substantially from conventional energy-integrating detectors. The new technique has several advantages, including lower radiation exposure, higher spatial resolution, reconstruction of images with less beam-hardening artifacts, and advanced opportunities for spectral imaging. Research PCD-CT systems have already demonstrated promising results, and recently, the first whole-body full field-of-view PCD-CT scanners became clinically available. Based on published studies of preclinical systems and the first experience with clinically approved scanners, the performance can be translated to valuable neuroimaging applications, including brain imaging, intracranial and extracranial CT angiographies, or head and neck imaging with detailed assessment of the temporal bone. In this review, we will provide an overview of the current status in neuroimaging with upcoming and potential clinical applications.
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Affiliation(s)
- Frederik Abel
- From the Department of Diagnostic and Interventional Radiology
| | - Tilman Schubert
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Sebastian Winklhofer
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Mannismäki L, Martinez-Majander N, Sibolt G, Suomalainen OP, Bäcklund K, Abou Elseoud A, Järveläinen J, Forss N, Curtze S. Association of admission plasma glucose level and cerebral computed tomographic perfusion deficit volumes. J Neurol Sci 2023; 451:120722. [PMID: 37393736 DOI: 10.1016/j.jns.2023.120722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/19/2023] [Accepted: 06/24/2023] [Indexed: 07/04/2023]
Abstract
INTRODUCTION Hyperglycemia in acute ischemic stroke (AIS) is frequent and associated with worse outcome. Yet, strict glycemic control in AIS patients has failed to yield beneficial outcome. So far, the underlying pathophysiological mechanisms of admission hyperglycemia in AIS have remained not fully understood. We aimed to evaluate the yet equivocal association of hyperglycemia with computed tomographic perfusion (CTP) deficit volumes. PATIENTS AND METHODS We included 832 consecutive AIS and transient ischemic attack (TIA) patients who underwent CTP as a part of screening for recanalization treatment (stroke code) between 3/2018 and 10/2020, from the prospective cohort of Helsinki Stroke Quality Registry. Associations of admission glucose level (AGL) and CTP deficit volumes, namely ischemic core, defined as relative cerebral blood flow <30%, and hypoperfusion lesions Time-to-maximum (Tmax) >6 s and Tmax >10s, as determined with RAPID® software, were analyzed with a linear regression model adjusted for age, sex, C-reactive protein, and time from symptom onset to imaging. RESULTS AGL median was 6.8 mmol/L (interquartile range 5.9-8.0 mmol/L), and 222 (27%) patients were hyperglycemic (glucose >7.8 mmol/L) on admission. In non-diabetic patients (643 [77%]), AGL was significantly associated with volume of Tmax. >6 s (regression coefficient [RC] 4.8, 95% confidence interval [CI] 0.49-9.1), of Tmax >10s (RC 4.6, 95% CI 1.2-8.1), and of ischemic core (RC 2.6, 95% CI 0.64-4.6). No significant associations were shown in diabetic patients. CONCLUSION Admission hyperglycemia appears to be associated with both larger volume of hypoperfusion lesions and of ischemic core in non-diabetic stroke code patients with AIS and TIA.
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Affiliation(s)
- Laura Mannismäki
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland.
| | - Nicolas Martinez-Majander
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Gerli Sibolt
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Olli P Suomalainen
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Katariina Bäcklund
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Ahmed Abou Elseoud
- Helsinki Medical Imaging Centre, Helsinki University Hospital, Helsinki, Finland
| | - Juha Järveläinen
- Helsinki Medical Imaging Centre, Helsinki University Hospital, Helsinki, Finland
| | - Nina Forss
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland; Department of Neuroscience and Biomedical Engineering, Aalto University, Espoo, Finland
| | - Sami Curtze
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
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Bani-Sadr A, Cho TH, Cappucci M, Hermier M, Ameli R, Filip A, Riva R, Derex L, De Bourguignon C, Mechtouff L, Eker OF, Nighoghossian N, Berthezene Y. Assessment of three MR perfusion software packages in predicting final infarct volume after mechanical thrombectomy. J Neurointerv Surg 2023; 15:393-398. [PMID: 35318959 DOI: 10.1136/neurintsurg-2022-018674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 02/28/2022] [Indexed: 11/04/2022]
Abstract
AIMS To evaluate the performance of three MR perfusion software packages (A: RAPID; B: OleaSphere; and C: Philips) in predicting final infarct volume (FIV). METHODS This cohort study included patients treated with mechanical thrombectomy following an admission MRI and undergoing a follow-up MRI. Admission MRIs were post-processed by three packages to quantify ischemic core and perfusion deficit volume (PDV). Automatic package outputs (uncorrected volumes) were collected and corrected by an expert. Successful revascularization was defined as a modified Thrombolysis in Cerebral Infarction (mTICI) score ≥2B. Uncorrected and corrected volumes were compared between each package and with FIV according to mTICI score. RESULTS Ninety-four patients were included, of whom 67 (71.28%) had a mTICI score ≥2B. In patients with successful revascularization, ischemic core volumes did not differ significantly from FIV regardless of the package used for uncorrected and corrected volumes (p>0.15). Conversely, assessment of PDV showed significant differences for uncorrected volumes. In patients with unsuccessful revascularization, the uncorrected PDV of packages A (median absolute difference -40.9 mL) and B (median absolute difference -67.0 mL) overestimated FIV to a lesser degree than package C (median absolute difference -118.7 mL; p=0.03 and p=0.12, respectively). After correction, PDV did not differ significantly from FIV for all three packages (p≥0.99). CONCLUSIONS Automated MRI perfusion software packages estimate FIV with high variability in measurement despite using the same dataset. This highlights the need for routine expert evaluation and correction of automated package output data for appropriate patient management.
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Affiliation(s)
- Alexandre Bani-Sadr
- Neuroradiology, Hospices Civils de Lyon, Bron, France .,MYRIAD, CREATIS, Villeurbanne, France
| | - Tae-Hee Cho
- Stroke Department, Hospices Civils de Lyon, Lyon, France
| | | | - Marc Hermier
- Neuroradiology, Hospices Civils de Lyon, Bron, France
| | - Roxana Ameli
- Neuroradiology, Hospices Civils de Lyon, Bron, France
| | - Andrea Filip
- Neuroradiology, Hospices Civils de Lyon, Bron, France
| | - Roberto Riva
- Neuroradiology, Hospices Civils de Lyon, Bron, France
| | - Laurent Derex
- Stroke Department, Hospices Civils de Lyon, Lyon, France
| | | | | | - Omer F Eker
- Neuroradiology, Hospices Civils de Lyon, Bron, France.,MYRIAD, CREATIS, Villeurbanne, France
| | | | - Yves Berthezene
- Neuroradiology, Hospices Civils de Lyon, Bron, France.,MYRIAD, CREATIS, Villeurbanne, France
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9
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Kumar M, Hu S, Beyea S, Kamal N. Is improved access to magnetic resonance imaging imperative for optimal ischemic stroke care? J Neurol Sci 2023; 446:120592. [PMID: 36821945 DOI: 10.1016/j.jns.2023.120592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/14/2023] [Indexed: 02/20/2023]
Abstract
Neuroimaging, including CT and MRI, is integral to ischemic stroke (IS) treatment, management, and prevention. However, the use of MRI for IS patients is limited despite its potential to provide high-quality images that yield definitive information related to the management of IS. MRI is beneficial when the information provided by CT is insufficient for decisions related to the diagnosis, etiology, or treatment of IS. In the emergency setting, MRI can improve the diagnostic accuracy of CT-negative acute ischemic strokes (AIS) and ensure a better selection of patients for reperfusion therapies with thrombolysis and/or thrombectomy. Moreover, MR imaging may help avoid hospital admissions for patients with stroke mimics, facilitate earlier discharge, and reduce overall hospital costs. MRI in the in-patient setting can help determine stroke etiology to aid in stroke prevention management upon discharge. Furthermore, early access to MRI in IS out-patients can aid in diagnosing, risk stratifying, and determining optimal management strategies for patients with a TIA or a minor stroke. Recent technological advances, particularly low-to-mid-field MR scanners, can improve access to MRI. These MR scanners provide faster protocols, cost-effectiveness, smaller footprints, safety, and lower power requirements. In conclusion, MRI use for IS treatment, management, and prevention is imperative and justifiable, and the latest technological advancements in MR scanners hold the potential to enhance access.
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Affiliation(s)
- Mukesh Kumar
- Department of Industrial Engineering, Dalhousie University, Halifax, Canada.
| | - Sherry Hu
- Department of Medicine, Division of Neurology, Dalhousie University, Halifax, Canada
| | - Steven Beyea
- Department of Diagnostic Radiology, Dalhousie University, Halifax, Canada; IWK Health, Halifax, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, Canada; Department of Medicine, Division of Neurology, Dalhousie University, Halifax, Canada; Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada
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10
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Predictive Value of CT Perfusion in Hemorrhagic Transformation after Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Brain Sci 2023; 13:brainsci13010156. [PMID: 36672136 PMCID: PMC9856940 DOI: 10.3390/brainsci13010156] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/02/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
Background: Existing studies indicate that some computed tomography perfusion (CTP) parameters may predict hemorrhagic transformation (HT) after acute ischemic stroke (AIS), but there is an inconsistency in the conclusions alongside a lack of comprehensive comparison. Objective: To comprehensively evaluate the predictive value of CTP parameters in HT after AIS. Data sources: A systematical literature review of existing studies was conducted up to 1st October 2022 in six mainstream databases that included original data on the CTP parameters of HT and non-HT groups or on the diagnostic performance of relative cerebral blood flow (rCBF), relative permeability-surface area product (rPS), or relative cerebral blood volume (rCBV) in patients with AIS that completed CTP within 24 h of onset. Data Synthesis: Eighteen observational studies were included. HT and non-HT groups had statistically significant differences in CBF, CBV, PS, rCBF, rCBV, and rPS (p < 0.05 for all). The hierarchical summary receiver operating characteristic (HSROC) revealed that rCBF (area under the curve (AUC) = 0.9), rPS (AUC = 0.89), and rCBV (AUC = 0.85) had moderate diagnostic performances in predicting HT. The pooled sensitivity and specificity of rCBF were 0.85 (95% CI, 0.75−0.91) and 0.83 (95% CI, 0.63−0.94), respectively. Conclusions: rCBF, rPS, and rCBV had moderate diagnostic performances in predicting HT, and rCBF had the best pooled sensitivity and specificity.
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11
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Fully automatic identification of post-treatment infarct lesions after endovascular therapy based on non-contrast computed tomography. Neural Comput Appl 2022. [DOI: 10.1007/s00521-022-08094-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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12
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Suomalainen OP, Martinez-Majander N, Sibolt G, Bäcklund K, Järveläinen J, Korvenoja A, Tiainen M, Forss N, Curtze S. Comparative analysis of core and perfusion lesion volumes between commercially available computed tomography perfusion software. Eur Stroke J 2022; 8:259-267. [PMID: 37021148 PMCID: PMC10069177 DOI: 10.1177/23969873221135915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 10/12/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction: Computed tomography perfusion (CTP) imaging has become an important tool in evaluating acute recanalization treatment candidates. Large clinical trials have successfully used RAPID automated imaging analysis software for quantifying ischemic core and penumbra, yet other commercially available software vendors are also on the market. We evaluated the possible difference in ischemic core and perfusion lesion volumes and the agreement rate of target mismatch between OLEA, MIStar, and Syngo.Via versus RAPID software in acute recanalization treatment candidates. Patients and methods: All consecutive stroke-code patients with baseline CTP RAPID imaging at Helsinki University Hospital during 8/2018–9/2021 were included. Ischemic core was defined as cerebral blood flow <30% than the contralateral hemisphere and within the area of delay time (DT) >3s with MIStar. Perfusion lesion volume was defined as DT > 3 s (MIStar) and Tmax > 6 s with all other software. A perfusion mismatch ratio of ⩾1.8, a perfusion lesion volume of ⩾15 mL, and ischemic core <70 mL was defined as target mismatch. The mean pairwise differences of the core and perfusion lesion volumes between software were calculated using the Bland-Altman method and the agreement of target mismatch between software using the Pearson correlation. Results: A total of 1606 patients had RAPID perfusion maps, 1222 of which had MIStar, 596 patients had OLEA, and 349 patients had Syngo.Via perfusion maps available. Each software was compared with simultaneously analyzed RAPID software. MIStar showed the smallest core difference compared with RAPID (−2 mL, confidence interval (CI) from −26 to 22), followed by OLEA (2 mL, CI from −33 to 38). Perfusion lesion volume differed least with MIStar (4 mL, CI from −62 to 71) in comparison with RAPID, followed by Syngo.Via (6 mL, CI from −94 to 106). MIStar had the best agreement rate with target mismatch of RAPID followed by OLEA and Syngo.Via. Discussion and conclusion: Comparison of RAPID with three other automated imaging analysis software showed variance in ischemic core and perfusion lesion volumes and in target mismatch.
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Affiliation(s)
- Olli P Suomalainen
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Finland
| | - Nicolas Martinez-Majander
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Finland
| | - Gerli Sibolt
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Finland
| | - Katariina Bäcklund
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Finland
| | - Juha Järveläinen
- Department of Neuroradiology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Finland
| | - Antti Korvenoja
- Department of Neuroradiology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Finland
| | - Marjaana Tiainen
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Finland
| | - Nina Forss
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Finland
- Department of Neuroscience and Biomedical Engineering, Aalto University, Finland
| | - Sami Curtze
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Finland
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13
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Chung KJ, Khaw AV, Lee DH, Pandey S, Mandzia J, Lee TY. Low-dose CT Perfusion with Sparse-view Filtered Back Projection in Acute Ischemic Stroke. Acad Radiol 2022; 29:1502-1511. [PMID: 35300907 DOI: 10.1016/j.acra.2022.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/15/2022] [Accepted: 01/24/2022] [Indexed: 12/30/2022]
Abstract
RATIONALE AND OBJECTIVES Radiation dose associated with computed tomography (CT) perfusion (CTP) may discourage its use despite its added diagnostic benefit in quantifying ischemic lesion volume. Sparse-view CT reduces scan dose by acquiring fewer X-ray projections per gantry rotation but is contaminated by streaking artifacts using filtered back projection (FBP). We investigated the achievable dose reduction by sparse-view CTP with FBP without affecting CTP lesion volume estimations. MATERIALS AND METHODS Thirty-eight consecutive patients with acute ischemic stroke and CTP were included in this simulation study. CTP projection data was simulated by forward projecting original reconstructions with 984 views and adding Gaussian noise. Full-view (984 views) and sparse-view (492, 328, 246, and 164 views) CTP studies were simulated by FBP of simulated projection data. Cerebral blood flow (CBF) and time-to-maximum of the impulse residue function (Tmax) maps were generated by deconvolution for each simulated CTP study. Ischemic volumes were measured by CBF<30% relative to the contralateral hemisphere and Tmax > 6 s. Volume accuracy was evaluated with respect to the full-view CTP study by the Friedman test with post hoc multiplicity-adjusted pairwise tests and Bland-Altman analysis. RESULTS Friedman and multiplicity-adjusted pairwise tests indicated that 164-view CBF < 30%, 246- and 164-view Tmax > 6 s volumes were significantly different to full-view volumes (p < 0.001). Mean difference ± standard deviation (sparse minus full-view lesion volume) ranged from -1.0 ± 2.8 ml to -4.1 ± 11.7 ml for CBF < 30% and -2.9 ± 3.8 ml to -12.5 ± 19.9 ml for Tmax > 6 s from 492 to 164 views, respectively. CONCLUSION By ischemic volume accuracy, our study indicates that sparse-view CTP may allow dose reduction by up to a factor of 3.
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Affiliation(s)
- Kevin J Chung
- Department of Medical Biophysics, University of Western Ontario, London, ON, Canada; Robarts Research Institute and Lawson Health Research Institute, University of Western Ontario, 1151 Richmond Street N, London, ON N6A 5B7, Canada
| | - Alexander V Khaw
- Department of Clinical Neurological Sciences, University of Western Ontario, London, ON, Canada
| | - Donald H Lee
- Department of Medical Imaging, University of Western Ontario, London, ON, Canada
| | - Sachin Pandey
- Department of Medical Imaging, University of Western Ontario, London, ON, Canada
| | - Jennifer Mandzia
- Department of Clinical Neurological Sciences, University of Western Ontario, London, ON, Canada
| | - Ting-Yim Lee
- Department of Medical Biophysics, University of Western Ontario, London, ON, Canada; Robarts Research Institute and Lawson Health Research Institute, University of Western Ontario, 1151 Richmond Street N, London, ON N6A 5B7, Canada; Department of Medical Imaging, University of Western Ontario, London, ON, Canada.
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14
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Garzon G, Gomez S, Mantilla D, Martinez F. A deep CT to MRI unpaired translation that preserve ischemic stroke lesions. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:2708-2711. [PMID: 36086325 DOI: 10.1109/embc48229.2022.9871154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Stroke is the second-leading cause of death world around. The immediate attention is key to patient prognosis. Ischemic stroke diagnosis typically involves neuroimaging studies (MRI and CT scans) and clinical protocols to characterize lesions and support decisions about treatment to be administered to the patient. Nowadays, multiparametric MRI images are the standard tool to visualize core and penumbra of ischemic stroke, supporting diagnosis and lesion prognosis. Specially, DWI modality (Diffusion Weighted Imaging) allows to quantify the cellular density of the tissue, and therefore allowing to quantify the lesion aggressiveness, and the recognition of micro-circulation properties. Nevertheless, MRI availability at hospitals is not widespread, and acquisition require special conditions requiring considerable time. Contrary, CT scans commonly have major availability but brain structures are poorly delineated, and even worse, ischemic lesions are only visible at advanced stages of the disease. This work introduces a deep generative strategy that allows ischemic stroke lesion translation over synthetic DWI-MRI images. This encoder-decoder architecture, include U-net modules, hierarchically organized, with inter-level connections that preserve brain structures, while codifying an embedding representation. Then a cyclic loss was here implemented to receive CT inputs and decode DWI-MRI images. To avoid mode collapse, this learning is inversely propagated, i.e., from synthetic DWI-MRI images to original CT-scans. Finally, an embedding projection is recovered to show a proper lesion-slice discrimination, regarding control studies. Clinical relevance- To recover synthetic DWI-MRI that preserved ischemic lesion using CT scans as an input and following an unpaired image translation setup.
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15
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Suomalainen OP, Elseoud Abou A, Martinez-Majander N, Tiainen M, Valkonen K, Virtanen P, Forss N, Curtze S. Is infarct core growth linear? Infarct volume estimation by computed tomography perfusion imaging. Acta Neurol Scand 2022; 145:684-691. [PMID: 35187642 DOI: 10.1111/ane.13601] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/08/2022] [Accepted: 02/09/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Current guidelines for recanalization treatment are based on the time elapsed between symptom onset and treatment and visualization of existing penumbra in computed tomography perfusion (CTP) imaging. The time window for treatment options relies on linear growth of infarction although individual infarct growth rate may vary. We aimed to test how accurately the estimated follow-up infarct volume (eFIV) can be approximated by using a linear growth model based on CTP baseline imaging. If eFIV did not fall within the margins of +/- 19% of the follow-up infarct volume (FIV) measured at 24 h from non-enhanced computed tomography images, the results would imply that the infarct growth is not linear. MATERIALS AND METHODS All consecutive endovascularly treated (EVT) patients from 11/2015 to 9/2019 at the Helsinki University Hospital with large vessel occlusion (LVO), CTP imaging, and known time of symptom onset were included. Infarct growth rate was assumed to be linear and calculated by dividing the ischemic core volume (CTPcore ) by the time from symptom onset to baseline imaging. eFIV was calculated by multiplying the infarct growth rate with the time from baseline imaging to recanalization or in case of futile recanalization to follow-up imaging at 24 h, limited to the penumbra. Collateral flow was estimated by calculating hypoperfusion intensity ratio (HIR). RESULTS Of 5234 patients, 48 had LVO, EVT, CTP imaging, and known time of symptom onset. In 40/48 patients (87%), infarct growth was not linear. HIR did not differ between patients with linear and nonlinear growth (p > .05). As expected, in over half of the patients with successful recanalization eFIV exceeded FIV. CONCLUSIONS Infarct growth was not linear in most patients and thus time elapsed from symptom onset and CTPcore appear to be insufficient parameters for clinical decision-making in EVT candidates.
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Affiliation(s)
- Olli P Suomalainen
- Departments of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Ahmed Elseoud Abou
- Neuroradiology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | | | - Marjaana Tiainen
- Departments of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Kati Valkonen
- Departments of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Pekka Virtanen
- Neuroradiology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Nina Forss
- Departments of Neurology, Helsinki University Hospital, Helsinki, Finland.,Department of Neuroscience and Biomedical Engineering, Aalto University, Espoo, Finland
| | - Sami Curtze
- Departments of Neurology, Helsinki University Hospital, Helsinki, Finland
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16
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Schlachetzki F, Nedelmann M, Eyding J, Ritter M, Schminke U, Schulte-Altedorneburg G, Köhrmann M, Harrer JU. Sonografisches Neuromonitoring auf der Stroke Unit und in der
neurologischen Intensivmedizin. KLIN NEUROPHYSIOL 2022. [DOI: 10.1055/a-1810-0728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Zusammenfassung
Hintergrund Der Artikel gibt einen Überblick über die
aktuellen diagnostischen Einsatzmöglichkeiten sonographischer Anwendung
in der neurologischen Intensivmedizin.
Methoden Selektive Literaturrecherche mit kritischer Beurteilung ab dem
Jahr 1984 sowie nationaler und internationaler Leitlinien sowie
Expertenmeinung.
Ergebnisse Neben der raschen validen Abklärung akuter
Schlaganfälle bieten verschiedene neurosonografische
Monitoring-verfahren gerade in der Intensivmedizin spezifische Vorteile wie die
beliebig häufige Wiederholbarkeit am Patientenbett selbst und die
Darstellung in Echtzeit. Innovative Entwicklungen machen die Neurosonografie
auch wissenschaftlich zu einem interessanten Gebiet.
Schlussfolgerung Die neurosonografische Diagnostik nimmt seit Jahren einen
wichtigen Stellenwert in der neurologischen Intensivmedizin ein. Weitere
Anstrengungen sind notwendig, um die Verbreitung der Methode zu fördern
und durch wissenschaftliche Evidenz zu stärken.
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Affiliation(s)
- Felix Schlachetzki
- Klinik und Poliklinik für Neurologie der Universität
Regensburg, Zentrum für Vaskuläre Neurologie und
Intensivmedizin, medbo Bezirksklinikum Regensburg, Regensburg
- Klinik und Poliklinik für Neurologie,
Universitätsklinikum Regensburg, Regensburg
| | - Max Nedelmann
- Klinik für Neurologie, Regio Kliniken Pinneberg,
Pinneberg
| | - Jens Eyding
- Abteilung für Neurologie, Gemeinschaftskrankenhaus Herdecke und
Medizinische Fakultät der Ruhr-Universität Bochum,
Bochum
| | | | - Ulf Schminke
- Klinik für Neurologie, Universitätsmedizin Greifswald,
Greifswald
| | | | | | - Judith U. Harrer
- Neurologische Praxis in der Villa Pfahler, St. Ingbert
- Klinik für Neurologie, Universitätsklinikum der RWTH
Aachen, Aachen
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17
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Endovascular thrombectomy for large cerebral infarction: how low should we go? Anaesth Crit Care Pain Med 2022; 41:101104. [PMID: 35598885 DOI: 10.1016/j.accpm.2022.101104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 11/23/2022]
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18
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Potential of Stroke Imaging Using a New Prototype of Low-Field MRI: A Prospective Direct 0.55 T/1.5 T Scanner Comparison. J Clin Med 2022; 11:jcm11102798. [PMID: 35628923 PMCID: PMC9147033 DOI: 10.3390/jcm11102798] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/06/2022] [Accepted: 05/13/2022] [Indexed: 12/05/2022] Open
Abstract
Objectives: Ischemic stroke is a leading cause of mortality and acquired disability worldwide and thus plays an enormous health-economic role. Imaging of choice is computed-tomographic (CT) or magnetic resonance imaging (MRI), especially diffusion-weighted (DW) sequences. However, MR imaging is associated with high costs and therefore has a limited availability leading to low-field-MRI techniques increasingly coming into focus. Thus, the aim of our study was to assess the potential of stroke imaging with low-field MRI. Material and Methods: A scanner comparison was performed including 27 patients (17 stroke cohort, 10 control group). For each patient, a brain scan was performed first with a 1.5T scanner and afterwards with a 0.55T scanner. Scan protocols were as identical as possible and optimized. Data analysis was performed in three steps: All DWI/ADC (apparent diffusion coefficient) and FLAIR (fluid attenuated inversion recovery) sequences underwent Likert rating with respect to image impression, resolution, noise, contrast, and diagnostic quality and were evaluated by two radiologists regarding number and localization of DWI and FLAIR lesions in a blinded fashion. Then segmentation of lesion volumes was performed by two other radiologists on DWI/ADC and FLAIR. Results: DWI/ADC lesions could be diagnosed with the same reliability by the most experienced reader in the 0.55T and 1.5T sequences (specificity 100% and sensitivity 92.9%, respectively). False positive findings did not occur. Detection of number/location of FLAIR lesions was mostly equivalent between 0.55T and 1.5T sequences. No significant difference (p = 0.789−0.104) for FLAIR resolution and contrast was observed regarding Likert scaling. For DWI/ADC noise, the 0.55T sequences were significantly superior (p < 0.026). Otherwise, the 1.5T sequences were significantly superior (p < 0.029). There was no significant difference in infarct volume and volume of infarct demarcation between the 0.55T and 1.5T sequences, when detectable. Conclusions: Low-field MRI stroke imaging at 0.55T may not be inferior to scanners with higher field strengths and thus has great potential as a low-cost alternative in future stroke diagnostics. However, there are limitations in the detection of very small infarcts. Further technical developments with follow-up studies must show whether this problem can be solved.
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19
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Yuen MM, Prabhat AM, Mazurek MH, Chavva IR, Crawford A, Cahn BA, Beekman R, Kim JA, Gobeske KT, Petersen NH, Falcone GJ, Gilmore EJ, Hwang DY, Jasne AS, Amin H, Sharma R, Matouk C, Ward A, Schindler J, Sansing L, de Havenon A, Aydin A, Wira C, Sze G, Rosen MS, Kimberly WT, Sheth KN. Portable, low-field magnetic resonance imaging enables highly accessible and dynamic bedside evaluation of ischemic stroke. SCIENCE ADVANCES 2022; 8:eabm3952. [PMID: 35442729 PMCID: PMC9020661 DOI: 10.1126/sciadv.abm3952] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 02/08/2022] [Indexed: 05/26/2023]
Abstract
Brain imaging is essential to the clinical management of patients with ischemic stroke. Timely and accessible neuroimaging, however, can be limited in clinical stroke pathways. Here, portable magnetic resonance imaging (pMRI) acquired at very low magnetic field strength (0.064 T) is used to obtain actionable bedside neuroimaging for 50 confirmed patients with ischemic stroke. Low-field pMRI detected infarcts in 45 (90%) patients across cortical, subcortical, and cerebellar structures. Lesions as small as 4 mm were captured. Infarcts appeared as hyperintense regions on T2-weighted, fluid-attenuated inversion recovery and diffusion-weighted imaging sequences. Stroke volume measurements were consistent across pMRI sequences and between low-field pMRI and conventional high-field MRI studies. Low-field pMRI stroke volumes significantly correlated with stroke severity and functional outcome at discharge. These results validate the use of low-field pMRI to obtain clinically useful imaging of stroke, setting the stage for use in resource-limited environments.
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Affiliation(s)
- Matthew M. Yuen
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Anjali M. Prabhat
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Mercy H. Mazurek
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Isha R. Chavva
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Anna Crawford
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Bradley A. Cahn
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Rachel Beekman
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Jennifer A. Kim
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Kevin T. Gobeske
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Nils H. Petersen
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Guido J. Falcone
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Emily J. Gilmore
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - David Y. Hwang
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Adam S. Jasne
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Hardik Amin
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Richa Sharma
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Adrienne Ward
- Neuroscience Intensive Care Unit, Yale New Haven Hospital, New Haven, CT, USA
| | - Joseph Schindler
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Lauren Sansing
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Adam de Havenon
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Ani Aydin
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Charles Wira
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Gordon Sze
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Matthew S. Rosen
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - W. Taylor Kimberly
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Kevin N. Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
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20
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Giammello F, De Martino SRM, Simonetti L, Agati R, Battaglia S, Cirillo L, Gentile M, Migliaccio L, Forlivesi S, Romoli M, Princiotta C, Tonon C, Stagni S, Galluzzo S, Lodi R, Trimarchi G, Toscano A, Musolino RF, Zini A. Predictive value of Tmax perfusion maps on final core in acute ischemic stroke: an observational single-center study. LA RADIOLOGIA MEDICA 2022; 127:414-425. [PMID: 35226245 DOI: 10.1007/s11547-022-01467-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 02/01/2022] [Indexed: 12/30/2022]
Abstract
PURPOSE To assess utility of computed tomography perfusion (CTP) protocols for selection of patients with acute ischemic stroke (AIS) for reperfusive treatments and compare the diagnostic accuracy (ACC) in predicting follow-up infarction, using time-to-maximum (Tmax) maps. METHODS We retrospectively reviewed consecutive AIS patients evaluated for reperfusive treatments at comprehensive stroke center, employing a multimodal computed tomography. To assess prognostic accuracy of CTP summary maps in predicting final infarct area (FIA) in AIS patients, we assumed the best correlation between non-viable tissue (NVT) and FIA in early and fully recanalized patients and/or in patients with favorable clinical response (FCR). On the other hand, the tissue at risk (TAR) should better correlate with FIA in untreated patients and in treatment failure. RESULTS We enrolled 158 patients, for which CTP maps with Tmax thresholds of 9.5 s and 16 s, presented sensitivity of 82.5%, specificity of 74.6%, and ACC of 75.9%. In patients selected for perfusion deficit in anterior circulation territory, CTP-Tmax > 16 s has proven relatively reliable to identify NVT in FCR patients, with a tendency to overestimate NVT. Similarly, CTP-Tmax > 9.5 s was reliable for TAR, but it was overestimated comparing to FIA, in patients with unfavorable outcomes. CONCLUSIONS In our experience, Tmax thresholds have proven sufficiently reliable to identify global hypoperfusion, with tendency to overestimate both NVT and TAR, not yielding satisfactory differentiation between true penumbra and benign oligoemia. In particular, the overestimation of NVT could have serious consequences in not selecting potential candidates for a reperfusion treatment.
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Affiliation(s)
- Fabrizio Giammello
- International PhD Translational Molecular Medicine and Surgery, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Polyclinic Hospital, Via Consolare Valeria 1, 98125, Messina, Italy.
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
| | - Sara Rosa Maria De Martino
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neuroradiology Unit, Bellaria Hospital, Bologna, Italy
| | - Luigi Simonetti
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neuroradiology Unit, Maggiore Hospital, Bologna, Italy
| | - Raffaele Agati
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Programma Neuroradiologia Con Tecniche Ad Elevata Complessità, Bellaria Hospital, Bologna, Italy
| | - Stella Battaglia
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Programma Neuroradiologia Con Tecniche Ad Elevata Complessità, Bellaria Hospital, Bologna, Italy
| | - Luigi Cirillo
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neuroradiology Unit, Bellaria Hospital, Bologna, Italy
- DIMES, Department of Specialty, Diagnostic and Experimental Medicine, University of Bologna, Bologna, Italy
| | - Mauro Gentile
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Maggiore Hospital, Bologna, Italy
| | - Ludovica Migliaccio
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Maggiore Hospital, Bologna, Italy
| | - Stefano Forlivesi
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Maggiore Hospital, Bologna, Italy
| | - Michele Romoli
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Maggiore Hospital, Bologna, Italy
| | - Ciro Princiotta
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neuroradiology Unit, Bellaria Hospital, Bologna, Italy
| | - Caterina Tonon
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
- Functional and Molecular Neuroimaging Unit, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Silvia Stagni
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neuroradiology Unit, Maggiore Hospital, Bologna, Italy
| | - Simone Galluzzo
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neuroradiology Unit, Maggiore Hospital, Bologna, Italy
| | - Raffaele Lodi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
- Functional and Molecular Neuroimaging Unit, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | | | - Antonio Toscano
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Rosa Fortunata Musolino
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Andrea Zini
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Maggiore Hospital, Bologna, Italy
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21
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Prabhat AM, Crawford AL, Mazurek MH, Yuen MM, Chavva IR, Ward A, Hofmann WV, Timario N, Qualls SR, Helland J, Wira C, Sze G, Rosen MS, Kimberly WT, Sheth KN. Methodology for Low-Field, Portable Magnetic Resonance Neuroimaging at the Bedside. Front Neurol 2021; 12:760321. [PMID: 34956049 PMCID: PMC8703196 DOI: 10.3389/fneur.2021.760321] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/02/2021] [Indexed: 01/18/2023] Open
Abstract
Neuroimaging is a critical component of triage and treatment for patients who present with neuropathology. Magnetic resonance imaging and non-contrast computed tomography are the gold standard for diagnosis and prognostication of patients with acute brain injuries. However, these modalities require intra-hospital transport to strict, access-controlled environments, which puts critically ill patients at risk for complications and secondary injuries. A novel, portable MRI (pMRI) device that can be deployed at the patient's bedside provides a needed solution. In a dual-center investigation, Yale New Haven Hospital has obtained regular neuroimaging on patients using the pMRI as part of routine clinical care in the Emergency Department and Intensive Care Unit (ICU) since August of 2020. Massachusetts General Hospital has begun using pMRI in the Neuroscience Intensive Care Unit since January 2021. This technology has expanded the population of patients who can receive MRI imaging by increasing accessibility and timeliness for scan completion by eliminating the need for transport and increasing the potential for serial monitoring. Here we describe our methods for screening, coordinating, and executing pMRI exams and provide further detail on how to scan specific patient populations.
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Affiliation(s)
- Anjali M Prabhat
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States
| | - Anna L Crawford
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States
| | - Mercy H Mazurek
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States
| | - Matthew M Yuen
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States
| | - Isha R Chavva
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States
| | - Adrienne Ward
- Neuroscience Intensive Care Unit, Yale New Haven Hospital, New Haven, CT, United States
| | - William V Hofmann
- Neuroscience Intensive Care Unit, Yale New Haven Hospital, New Haven, CT, United States
| | - Nona Timario
- Neuroscience Intensive Care Unit, Yale New Haven Hospital, New Haven, CT, United States
| | - Stephanie R Qualls
- Neuroscience Intensive Care Unit, Massachusetts General Hospital, Boston, MA, United States
| | - Juliana Helland
- Neuroscience Intensive Care Unit, Massachusetts General Hospital, Boston, MA, United States
| | - Charles Wira
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Gordon Sze
- Department of Neuroradiology, Yale School of Medicine, New Haven, CT, United States
| | - Matthew S Rosen
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, United States.,Department of Radiology, Harvard Medical School, Boston, MA, United States.,Department of Physics, Harvard University, Cambridge, MA, United States
| | | | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States
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22
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Evans B, Ekpo E. Do referral guidelines recommend chest x-rays for patients with abdominal pain? A review. J Med Imaging Radiat Sci 2021; 52:606-614. [PMID: 34903354 DOI: 10.1016/j.jmir.2021.08.019] [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: 05/03/2021] [Revised: 08/02/2021] [Accepted: 08/31/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chest X-rays (CXRs) are often requested for patients who present to emergency with abdominal pain, but its benefit to patient management remains unclear. Several guidelines have been developed to ensure that imaging investigations have the highest diagnostic impact. This study aims to compare referral guidelines to establish their recommendations and circumstances for recommendations regarding CXRs for patients with abdominal pain. METHODS A systematic search of the literature was performed using Medline (via OVID), PubMed, Google, and Google Scholar. Referral guidelines were included if they provided recommendations for imaging of abdominal pain, were based on published evidence, and were broadly utilised. Data related to their recommendations for CXR for abdominal pain was recorded and analysed. RESULTS Three guidelines supported the use of CXRs in the case of suspected perforation. Two guidelines included CXR for patients presenting with blunt abdominal trauma and severe abdominal pain requiring admission. One of the guidelines included use of CXRs for patients presenting with suspected small bowel obstruction, cholecystitis, and penetrating trauma. Two guidelines recorded no circumstances where the use of CXRs were recommended. CONCLUSION Published evidence-based guidelines allow for the use of CXRs for patients presenting with abdominal pain in very limited circumstances.
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Affiliation(s)
- Brian Evans
- Medical Image Optimisation and Perception Group (MIOPeG), Faculty of Medicine and Health, The University of Sydney, Australia; Orange Radiology, Laboratories and Research Centre, Calabar, Nigeria.
| | - Ernest Ekpo
- Medical Image Optimisation and Perception Group (MIOPeG), Faculty of Medicine and Health, The University of Sydney, Australia; Orange Radiology, Laboratories and Research Centre, Calabar, Nigeria
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23
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Zhang L, Tang X, Wang C, Ding D, Zhu J, Zhou Y, Diao S, Kong Y, Cai X, Li C, Yao Y, Fang Q. Predictive Model of Dysphagia and Brain Lesion-Symptom Mapping in Acute Ischemic Stroke. Front Aging Neurosci 2021; 13:753364. [PMID: 34744695 PMCID: PMC8564389 DOI: 10.3389/fnagi.2021.753364] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/29/2021] [Indexed: 11/13/2022] Open
Abstract
Background and purpose: Early recognition and management of post-stroke dysphagia (PSD) based on MRI may reduce the incidence of complications. Combining clinical symptoms with applications of MRI, we aimed to identify the risk factors of PSD, develop a prediction scale with high accuracy and map key dysphagia brain areas. Methods: A total of 275 acute ischemic stroke patients were enrolled in this study, and 113 (41.1%) patients were diagnosed with PSD. All patients underwent the water-swallowing test (WST) and volume-viscosity swallow test (V-VST) within first 24 h following admission to assess swallowing. Vascular factors were evaluated and MRI brain scans were obtained within 3 days after symptom onset for each participant admitted to the hospital. T-test, chi-squared test and Fisher’s exact test were used to investigate the associations of various patient characteristics with dysphagia, and multivariable logistic regression models were used to construct a prediction scale. Scale accuracy was assessed using receiver operating characteristic (ROC) analysis. We extracted white matter hyperintensities for each patient as potential brain lesions. Voxel-based lesion-symptom mapping (VLSM) was used to identify key brain areas for dysphagia. Results: Risk factors related with PSD were older age, history of atrial fibrillation, higher fasting blood glucose, NIH stroke scale, TOAST classification, progressive stroke, middle cerebral artery lesion and anterior cerebral artery lesion. Three variables with most significant associations, including NIH stroke scale, TOAST classification and progressive stroke, combined with age and gender, were used to construct a dysphagia prediction scale with high accuracy (AUC = 0.86). VLSM identified left inferior parietal gyrus as a key brain region for PSD. Conclusion: Risk factors of PSD were identified and a predictive model of dysphagia was constructed intelligently and automatically. The left inferior parietal gyrus was identified as a key brain area for dysphagia, which provides a new symptom-based treatment target for early rehabilitation in the future.
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Affiliation(s)
- Lulu Zhang
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiang Tang
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Can Wang
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Dongxue Ding
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Juehua Zhu
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yun Zhou
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Shanshan Diao
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yan Kong
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiuying Cai
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Cuiping Li
- Shanghai Zhiyu Software Technology Co., Ltd., Shanghai, China
| | - Ye Yao
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai, China.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China.,Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
| | - Qi Fang
- Department of Neurology, First Affiliated Hospital of Soochow University, Suzhou, China
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24
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Althaus K, Dreyhaupt J, Hyrenbach S, Pinkhardt EH, Kassubek J, Ludolph AC. MRI as a first-line imaging modality in acute ischemic stroke: a sustainable concept. Ther Adv Neurol Disord 2021; 14:17562864211030363. [PMID: 34471423 PMCID: PMC8404629 DOI: 10.1177/17562864211030363] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/17/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Computed tomography (CT) scans are the first-line imaging technique in acute stroke patients based on the argument of rapid feasibility. Using magnetic resonance imaging (MRI) as the first-line imaging technique is the exception to the rule, although it provides much more diagnostic information and avoids exposure to radiation. We evaluated whether an MRI-based acute stroke concept is fast, suitable, and useful to improve recanalization rates and patient outcomes. Methods: We performed a retrospective observational cohort study comparing patients treated at a comprehensive stroke center (Ulm/Germany) applying an MRI-based acute stroke concept with patients recorded in a large comprehensive stroke registry in Baden-Württemberg (Germany). We analyzed the quality indicators of acute stroke treatment, patient’s outcome, and the rate of transient ischemic attack (TIA) at discharge. Results: A total of 2182 patients from Ulm and 82,760 patients from the Baden-Württemberg (BW) stroke registry (including 29,575 patients of comprehensive stroke centers (BWc)) were included. Intravenous thrombolysis rate was higher in Ulm than in BW or the BWc stroke centers (Ulm 27.4% versus BW 20.9% versus BWc 26.1; p < 0.01), while a door-to-needle time <30 min could be achieved more frequently (Ulm 73.6% versus BW 44.1% versus BWc 47.1%; p < 0.01). Thrombectomy rate in patients with a proximal vascular occlusion was higher (Ulm 69.2% versus BW 50.7% versus BWc 59.3; p < 0.01). The number of TIA diagnoses was lower (Ulm 16.2% versus BW 24.6% versus BWc 19.9%; p < 0.01). More patients showed a shift to a favorable outcome (Ulm 21.1% versus BW 16.9% versus BWc 15.3; p < 0.01). Complication rates were similar. Conclusions: The MRI-based acute stroke concept is suitable, fast and seems to be beneficial. The time-dependent quality indicators were better both in comparison to all stroke units and to the comprehensive stroke units in the area. Based on the MRI concept, high rates of recanalization procedures and fewer TIA diagnoses could be observed. In addition, there was a clear trend towards an improved clinical outcome. A clinical trial comparing the effects of CT and MRI as the primary imaging technique in otherwise identical stroke unit settings is warranted.
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Affiliation(s)
- Katharina Althaus
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, Ulm, Baden-Wuerttemberg 89075, Germany
| | - Jens Dreyhaupt
- Institute of Epidemiology and Medical Biometry, University of Ulm, Germany
| | - Sonja Hyrenbach
- Qualitätssicherung im Gesundheitswesen Baden-Württemberg, Stuttgart, Germany
| | | | - Jan Kassubek
- Department of Neurology, University of Ulm, Germany
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25
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Portable, bedside, low-field magnetic resonance imaging for evaluation of intracerebral hemorrhage. Nat Commun 2021; 12:5119. [PMID: 34433813 PMCID: PMC8387402 DOI: 10.1038/s41467-021-25441-6] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 08/05/2021] [Indexed: 02/07/2023] Open
Abstract
Radiological examination of the brain is a critical determinant of stroke care pathways. Accessible neuroimaging is essential to detect the presence of intracerebral hemorrhage (ICH). Conventional magnetic resonance imaging (MRI) operates at high magnetic field strength (1.5-3 T), which requires an access-controlled environment, rendering MRI often inaccessible. We demonstrate the use of a low-field MRI (0.064 T) for ICH evaluation. Patients were imaged using conventional neuroimaging (non-contrast computerized tomography (CT) or 1.5/3 T MRI) and portable MRI (pMRI) at Yale New Haven Hospital from July 2018 to November 2020. Two board-certified neuroradiologists evaluated a total of 144 pMRI examinations (56 ICH, 48 acute ischemic stroke, 40 healthy controls) and one ICH imaging core lab researcher reviewed the cases of disagreement. Raters correctly detected ICH in 45 of 56 cases (80.4% sensitivity, 95%CI: [0.68-0.90]). Blood-negative cases were correctly identified in 85 of 88 cases (96.6% specificity, 95%CI: [0.90-0.99]). Manually segmented hematoma volumes and ABC/2 estimated volumes on pMRI correlate with conventional imaging volumes (ICC = 0.955, p = 1.69e-30 and ICC = 0.875, p = 1.66e-8, respectively). Hematoma volumes measured on pMRI correlate with NIH stroke scale (NIHSS) and clinical outcome (mRS) at discharge for manual and ABC/2 volumes. Low-field pMRI may be useful in bringing advanced MRI technology to resource-limited settings.
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26
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de la Rosa E, Sima DM, Menze B, Kirschke JS, Robben D. AIFNet: Automatic vascular function estimation for perfusion analysis using deep learning. Med Image Anal 2021; 74:102211. [PMID: 34425318 DOI: 10.1016/j.media.2021.102211] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 06/25/2021] [Accepted: 08/04/2021] [Indexed: 12/30/2022]
Abstract
Perfusion imaging is crucial in acute ischemic stroke for quantifying the salvageable penumbra and irreversibly damaged core lesions. As such, it helps clinicians to decide on the optimal reperfusion treatment. In perfusion CT imaging, deconvolution methods are used to obtain clinically interpretable perfusion parameters that allow identifying brain tissue abnormalities. Deconvolution methods require the selection of two reference vascular functions as inputs to the model: the arterial input function (AIF) and the venous output function, with the AIF as the most critical model input. When manually performed, the vascular function selection is time demanding, suffers from poor reproducibility and is subject to the professionals' experience. This leads to potentially unreliable quantification of the penumbra and core lesions and, hence, might harm the treatment decision process. In this work we automatize the perfusion analysis with AIFNet, a fully automatic and end-to-end trainable deep learning approach for estimating the vascular functions. Unlike previous methods using clustering or segmentation techniques to select vascular voxels, AIFNet is directly optimized at the vascular function estimation, which allows to better recognise the time-curve profiles. Validation on the public ISLES18 stroke database shows that AIFNet almost reaches inter-rater performance for the vascular function estimation and, subsequently, for the parameter maps and core lesion quantification obtained through deconvolution. We conclude that AIFNet has potential for clinical transfer and could be incorporated in perfusion deconvolution software.
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Affiliation(s)
- Ezequiel de la Rosa
- icometrix, Leuven, Belgium; Department of Computer Science, Technical University of Munich, Munich, Germany.
| | | | - Bjoern Menze
- Department of Computer Science, Technical University of Munich, Munich, Germany
| | - Jan S Kirschke
- Neuroradiology, School of Medicine, Technical University of Munich, Munich, Germany
| | - David Robben
- icometrix, Leuven, Belgium; Medical Imaging Research Center (MIRC), KU Leuven, Leuven, Belgium; Medical Image Computing (MIC), ESAT-PSI, Department of Electrical Engineering, KU Leuven, Leuven, Belgium
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27
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Galmiche C, Moal B, Marnat G, Sagnier S, Schweitzer C, Dousset V, Sibon I, Tourdias T. Delayed Gadolinium Leakage in Ocular Structures: A Potential Marker for Age- and Vascular Risk Factor-Related Small Vessel Disease? Invest Radiol 2021; 56:425-432. [PMID: 33481460 DOI: 10.1097/rli.0000000000000757] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Gadolinium leakage in ocular structures (GLOS) was recently observed in fluid-attenuated inversion recovery (FLAIR) images obtained the day after an initial gadolinium injection in stroke patients. The specificity of GLOS to stroke and its mechanisms remain unclear. OBJECTIVE We investigated the factors associated with GLOS in a cohort of patients presenting with acute neurological deficits. MATERIALS AND METHODS This retrospective study included consecutive patients admitted to our stroke unit for acute neurological deficit between July 2017 and August 2018 who underwent baseline brain magnetic resonance imaging with the injection of a macrocyclic gadolinium agent and another scan without injection within 72 hours. The patients were separated into a stroke group and a stroke mimic group based on diffusion-weighted images. Gadolinium leakage in ocular structures was defined as a bright signal in the vitreous in follow-up FLAIR compared with baseline FLAIR (pregadolinium). Clinical data were collected together with imaging features from the baseline scans, including the volume of the infarct and of hypoperfusion if applicable, white matter hyperintensities, the number of lacunes, and the number of microbleeds, which were combined to yield a small vessel disease (SVD) score. We compared the prevalence of GLOS in both groups using the χ2 test. In the entire cohort, univariate and multivariate regression models were used to test the associations between GLOS and the collected data. RESULTS Among the 467 patients included in the study, GLOS was observed in similar proportions in the stroke group (32.2%, 136/422) and the stroke mimic group (28.9%, 13/45; mean difference, 3.3%; 95% confidence interval, -10.9 to 17.6; P = 0.65). In univariate analysis, GLOS was associated with older age, increased prevalence of vascular risk factors, brain imaging features of SVD (white matter hyperintensities, lacunes, microbleeds), as well as with impairment of renal function and increased dose of gadolinium. No associations were found with factors related to stroke, such as its volume, acute treatment, or rate of recanalization. Multivariate analyses showed that aging (P < 0.001), diabetes (P = 0.010), severe renal failure (P = 0.004), and increased dose of gadolinium (P < 0.001) were independent contributors to GLOS. CONCLUSIONS Gadolinium leakage in ocular structures, which occurs more commonly at higher concentrations of gadolinium, is not specific to stroke and may represent increased permeability of the blood-retinal barrier associated with age- and vascular risk factor-related SVD.
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Affiliation(s)
- Chloé Galmiche
- From the Service de Neuroimagerie Diagnostique et Thérapeutique
| | - Bertrand Moal
- Pôle de Santé Publique, Unité de Soutien Méthodologique à la Recherche Clinique et Epidémiologique
| | - Gaultier Marnat
- From the Service de Neuroimagerie Diagnostique et Thérapeutique
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28
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Martinez G, Katz JM, Pandya A, Wang JJ, Boltyenkov A, Malhotra A, Mushlin AI, Sanelli PC. Cost-Effectiveness Study of Initial Imaging Selection in Acute Ischemic Stroke Care. J Am Coll Radiol 2021; 18:820-833. [PMID: 33387454 PMCID: PMC8186007 DOI: 10.1016/j.jacr.2020.12.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/04/2020] [Accepted: 12/06/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE National guidelines recommend prompt identification of candidates for acute ischemic stroke (AIS) treatment, requiring timely neuroimaging with CT and/or MRI. CT is often preferred because of its widespread availability and rapid acquisition. Despite higher diagnostic accuracy of MRI, it commonly involves complex workflows that could potentially cause treatment time delays. The purpose of this study was to analyze the impact on outcomes of imaging utilization before treatment decisions at comprehensive stroke centers for patients presenting with suspected AIS in the anterior circulation with last-known-well-to-arrival time 0 to 24 hours. METHODS A decision simulation model based on the American Heart Association's recommendations for AIS care pathways was developed from a health care perspective to compare initial imaging strategies: (1) stepwise-CT: noncontrast CT (NCCT) at the time of presentation, with CT angiography (CTA) ± CT perfusion (CTP) only in select patients (initial imaging to exclude hemorrhage and extensive ischemia) for mechanical thrombectomy (MT) evaluation; (2) stepwise-hybrid: NCCT at the time of presentation, with MR angiography (MRA) ± MR perfusion (MRP) only for MT evaluation; (3) stepwise-advanced: NCCT + CTA at presentation, with MR diffusion-weighted imaging (MR DWI) + MRP only for MT evaluation; (4) comprehensive-CT: NCCT + CTA + CTP at the time of presentation; and (5) comprehensive-MR: MR DWI + MRA + MRP at the time of presentation. Model parameters were defined using evidence-based data. Cost-effectiveness and sensitivity analyses were performed. RESULTS The cost-effectiveness analyses revealed that comprehensive-CT and comprehensive-MR yield the highest lifetime quality-adjusted life-years (QALYs) (4.81 and 4.82, respectively). However, the incremental cost-effectiveness ratio of comprehensive-MR is $233,000/QALY compared with comprehensive-CT. Stepwise-CT, stepwise-hybrid, and stepwise-advanced strategies are dominated, yielding lower QALYs and higher costs compared with comprehensive-CT. CONCLUSIONS Performing comprehensive-CT at presentation is the most cost-effective initial imaging strategy at comprehensive stroke centers.
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Affiliation(s)
- Gabriela Martinez
- Siemens Healthineers, Malvern, Pennsylvania; Department of Radiology, Northwell Health, Manhasset, New York; Feinstein Institutes for Medical Research, Manhasset, New York.
| | - Jeffrey M Katz
- Chief, Neurovascular Services and Director Comprehensive Stroke Center at North Shore University Hospital, Department of Neurology, North Shore University Hospital, Manhasset, New York; Director of Neuroendovascular surgery, Neurology Service Line, Northwell Health, Manhasset, New York; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Ankur Pandya
- T. H. Trustee (unpaid), Society for Medical Decision Making, T.H Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Jason J Wang
- Feinstein Institutes for Medical Research, Manhasset, New York; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Artem Boltyenkov
- Siemens Healthineers, Malvern, Pennsylvania; Department of Radiology, Northwell Health, Manhasset, New York; Feinstein Institutes for Medical Research, Manhasset, New York
| | - Ajay Malhotra
- Radiology & Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Alvin I Mushlin
- Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Pina C Sanelli
- Department of Radiology, Northwell Health, Manhasset, New York; Feinstein Institutes for Medical Research, Manhasset, New York; Radiology & Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut; Healthcare Policy and Research, Weill Cornell Medical College, New York, New York; Vice Chair of Research, Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
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Suomalainen OP, Elseoud AA, Martinez-Majander N, Tiainen M, Forss N, Curtze S. Comparison of automated infarct core volume measures between non-contrast computed tomography and perfusion imaging in acute stroke code patients evaluated for potential endovascular treatment. J Neurol Sci 2021; 426:117483. [PMID: 33989851 DOI: 10.1016/j.jns.2021.117483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Patients with small core infarction and salvageable penumbra are likely to benefit from endovascular treatment (EVT). As computed tomography perfusion imaging (CTP) is not always available 24/7 for patient selection, many patients are transferred to stroke centers for CTP. We compared automatically measured infarct core volume (NCCTcore) from the non-contrast computed tomography (NCCT) with ischemic core volume (CTPcore) from CTP and the outcome of EVT to clarify if NCCTcore measurement alone is sufficient to identify patients that benefit from transfer to stroke centers for EVT. PATIENTS AND METHODS We included all consecutive stroke-code patients imaged with both NCCT and CTP at Helsinki University Hospital during 9/2016-01/2018. NCCTcore and CTPcore volumes were automatically calculated from the acute NCCT images. Follow-up infarct volume (FIV) was measured from 24 h follow-up NCCT to evaluate efficacy of EVT. To study whether NCCTcore could be used to identify patients eligible to EVT, we sub-grouped patients based on NCCTcore volumes (>50 mL and ≥ 70 mL). RESULTS Out of 1743 patients, baseline NCCTcore, CTPcore and follow-up NCCT was available for 288 patients. Median time from symptom onset to baseline imaging was 74 min (IQR 52-118), and time to follow-up imaging 24.15 h (22.25-26.33). Baseline NCCTcore was 20 mL (10-42), CTPcore 4 mL (0-16), and FIV 5 mL (1-49). Out of 288 patients, 23 had NCCTcore ≥ 70 mL and 26 had CTPcore ≥ 70 mL. NCCTcore and CTPcore performed similarly well in predicting large FIV (≥70 ml). CONCLUSION NCCTcore is a promising tool to identify patients that are not eligible to EVT due to large ischemic cores at baseline imaging.
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Affiliation(s)
- Olli P Suomalainen
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Finland.
| | - Ahmed Abou Elseoud
- Department of Neuroradiology, University of Helsinki and Helsinki University Hospital, Finland.
| | | | - Marjaana Tiainen
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Finland.
| | - Nina Forss
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Finland; Department of Neuroscience and Biomedical Engineering, Aalto University, Finland.
| | - Sami Curtze
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Finland.
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Are chest X-rays valuable for patients presenting to emergency departments with acute abdominal pain? Australas Emerg Care 2021; 25:84-87. [PMID: 33879427 DOI: 10.1016/j.auec.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/23/2021] [Accepted: 03/23/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Emergency department patients presenting with acute abdominal pain are often prescribed a chest X-ray; however, the value of chest X-rays in acute abdominal pain is poorly understood. The aim of this study was to assess the value of chest X-rays in acute abdominal pain. METHODS A retrospective analysis of 944 chest X-rays performed for acute abdominal pain was conducted. Patient clinical information, radiology reports, and findings of other diagnostic investigations were also collected. MedCal® software was used to calculate diagnostic performance of chest X-rays. A Chi-Square test was used to assess the association between positive chest X-ray findings and both age and gender. RESULTS Of the 944 chest X-rays identified as satisfying inclusion factors, only 10 cases (approximately 1%) demonstrated pathology that was likely to be the cause of the abdominal pain. Further analysis demonstrated the following performance metrics at 95%CI: sensitivity (12.8; 8.78-17.72); specificity (100; 98.4-100); positive predictive value (100%); negative predictive value (52.76; 51.54-53.98); accuracy (55.82; 51.17-60.40). CONCLUSION Chest X-ray has limited sensitivity and diagnostic value in patients presenting to the emergency department with abdominal pain and does not appear to be a useful diagnostic investigation for abdominal pain.
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31
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Derraz I, Ahmed R, Benali A, Corti L, Cagnazzo F, Dargazanli C, Gascou G, Riquelme C, Lefevre PH, Bonafe A, Arquizan C, Costalat V. FLAIR vascular hyperintensities and functional outcome in nonagenarians with anterior circulation large-vessel ischemic stroke treated with endovascular thrombectomy. Eur Radiol 2021; 31:7406-7416. [PMID: 33851277 DOI: 10.1007/s00330-021-07866-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 03/04/2021] [Accepted: 03/11/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To establish whether imaging assessments of irreversibly injured ischemic core and potentially salvageable penumbral volumes and collateral circulation were associated with functional outcome in nonagenarians (90 years or older) undergoing endovascular thrombectomy (EVT). METHODS Data from a prospectively maintained institutional registry of consecutive stroke patients treated with EVT from January 2012 to December 2018 were retrospectively analyzed. Functional outcome was evaluated with the modified Rankin scale (mRS) at 3 months. mRS score of 0-3 was defined as a good clinical outcome. Ischemic core and penumbral volumes were calculated using the RAPID software. Quantification of collateral circulation was performed using a fluid-attenuated inversion recovery vascular hyperintensity (FVH)-Alberta Stroke Program Early CT Score (ASPECTS) rating system. RESULTS Among 85 patients (age, 92.4 ± 2.6 years; men, 30.6%) treated with EVT, good outcome (mRS 0-3) was achieved in 29 (34.1%) patients and 31 (36.5%) patients died at 90 days. The median estimated ischemic core volume was 15 mL (IQR, 7-27 mL). The median mismatch volume was 83 mL (IQR, 43-120 mL). The median FVH score was 4 (IQR, 3-4). FVH score was independently associated with good functional outcome (adjusted OR = 1.96 [95% CI, 1.16-3.32]; p = 0.01 per 1-point increase) and mortality (adjusted OR = 0.54 [95% CI, 0.34-0.85]; p = 0.007 per 1-point increase). Ischemic core and mismatch volumes were associated with neither good outcome nor mortality. CONCLUSIONS In nonagenarians with anterior circulation large-vessel ischemic stroke, good collaterals as measured by the FVH-ASPECTS rating system are independently associated with improved outcomes and may help select patients for reperfusion therapy in this frail population. KEY POINTS • Endovascular thrombectomy can allow at least 1 in 3 patients older than 90 years of age to achieve good functional outcome (modified Rankin scale of 0-3) at 3 months. • Functional outcome at 3 months is associated with pre-stroke status (number and severity of patients' comorbidities). • A higher FVH score (as reflected by higher FLAIR vascular hyperintensity [FVH]-Alberta Stroke Program Early CT Score [ASPECTS] values) is independently associated with better 3-month functional outcome and mortality in nonagenarians with anterior circulation ischemic stroke.
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Affiliation(s)
- Imad Derraz
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France.
| | - Raed Ahmed
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Amel Benali
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Lucas Corti
- Department of Neurology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Federico Cagnazzo
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Cyril Dargazanli
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Gregory Gascou
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Carlos Riquelme
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Pierre-Henri Lefevre
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Alain Bonafe
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Caroline Arquizan
- Department of Neurology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Vincent Costalat
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
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García-Tornel Á, Campos D, Rubiera M, Boned S, Olivé-Gadea M, Requena M, Ciolli L, Muchada M, Pagola J, Rodriguez-Luna D, Deck M, Juega J, Rodríguez-Villatoro N, Sanjuan E, Tomasello A, Piñana C, Hernández D, Álvarez-Sabin J, Molina CA, Ribó M. Ischemic Core Overestimation on Computed Tomography Perfusion. Stroke 2021; 52:1751-1760. [PMID: 33682453 DOI: 10.1161/strokeaha.120.031800] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Álvaro García-Tornel
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Daniel Campos
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Marta Rubiera
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Sandra Boned
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Marta Olivé-Gadea
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Manuel Requena
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Ludovico Ciolli
- Stroke Unit, Neurology Unit, Department of Neuroscience, Ospedale Civile, Azienda Ospedaliera Universitaria di Modena, Italy (L.C.)
| | - Marian Muchada
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Jorge Pagola
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - David Rodriguez-Luna
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Matias Deck
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Jesus Juega
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Noelia Rodríguez-Villatoro
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Estela Sanjuan
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Alejandro Tomasello
- Department of Interventional Neurorradiology (A.T., C.P., D.H.), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Carlos Piñana
- Department of Interventional Neurorradiology (A.T., C.P., D.H.), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - David Hernández
- Department of Interventional Neurorradiology (A.T., C.P., D.H.), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - José Álvarez-Sabin
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Carlos A Molina
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Marc Ribó
- Stroke Unit, Department of Neurology (A.G.-T., D.C., M. Rubiera, S.B., M.O.-G., M. Requena, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., E.S., J.A.-S., C.A.M., M.Ribó), Hospital Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain
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Di Iorio R, Pilato F, Valente I, Laurienzo A, Gaudino S, Frisullo G, Profice P, Cottonaro S, Alexandre A, Caliandro P, Morosetti R, Lozupone E, D'Argento F, Pedicelli A, Colosimo C, Calabresi P, Della Marca G, Broccolini A. Role of Favorable Perfusion Imaging in Predicting the Outcome of Patients with Acute Ischemic Stroke due to Large Vessel Occlusion Undergoing Effective Thrombectomy: A Single-Center Study. Cerebrovasc Dis Extra 2021; 11:1-8. [PMID: 33454704 PMCID: PMC7879261 DOI: 10.1159/000513025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 11/11/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction We sought to verify the predicting role of a favorable profile on computed tomography perfusion (CTP) in the outcome of patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) undergoing effective mechanical thrombectomy (MT). Methods We retrospectively enrolled 25 patients with AIS due to LVO and with a CTP study showing the presence of ischemic penumbra who underwent effective MT, regardless of the time of onset. The controls were 25 AIS patients with overlapping demographics and clinical and computed tomography angiography features at admission who had undergone successful MT within 6 h from onset and without a previous CTP study. The outcome measure was the modified Rankin Scale (mRS) score at 90 days. Results Sixty-four percent of the study patients had an mRS score of 0–1 at 90 days versus 12% of the control patients (p < 0.001). Patients of the study group had a more favorable distribution of disability scores (median mRS [IQR] score of 0 [0–2] vs. 2 [2–3]). Multivariate analysis showed that the selection of patients based on a favorable CTP study was strongly associated (p < 0.001) with a better neurological outcome. Conclusions In our small-sized and retrospective study, the presence of ischemic penumbra was associated with a better clinical outcome in patients with AIS due to LVO after MT. In the future, a larger and controlled study with similar criteria of enrollment is needed to further validate the role of CTP in patient selection for MT, regardless of the time from the onset of symptoms.
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Affiliation(s)
- Riccardo Di Iorio
- Area Neuroscienze, UOC Neurologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Fabio Pilato
- Area Neuroscienze, UOC Neurologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Iacopo Valente
- Area Diagnostica per Immagini, UOC Radiologia e Neuroradiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Andrea Laurienzo
- Area Neuroscienze, UOC Neurologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Simona Gaudino
- Area Diagnostica per Immagini, UOC Radiologia e Neuroradiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Frisullo
- Area Neuroscienze, UOC Neurologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Paolo Profice
- Area Neuroscienze, UOC Neurologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Neurology Unit, Mater Olbia Hospital, Olbia, Italy
| | - Simone Cottonaro
- Area Diagnostica per Immagini, UOC Radiologia e Neuroradiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Andrea Alexandre
- Area Diagnostica per Immagini, UOC Radiologia e Neuroradiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Pietro Caliandro
- Area Neuroscienze, UOC Neurologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Roberta Morosetti
- Area Neuroscienze, UOC Neurologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Emilio Lozupone
- Area Diagnostica per Immagini, UOC Radiologia e Neuroradiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco D'Argento
- Area Diagnostica per Immagini, UOC Radiologia e Neuroradiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessandro Pedicelli
- Area Diagnostica per Immagini, UOC Radiologia e Neuroradiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Cesare Colosimo
- Area Diagnostica per Immagini, UOC Radiologia e Neuroradiologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Catholic University School of Medicine, Rome, Italy
| | - Paolo Calabresi
- Area Neuroscienze, UOC Neurologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Catholic University School of Medicine, Rome, Italy
| | - Giacomo Della Marca
- Area Neuroscienze, UOC Neurologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Catholic University School of Medicine, Rome, Italy
| | - Aldobrando Broccolini
- Area Neuroscienze, UOC Neurologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy, .,Catholic University School of Medicine, Rome, Italy,
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Role of neuroimaging before reperfusion therapy. Part 1 - IV thrombolysis - Review. Rev Neurol (Paris) 2021; 177:908-918. [PMID: 33455833 DOI: 10.1016/j.neurol.2020.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/25/2020] [Accepted: 10/05/2020] [Indexed: 11/22/2022]
Abstract
This review paper summarises the yield of the different imaging modalities in the evaluation of patients for IV thrombolysis. Non-contrast CT and CTA or brain MRI combined with MRA are the recommended sequences for the evaluation of patients within the 4.5 hours time window. Multimodal MRI (DWI/PWI), and more recently, CT perfusion, offer reliable surrogate of salvageable penumbra, the target mismatch, which is now currently used as selection criteria for revascularisation treatment in an extended time window. Those sequences may also help the physician for the management of other limited cases when the diagnosis of acute ischemic stroke is difficult. Another approach the DWI/FLAIR mismatch has been proposed to identify among wake-up stroke patients those who have been experiencing an acute ischemic stroke evolving from less than 4.5hrs. Other biomarkers, such as the clot imaging on MRI and CT, help to predict the recanalisation rate after IVT, while the impact of the presence microbleeds on MRI remains to be determined.
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Lin L, Yang J, Chen C, Tian H, Bivard A, Spratt NJ, Levi CR, Parsons MW. Association of Collateral Status and Ischemic Core Growth in Patients With Acute Ischemic Stroke. Neurology 2020; 96:e161-e170. [PMID: 33262233 DOI: 10.1212/wnl.0000000000011258] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 08/12/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To test the hypothesis that patients with acute ischemic stroke with poorer collaterals would have faster ischemic core growth, we included 2 cohorts in the study: cohort 1 of 342 patients for derivation and cohort 2 of 414 patients for validation. METHODS Patients with acute ischemic stroke with large vessel occlusion were included. Core growth rate was calculated by the following equation: core growth rate = acute core volume on CT perfusion (CTP)/time from stroke onset to CTP. Collateral status was assessed by the ratio of severe hypoperfusion volume within the hypoperfusion region of CTP. The CTP collateral index was categorized in tertiles; for each tertile, core growth rate was summarized as median and interquartile range. Simple linear regressions were then performed to measure the predictive power of CTP collateral index in core growth rate. RESULTS For patients allocated to good collateral on CTP (tertile 1 of collateral index), moderate collateral (tertile 2), and poor collateral (tertile 3), the median core growth rate was 2.93 mL/h (1.10-7.94), 8.65 mL/h (4.53-18.13), and 25.41 mL/h (12.83-45.07), respectively. Increments in the collateral index by 1% resulted in an increase of core growth by 0.57 mL/h (coefficient 0.57, 95% confidence interval [0.46, 0.68], p < 0.001). The relationship of core growth and CTP collateral index was validated in cohort 2. An increment in collateral index by 1% resulted in an increase of core growth by 0.59 mL/h (coefficient 0.59 [0.48-0.71], p < 0.001) in cohort 2. CONCLUSION Collateral status is a major determinant of ischemic core growth.
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Affiliation(s)
- Longting Lin
- From the Department of Neurology (L.L., J.Y.), Ningbo First Hospital, China; School of Medicine and Public Health (L.L., C.C., H.T., N.J.S., C.R.L., M.W.P.), University of Newcastle; Melbourne Brain Centre at Royal Melbourne Hospital (A.B., M.W.P.), University of Melbourne; and The Sydney Partnership for Health, Education, Research and Enterprise (C.R.L.), Australia
| | - Jianhong Yang
- From the Department of Neurology (L.L., J.Y.), Ningbo First Hospital, China; School of Medicine and Public Health (L.L., C.C., H.T., N.J.S., C.R.L., M.W.P.), University of Newcastle; Melbourne Brain Centre at Royal Melbourne Hospital (A.B., M.W.P.), University of Melbourne; and The Sydney Partnership for Health, Education, Research and Enterprise (C.R.L.), Australia
| | - Chushuang Chen
- From the Department of Neurology (L.L., J.Y.), Ningbo First Hospital, China; School of Medicine and Public Health (L.L., C.C., H.T., N.J.S., C.R.L., M.W.P.), University of Newcastle; Melbourne Brain Centre at Royal Melbourne Hospital (A.B., M.W.P.), University of Melbourne; and The Sydney Partnership for Health, Education, Research and Enterprise (C.R.L.), Australia
| | - Huiqiao Tian
- From the Department of Neurology (L.L., J.Y.), Ningbo First Hospital, China; School of Medicine and Public Health (L.L., C.C., H.T., N.J.S., C.R.L., M.W.P.), University of Newcastle; Melbourne Brain Centre at Royal Melbourne Hospital (A.B., M.W.P.), University of Melbourne; and The Sydney Partnership for Health, Education, Research and Enterprise (C.R.L.), Australia
| | - Andrew Bivard
- From the Department of Neurology (L.L., J.Y.), Ningbo First Hospital, China; School of Medicine and Public Health (L.L., C.C., H.T., N.J.S., C.R.L., M.W.P.), University of Newcastle; Melbourne Brain Centre at Royal Melbourne Hospital (A.B., M.W.P.), University of Melbourne; and The Sydney Partnership for Health, Education, Research and Enterprise (C.R.L.), Australia
| | - Neil J Spratt
- From the Department of Neurology (L.L., J.Y.), Ningbo First Hospital, China; School of Medicine and Public Health (L.L., C.C., H.T., N.J.S., C.R.L., M.W.P.), University of Newcastle; Melbourne Brain Centre at Royal Melbourne Hospital (A.B., M.W.P.), University of Melbourne; and The Sydney Partnership for Health, Education, Research and Enterprise (C.R.L.), Australia
| | - Christopher R Levi
- From the Department of Neurology (L.L., J.Y.), Ningbo First Hospital, China; School of Medicine and Public Health (L.L., C.C., H.T., N.J.S., C.R.L., M.W.P.), University of Newcastle; Melbourne Brain Centre at Royal Melbourne Hospital (A.B., M.W.P.), University of Melbourne; and The Sydney Partnership for Health, Education, Research and Enterprise (C.R.L.), Australia
| | - Mark W Parsons
- From the Department of Neurology (L.L., J.Y.), Ningbo First Hospital, China; School of Medicine and Public Health (L.L., C.C., H.T., N.J.S., C.R.L., M.W.P.), University of Newcastle; Melbourne Brain Centre at Royal Melbourne Hospital (A.B., M.W.P.), University of Melbourne; and The Sydney Partnership for Health, Education, Research and Enterprise (C.R.L.), Australia.
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Jillella DV, Calder CS, Uchino K, Qeadan F, Ikram A, Casul YR, Tran HQ. Blood Pressure and Hospital Discharge Outcomes in Acute Ischemic Stroke Patients Undergoing Reperfusion Therapy. J Stroke Cerebrovasc Dis 2020; 29:105211. [PMID: 33066897 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 07/20/2020] [Accepted: 07/26/2020] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Acute management of blood pressure in ischemic stroke treated with reperfusion therapy remains uncertain. We evaluated blood pressures during the first 24-hours after reperfusion therapy in relation to in-hospital outcomes. METHODS We conducted a single-center retrospective study of blood pressure in the first 24 hours among ischemic stroke patients who underwent reperfusion therapy with intravenous thrombolysis (IVT) or mechanical thrombectomy (MT) at a tertiary referral center. Blood pressure variability was expressed as the range between the highest and the lowest pressures. Outcomes of interest were discharge disposition and in-hospital mortality. Favorable outcome was defined as a discharge destination to home or inpatient rehabilitation facility (IRF). Multivariable logistic regression analysis was performed with adjustment for age, National Institutes of Health Stroke Scale score, and patients receiving reperfusion therapy. RESULTS Among the 140 ischemic stroke patients (117 IVT, 84 MT and 61 both), 95 (67.8%) had favorable discharge disposition and 24 (17.1%) died. Higher 24-hour peak systolic blood pressures (SBPs) and peak mean arterial pressures (MAPs) were independently associated with a lower likelihood of favorable discharge disposition, with an adjusted odds ratio (aOR) 0.868, 95 % CI 0.760 - 0.990 per 10 mm Hg for SBP and aOR 0.710, 95% CI 0.515 - 0.980 for MAP, and with increased odds of death aOR 1.244, 95% CI 1.056-1.467 and aOR 1.760, 95% CI 1.119 - 2.769 respectively. Greater variability of SBP and MAP was also associated with odds of death aOR 1.327, 95% CI 1.104 - 1.595 and aOR 1.577, 95% CI 1.060- 2.345 respectively, without a significant effect on discharge disposition. CONCLUSION In the first 24 hours after reperfusion therapy, higher peak and variable blood pressures are associated with unfavorable discharge outcomes and increased in-hospital mortality. Further studies in stroke patients undergoing reperfusion therapy might target blood pressure reduction and variability to improve patient outcomes.
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Affiliation(s)
- Dinesh V Jillella
- Department of Neurology, Emory University School of Medicine and Grady Memorial Hospital, 49 Jesse Hill Jr. Dr. SE, Atlanta, GA 30303, USA.
| | - Christopher S Calder
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Fares Qeadan
- Division of Public Health, Department of Family and Preventive Medicine, Health University of Utah, Salt Lake City, UT, USA
| | - Asad Ikram
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Yoram Roman Casul
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Huy Q Tran
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, NM, USA; Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
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37
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Bhat SS, Fernandes TT, Poojar P, Silva Ferreira M, Rao PC, Hanumantharaju MC, Ogbole G, Nunes RG, Geethanath S. Low‐Field MRI of Stroke: Challenges and Opportunities. J Magn Reson Imaging 2020; 54:372-390. [DOI: 10.1002/jmri.27324] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 07/24/2020] [Accepted: 07/27/2020] [Indexed: 12/12/2022] Open
Affiliation(s)
- Seema S. Bhat
- Medical Imaging Research Centre Dayananda Sagar College of Engineering Bangalore India
| | - Tiago T. Fernandes
- Institute for Systems and Robotics and Department of Bioengineering, Instituto Superior Técnico Universidade de Lisboa Lisbon Portugal
| | - Pavan Poojar
- Medical Imaging Research Centre Dayananda Sagar College of Engineering Bangalore India
- Columbia University Magnetic Resonance Research Center New York New York USA
| | - Marta Silva Ferreira
- Institute for Systems and Robotics and Department of Bioengineering, Instituto Superior Técnico Universidade de Lisboa Lisbon Portugal
| | - Padma Chennagiri Rao
- Medical Imaging Research Centre Dayananda Sagar College of Engineering Bangalore India
| | | | - Godwin Ogbole
- Department of Radiology, College of Medicine University of Ibadan Ibadan Nigeria
| | - Rita G. Nunes
- Institute for Systems and Robotics and Department of Bioengineering, Instituto Superior Técnico Universidade de Lisboa Lisbon Portugal
| | - Sairam Geethanath
- Medical Imaging Research Centre Dayananda Sagar College of Engineering Bangalore India
- Columbia University Magnetic Resonance Research Center New York New York USA
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38
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Affiliation(s)
- Bruce C.V. Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
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39
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Baron JC, Markus HS, Pickard JD, Davis SM, Donnan GA. Lindsay Symon: A giant of stroke. Int J Stroke 2020; 15:356-360. [DOI: 10.1177/1747493020913088] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jean-Claude Baron
- Department of Neurology, Hôpital Sainte-Anne, Université de Paris, France
- Institut de Psychiatrie et Neurosciences de Paris, Inserm U1266, Paris, France
| | - Hugh S Markus
- Department of Clinical Neurosciences, Stroke Research Group, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - John D Pickard
- Department of Clinical Neurosciences, Neurosurgery Unit, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Stephen M Davis
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Geoffrey A Donnan
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
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40
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Seners P, Turc G, Lion S, Cottier JP, Cho TH, Arquizan C, Bracard S, Ozsancak C, Legrand L, Naggara O, Debiais S, Berthezene Y, Costalat V, Richard S, Magni C, Nighoghossian N, Narata AP, Dargazanli C, Gory B, Mas JL, Oppenheim C, Baron JC. Relationships between brain perfusion and early recanalization after intravenous thrombolysis for acute stroke with large vessel occlusion. J Cereb Blood Flow Metab 2020; 40:667-677. [PMID: 30890074 PMCID: PMC7026851 DOI: 10.1177/0271678x19836288] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
In large vessel occlusion (LVO) stroke, it is unclear whether severity of ischemia is involved in early post-thrombolysis recanalization over and above thrombus site and length. Here we assessed the relationships between perfusion parameters and early recanalization following intravenous thrombolysis administration in LVO patients. From a multicenter registry, we identified 218 thrombolysed LVO patients referred for thrombectomy with both (i) pre-thrombolysis MRI, including diffusion-weighted imaging (DWI), T2*-imaging, MR-angiography and dynamic susceptibility-contrast perfusion-weighted imaging (PWI); and (ii) evaluation of recanalization on first angiographic run or non-invasive imaging ≤ 3 h from thrombolysis start. Infarct core volume on DWI, PWI-DWI mismatch volume and hypoperfusion intensity ratio (HIR; defined as Tmax ≥ 10 s volume/ Tmax ≥ 6 s volume, low HIR indicating milder hypoperfusion) were determined using a commercially available software. Early recanalization occurred in 34 (16%) patients, and multivariable analysis was associated with lower HIR (P = 0.006), shorter thrombus on T2*-imaging (P < 0.001) and more distal occlusion (P = 0.006). However, the relationship between HIR and early recanalization was robust only for thrombus length <14 mm. In summary, the present study disclosed an association between lower HIR and early post-thrombolysis recanalization. Early post-thrombolysis recanalization is therefore determined not only by thrombus site and length but also by severity of ischemia.
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Affiliation(s)
- Pierre Seners
- Neurology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
| | - Guillaume Turc
- Neurology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
| | - Stéphanie Lion
- Radiology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
| | - Jean-Philippe Cottier
- Department of Neuroradiology, Bretonneau Hospital, University of Tours, Tours, France
| | - Tae-Hee Cho
- Department of Stroke Medicine, Hospices Civils de Lyon, Université Lyon 1, CREATIS, CNRS UMR 5220-INSERM U1044, INSALyon, Lyon, France
| | | | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, INSERM U 947, Nancy, France
| | | | - Laurence Legrand
- Radiology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
| | - Olivier Naggara
- Radiology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
| | - Séverine Debiais
- Department of Neurology, Bretonneau Hospital, University of Tours, Tours, France
| | - Yves Berthezene
- Neuroradiology Department, Hospices Civils de Lyon, Lyon, France
| | - Vincent Costalat
- Department of Interventional Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | | | | | - Norbert Nighoghossian
- Department of Stroke Medicine, Hospices Civils de Lyon, Université Lyon 1, CREATIS, CNRS UMR 5220-INSERM U1044, INSALyon, Lyon, France
| | - Ana-Paula Narata
- Department of Neuroradiology, Bretonneau Hospital, University of Tours, Tours, France
| | - Cyril Dargazanli
- Department of Interventional Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, INSERM U 947, Nancy, France
| | - Jean-Louis Mas
- Neurology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
| | - Catherine Oppenheim
- Radiology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
| | - Jean-Claude Baron
- Neurology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
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41
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Bhan C, Koehler TJ, Elisevich L, Singer J, Mazaris P, James E, Zachariah J, Combs J, Dejesus M, Tubergen T, Packard L, Min J, Wees N, Khan N, Mulderink T, Khan M. Mechanical Thrombectomy for Acute Stroke: Early versus Late Time Window Outcomes. J Neuroimaging 2020; 30:315-320. [DOI: 10.1111/jon.12698] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 01/31/2020] [Accepted: 02/03/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Chantal Bhan
- Division of Neurology, Neuroscience InstituteSpectrum Health Grand Rapids MI
- Michgan State University East Lansing MI
| | | | | | - Justin Singer
- Michgan State University East Lansing MI
- Division of Neurosurgery, Neuroscience InstituteSpectrum Health Grand Rapids MI
| | - Paul Mazaris
- Michgan State University East Lansing MI
- University of Michigan Ann Arbor MI
| | - Elysia James
- Division of Neurology, Neuroscience InstituteSpectrum Health Grand Rapids MI
- Michgan State University East Lansing MI
| | - Joseph Zachariah
- Division of Neurology, Neuroscience InstituteSpectrum Health Grand Rapids MI
- Michgan State University East Lansing MI
| | - Jordan Combs
- Division of Neurology, Neuroscience InstituteSpectrum Health Grand Rapids MI
- Michgan State University East Lansing MI
| | - Michelle Dejesus
- Division of Neurology, Neuroscience InstituteSpectrum Health Grand Rapids MI
- Michgan State University East Lansing MI
| | | | - Laurel Packard
- Division of Neurology, Neuroscience InstituteSpectrum Health Grand Rapids MI
| | - Jiangyong Min
- Division of Neurology, Neuroscience InstituteSpectrum Health Grand Rapids MI
- Michgan State University East Lansing MI
| | - Nabil Wees
- Division of Neurology, Neuroscience InstituteSpectrum Health Grand Rapids MI
- Michgan State University East Lansing MI
| | - Nadeem Khan
- Division of Neurology, Neuroscience InstituteSpectrum Health Grand Rapids MI
- Michgan State University East Lansing MI
| | - Todd Mulderink
- Department of RadiologySpectrum Health Grand Rapids MI
- Division of RadiologyMichigan State University Grand Rapids MI
- Advanced Radiology ServicesPC Grand Rapids MI
| | - Muhib Khan
- Division of Neurology, Neuroscience InstituteSpectrum Health Grand Rapids MI
- Michgan State University East Lansing MI
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Han Q, Huang Y. Quantitative analysis of revascularization in ischemic moyamoya disease via whole-brain computed tomography perfusion: A retrospective single-center study. Medicine (Baltimore) 2020; 99:e19168. [PMID: 32049846 PMCID: PMC7035121 DOI: 10.1097/md.0000000000019168] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Ischemic moyamoya disease (MMD) can be treated with the revascularization of superficial temporal artery to middle cerebral artery (STA-MCA) bypass combined with encephalo-duro-arterio-myo-synangiosis (EDAMS) effectively. The purpose of the present study was to quantify the revascularization of STA-MCA bypass combined with EDAMS via whole-brain computed tomography perfusion (WB-CTP).Seventy-nine consecutive patients with ischemic MMD who admitted to our hospital from August 2012 to October 2018 were carried out STA-MCA bypass combined with EDAMS. WB-CTP was performed at 24 hours prior to operation and 3 months following bypass with a follow-up WB-CTP, respectively. Both automatic analysis of WB-CTP (MIStar, Apollo Medical imaging Technology, Melbourne, Australia) for analyzing values of brain volume in delayed time (DT) >3 seconds and DT > 6 seconds, relative cerebral blood flow (γCBF) < 30% and its mismatch ratio or percentage and diffusion-weighted imaging of magnetic resonance imaging in the ischemic penumbra and the infarct core at the 2 time points were studied for verifying the effectiveness of the combined revascularization. Changes in DT values at MCA-terminal territory after revascularization had been investigated. The dynamic data were with reference to the individual cerebellar arteries.All patients with ischemic MMD underwent STA-MCA bypass combined with EDAMS successfully. The preoperative brain volume in DT > 3 seconds in MCA-terminal territory was significantly larger than that of postoperative one (P < .05) in the ischemic penumbra in ischemic MMD. The mismatch ratio in brain volume of 24 hours prior to revascularization in MCA-terminal territory was significantly lower than that of 3 months (P < .05) following combined revascularization. The percentage of mismatch in brain volume of 24 hours prior to revascularization vs that of 3 months and the value of γCBF < 30% were similar to the above mismatch ratio (P < .05). The ratio of postoperative brain volume in DT > 3 seconds vs DT > 6 seconds indicated no significant differences compared with that of preoperative one (P > .05).The WB-CTP can be regarded as a choice for quantifying the combined revascularization in the ischemic penumbra and the infarct core in ischemic MMD. As proposed methods, brain volume in DT > 3 seconds, the value of γCBF < 30% and mismatch ratio in brain volume in MCA-terminal territory should be paid more attention in assessing the validity of STA-MCA bypass combined with EDAMS in ischemic MMD.
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43
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Wang K, Shou Q, Ma SJ, Liebeskind D, Qiao XJ, Saver J, Salamon N, Kim H, Yu Y, Xie Y, Zaharchuk G, Scalzo F, Wang DJJ. Deep Learning Detection of Penumbral Tissue on Arterial Spin Labeling in Stroke. Stroke 2019; 51:489-497. [PMID: 31884904 DOI: 10.1161/strokeaha.119.027457] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background and Purpose- Selection of patients with acute ischemic stroke for endovascular treatment generally relies on dynamic susceptibility contrast magnetic resonance imaging or computed tomography perfusion. Dynamic susceptibility contrast magnetic resonance imaging requires injection of contrast, whereas computed tomography perfusion requires high doses of ionizing radiation. The purpose of this work was to develop and evaluate a deep learning (DL)-based algorithm for assisting the selection of suitable patients with acute ischemic stroke for endovascular treatment based on 3-dimensional pseudo-continuous arterial spin labeling (pCASL). Methods- A total of 167 image sets of 3-dimensional pCASL data from 137 patients with acute ischemic stroke scanned on 1.5T and 3.0T Siemens MR systems were included for neural network training. The concurrently acquired dynamic susceptibility contrast magnetic resonance imaging was used to produce labels of hypoperfused brain regions, analyzed using commercial software. The DL and 6 machine learning (ML) algorithms were trained with 10-fold cross-validation. The eligibility for endovascular treatment was determined retrospectively based on the criteria of perfusion/diffusion mismatch in the DEFUSE 3 trial (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke). The trained DL algorithm was further applied on twelve 3-dimensional pCASL data sets acquired on 1.5T and 3T General Electric MR systems, without fine-tuning of parameters. Results- The DL algorithm can predict the dynamic susceptibility contrast-defined hypoperfusion region in pCASL with a voxel-wise area under the curve of 0.958, while the 6 ML algorithms ranged from 0.897 to 0.933. For retrospective determination for subject-level endovascular treatment eligibility, the DL algorithm achieved an accuracy of 92%, with a sensitivity of 0.89 and specificity of 0.95. When applied to the GE pCASL data, the DL algorithm achieved a voxel-wise area under the curve of 0.94 and a subject-level accuracy of 92% for endovascular treatment eligibility. Conclusions- pCASL perfusion magnetic resonance imaging in conjunction with the DL algorithm provides a promising approach for assisting decision-making for endovascular treatment in patients with acute ischemic stroke.
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Affiliation(s)
- Kai Wang
- From the Stevens Neuroimaging and Informatics Institute, Keck School of Medicine of USC, Los Angeles (K.W., Q.S., S.J.M., H.K., D.J.J.W.)
| | - Qinyang Shou
- From the Stevens Neuroimaging and Informatics Institute, Keck School of Medicine of USC, Los Angeles (K.W., Q.S., S.J.M., H.K., D.J.J.W.)
| | - Samantha J Ma
- From the Stevens Neuroimaging and Informatics Institute, Keck School of Medicine of USC, Los Angeles (K.W., Q.S., S.J.M., H.K., D.J.J.W.)
| | - David Liebeskind
- Department of Neurology (D.L., J.S., F.S.), University of California, Los Angeles
| | - Xin J Qiao
- Department of Radiology (X.J.Q., N.S.), University of California, Los Angeles
| | - Jeffrey Saver
- Department of Neurology (D.L., J.S., F.S.), University of California, Los Angeles
| | - Noriko Salamon
- Department of Radiology (X.J.Q., N.S.), University of California, Los Angeles
| | - Hosung Kim
- From the Stevens Neuroimaging and Informatics Institute, Keck School of Medicine of USC, Los Angeles (K.W., Q.S., S.J.M., H.K., D.J.J.W.)
| | - Yannan Yu
- Department of Radiology, Stanford University, Palo Alto, CA (Y.Y., Y.X., G.Z.)
| | - Yuan Xie
- Department of Radiology, Stanford University, Palo Alto, CA (Y.Y., Y.X., G.Z.)
| | - Greg Zaharchuk
- Department of Radiology, Stanford University, Palo Alto, CA (Y.Y., Y.X., G.Z.)
| | - Fabien Scalzo
- Department of Neurology (D.L., J.S., F.S.), University of California, Los Angeles
| | - Danny J J Wang
- From the Stevens Neuroimaging and Informatics Institute, Keck School of Medicine of USC, Los Angeles (K.W., Q.S., S.J.M., H.K., D.J.J.W.)
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44
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Tsivgoulis G, Katsanos AH, Schellinger PD, Köhrmann M, Caso V, Palaiodimou L, Magoufis G, Arthur A, Fischer U, Alexandrov AV. Advanced Neuroimaging in Stroke Patient Selection for Mechanical Thrombectomy. Stroke 2019; 49:3067-3070. [PMID: 30571421 DOI: 10.1161/strokeaha.118.022540] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- There is clinical equipoise about the use of advanced imaging for selecting acute ischemic stroke patients eligible for mechanical thrombectomy (MT) during the first 6 hours from symptom onset. However, accumulating evidence indicates that advanced neuroimaging represents an invaluable and time-independent prognostic factor. Methods- We performed a systematic review and meta-analysis of available randomized clinical trials to evaluate the impact of patient selection with advanced neuroimaging on the 3-month: (1) functional independence (modified Rankin Scale score, 0-2), (2) favorable functional outcome (modified Rankin Scale scores, 0-1), (3) all-cause mortality, and (4) functional improvement (assessed with ordinal analysis of the modified Rankin Scale-scores). We compared patients with perfusion imaging documented penumbra to patients who did not have documented penumbra or perfusion imaging. Results- Among the 10 eligible randomized clinical trials (2227 total patients, mean age: 67 years), 5 studies reported the use of advanced imaging. Studies using advanced neuroimaging showed higher treatment effects of MT on 3-month functional independence (odds ratio [OR], 3.79; 95% CI, 2.71-5.28 versus OR, 1.89; 95% CI, 1.52-2.35; P for subgroup differences <0.001), favorable functional outcome (OR, 3.16; 95% CI, 1.94-5.14 versus OR, 1.75; 95% CI, 1.30-2.34; P for subgroup differences=0.04), and functional improvement (common OR, 2.66; 95% CI, 1.95-3.63 versus common OR, 1.60; 95% CI, 1.32-1.95; P for subgroup differences=0.007) compared with studies using conventional neuroimaging. The pooled rate of successful reperfusion after MT was higher in studies with advanced neuroimaging ( P for subgroup differences=0.003). No difference in the mortality and symptomatic intracranial hemorrhage rates was found between the 2 groups. No evidence of heterogeneity was documented in all reported analyses. Conclusions- The present indirect comparisons indicate that acute ischemic stroke patient selection for MT using advanced neuroimaging appears to be associated with improved clinical outcomes. The use of advanced neuroimaging for both the selection and prediction of prognosis for MT candidates should not depend on the elapsed time from symptom onset.
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Affiliation(s)
- Georgios Tsivgoulis
- From the Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Greece (G.T., A.H.K., L.P.).,Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis.,Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute (A.A.), University of Tennessee Health Science Center, Memphis.,Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany (P.D.S.).,Department of Neurology, Universitätsklinikum Essen, Germany (M.K.).,Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (V.C.).,Stroke Unit, Metropolitan Hospital, Piraeus, Greece (G.M.).,Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Switzerland (U.F.)
| | - Aristeidis H Katsanos
- From the Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Greece (G.T., A.H.K., L.P.).,Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis.,Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute (A.A.), University of Tennessee Health Science Center, Memphis.,Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany (P.D.S.).,Department of Neurology, Universitätsklinikum Essen, Germany (M.K.).,Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (V.C.).,Stroke Unit, Metropolitan Hospital, Piraeus, Greece (G.M.).,Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Switzerland (U.F.)
| | - Peter D Schellinger
- From the Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Greece (G.T., A.H.K., L.P.).,Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis.,Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute (A.A.), University of Tennessee Health Science Center, Memphis.,Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany (P.D.S.).,Department of Neurology, Universitätsklinikum Essen, Germany (M.K.).,Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (V.C.).,Stroke Unit, Metropolitan Hospital, Piraeus, Greece (G.M.).,Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Switzerland (U.F.)
| | - Martin Köhrmann
- From the Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Greece (G.T., A.H.K., L.P.).,Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis.,Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute (A.A.), University of Tennessee Health Science Center, Memphis.,Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany (P.D.S.).,Department of Neurology, Universitätsklinikum Essen, Germany (M.K.).,Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (V.C.).,Stroke Unit, Metropolitan Hospital, Piraeus, Greece (G.M.).,Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Switzerland (U.F.)
| | - Valeria Caso
- From the Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Greece (G.T., A.H.K., L.P.).,Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis.,Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute (A.A.), University of Tennessee Health Science Center, Memphis.,Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany (P.D.S.).,Department of Neurology, Universitätsklinikum Essen, Germany (M.K.).,Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (V.C.).,Stroke Unit, Metropolitan Hospital, Piraeus, Greece (G.M.).,Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Switzerland (U.F.)
| | - Lina Palaiodimou
- From the Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Greece (G.T., A.H.K., L.P.).,Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis.,Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute (A.A.), University of Tennessee Health Science Center, Memphis.,Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany (P.D.S.).,Department of Neurology, Universitätsklinikum Essen, Germany (M.K.).,Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (V.C.).,Stroke Unit, Metropolitan Hospital, Piraeus, Greece (G.M.).,Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Switzerland (U.F.)
| | - Georgios Magoufis
- From the Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Greece (G.T., A.H.K., L.P.).,Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis.,Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute (A.A.), University of Tennessee Health Science Center, Memphis.,Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany (P.D.S.).,Department of Neurology, Universitätsklinikum Essen, Germany (M.K.).,Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (V.C.).,Stroke Unit, Metropolitan Hospital, Piraeus, Greece (G.M.).,Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Switzerland (U.F.)
| | - Adam Arthur
- From the Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Greece (G.T., A.H.K., L.P.).,Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis.,Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute (A.A.), University of Tennessee Health Science Center, Memphis.,Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany (P.D.S.).,Department of Neurology, Universitätsklinikum Essen, Germany (M.K.).,Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (V.C.).,Stroke Unit, Metropolitan Hospital, Piraeus, Greece (G.M.).,Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Switzerland (U.F.)
| | - Urs Fischer
- From the Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Greece (G.T., A.H.K., L.P.).,Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis.,Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute (A.A.), University of Tennessee Health Science Center, Memphis.,Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany (P.D.S.).,Department of Neurology, Universitätsklinikum Essen, Germany (M.K.).,Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (V.C.).,Stroke Unit, Metropolitan Hospital, Piraeus, Greece (G.M.).,Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Switzerland (U.F.)
| | - Andrei V Alexandrov
- From the Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Greece (G.T., A.H.K., L.P.).,Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis.,Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute (A.A.), University of Tennessee Health Science Center, Memphis.,Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany (P.D.S.).,Department of Neurology, Universitätsklinikum Essen, Germany (M.K.).,Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (V.C.).,Stroke Unit, Metropolitan Hospital, Piraeus, Greece (G.M.).,Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Switzerland (U.F.)
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45
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Meier R, Lux P, Med B, Jung S, Fischer U, Gralla J, Reyes M, Wiest R, McKinley R, Kaesmacher J. Neural Network-derived Perfusion Maps for the Assessment of Lesions in Patients with Acute Ischemic Stroke. Radiol Artif Intell 2019; 1:e190019. [PMID: 33937801 DOI: 10.1148/ryai.2019190019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 06/03/2019] [Accepted: 06/14/2019] [Indexed: 11/11/2022]
Abstract
Purpose To perform a proof-of-concept study to investigate the clinical utility of perfusion maps derived from convolutional neural networks (CNNs) for the workup of patients with acute ischemic stroke presenting with a large vessel occlusion. Materials and Methods Data on endovascularly treated patients with acute ischemic stroke (n = 151; median age, 68 years [interquartile range, 59-75 years]; 82 of 151 [54.3%] women) were retrospectively extracted from a single-center institutional prospective registry (between January 2011 and December 2015). Dynamic susceptibility perfusion imaging data were processed by applying a commercially available reference method and in parallel by a recently proposed CNN method to automatically infer time to maximum of the tissue residue function (Tmax) perfusion maps. The outputs were compared by using quantitative markers of tissue at risk derived from manual segmentations of perfusion lesions from two expert raters. Results Strong correlations of lesion volumes (Tmax > 4 seconds, > 6 seconds, and > 8 seconds; R = 0.865-0.914; P < .001) and good spatial overlap of respective lesion segmentations (Dice coefficients, 0.70-0.85) between the CNN method and reference output were observed. Eligibility for late-window reperfusion treatment was feasible with use of the CNN method, with complete interrater agreement for the CNN method (Cohen κ = 1; P < .001), although slight discrepancies compared with the reference-based output were observed (Cohen κ = 0.609-0.64; P < .001). The CNN method tended to underestimate smaller lesion volumes, leading to a disagreement between the CNN and reference method in five of 45 patients (9%). Conclusion Compared with standard deconvolution-based processing of raw perfusion data, automatic CNN-derived Tmax perfusion maps can be applied to patients who have acute ischemic large vessel occlusion stroke, with similar clinical utility.© RSNA, 2019Supplemental material is available for this article.
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Affiliation(s)
- Raphael Meier
- Support Center for Advanced Neuroimaging-University Institute of Diagnostic and Interventional Neuroradiology (R. Meier, P.L., J.G., R.W., R. McKinley, J.K.), Department of Neurology (S.J., U.F., J.K.), Institute for Surgical Technology and Biomechanics (M.R.), and Institute for Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Inselspital and University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Paula Lux
- Support Center for Advanced Neuroimaging-University Institute of Diagnostic and Interventional Neuroradiology (R. Meier, P.L., J.G., R.W., R. McKinley, J.K.), Department of Neurology (S.J., U.F., J.K.), Institute for Surgical Technology and Biomechanics (M.R.), and Institute for Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Inselspital and University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - B Med
- Support Center for Advanced Neuroimaging-University Institute of Diagnostic and Interventional Neuroradiology (R. Meier, P.L., J.G., R.W., R. McKinley, J.K.), Department of Neurology (S.J., U.F., J.K.), Institute for Surgical Technology and Biomechanics (M.R.), and Institute for Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Inselspital and University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Simon Jung
- Support Center for Advanced Neuroimaging-University Institute of Diagnostic and Interventional Neuroradiology (R. Meier, P.L., J.G., R.W., R. McKinley, J.K.), Department of Neurology (S.J., U.F., J.K.), Institute for Surgical Technology and Biomechanics (M.R.), and Institute for Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Inselspital and University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Urs Fischer
- Support Center for Advanced Neuroimaging-University Institute of Diagnostic and Interventional Neuroradiology (R. Meier, P.L., J.G., R.W., R. McKinley, J.K.), Department of Neurology (S.J., U.F., J.K.), Institute for Surgical Technology and Biomechanics (M.R.), and Institute for Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Inselspital and University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Jan Gralla
- Support Center for Advanced Neuroimaging-University Institute of Diagnostic and Interventional Neuroradiology (R. Meier, P.L., J.G., R.W., R. McKinley, J.K.), Department of Neurology (S.J., U.F., J.K.), Institute for Surgical Technology and Biomechanics (M.R.), and Institute for Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Inselspital and University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Mauricio Reyes
- Support Center for Advanced Neuroimaging-University Institute of Diagnostic and Interventional Neuroradiology (R. Meier, P.L., J.G., R.W., R. McKinley, J.K.), Department of Neurology (S.J., U.F., J.K.), Institute for Surgical Technology and Biomechanics (M.R.), and Institute for Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Inselspital and University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Roland Wiest
- Support Center for Advanced Neuroimaging-University Institute of Diagnostic and Interventional Neuroradiology (R. Meier, P.L., J.G., R.W., R. McKinley, J.K.), Department of Neurology (S.J., U.F., J.K.), Institute for Surgical Technology and Biomechanics (M.R.), and Institute for Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Inselspital and University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Richard McKinley
- Support Center for Advanced Neuroimaging-University Institute of Diagnostic and Interventional Neuroradiology (R. Meier, P.L., J.G., R.W., R. McKinley, J.K.), Department of Neurology (S.J., U.F., J.K.), Institute for Surgical Technology and Biomechanics (M.R.), and Institute for Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Inselspital and University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Johannes Kaesmacher
- Support Center for Advanced Neuroimaging-University Institute of Diagnostic and Interventional Neuroradiology (R. Meier, P.L., J.G., R.W., R. McKinley, J.K.), Department of Neurology (S.J., U.F., J.K.), Institute for Surgical Technology and Biomechanics (M.R.), and Institute for Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Inselspital and University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland
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46
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Dual-phase 16 slice CT angiography in stroke imaging: a poor man's multiphase study? Acta Neurol Belg 2019; 119:187-192. [PMID: 30196370 DOI: 10.1007/s13760-018-1019-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 08/30/2018] [Indexed: 01/19/2023]
Abstract
Multiphase CT angiography (CTA) in collateral assessment provides time-resolved cerebral angiograms of the intracranial vasculature, requiring a high-speed multidetector CT (MDCT) scanner with ≥ 64 slices. Unfortunately, many hospitals are equipped with lower speed MDCT scanners. Herein, we present our experience performing dual-phase CTA (d-CTA) on a 16 slice MDCT with a biphasic rate injection to grade intracranial collaterals as predictor of clinical outcome. 42 patients were evaluated with both dual-phase CTA (d-CTA) and single-phase CTA (s-CTA) for occluded anterior intracranial circulation and collaterals. They were treated with endovascular reperfusion. Univariate and multivariate analyses were performed to define the independent predictors for favorable outcome at 3 months. Good collateral circulation status on d-CTA was associated with a lower median 24-h (5 vs. 7.5, p = 0.03) and discharge (2 vs. 4.6, p = 0.04) NIHSS. A logistic regression model showed that only age (OR 0.95, 95% CI 0.91-0.98, p = 0.03) and good collateral circulation status at d-CTA (OR 4.3, 95% CI 1.87-11.3, p < 0.01) were independent predictors of favorable functional outcome at 3 months, but that s-CTA was not. The collateral status on d-CTA can be a useful predictor for clinical outcome in acute stroke patients. The proposed protocol adapted to a low-speed MDCT scanner could be of particular interest in hospitals without access to the more up-to-date technology.
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47
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Seners P, Roca P, Legrand L, Turc G, Cottier JP, Cho TH, Arquizan C, Bracard S, Ozsancak C, Ben Hassen W, Naggara O, Lion S, Debiais S, Berthezene Y, Costalat V, Richard S, Magni C, Mas JL, Baron JC, Oppenheim C. Better Collaterals Are Independently Associated With Post-Thrombolysis Recanalization Before Thrombectomy. Stroke 2019; 50:867-872. [DOI: 10.1161/strokeaha.118.022815] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
In acute stroke patients with large vessel occlusion, the goal of intravenous thrombolysis (IVT) is to achieve early recanalization (ER). Apart from occlusion site and thrombus length, predictors of early post-IVT recanalization are poorly known. Better collaterals might also facilitate ER, for instance, by improving delivery of the thrombolytic agent to both ends of the thrombus. In this proof-of-concept study, we tested the hypothesis that good collaterals independently predict post-IVT recanalization before thrombectomy.
Methods—
Patients from the registries of 6 French stroke centers with the following criteria were included: (1) acute stroke with large vessel occlusion treated with IVT and referred for thrombectomy between May 2015 and March 2017; (2) pre-IVT brain magnetic resonance imaging, including diffusion-weighted imaging, T2*, MR angiography, and dynamic susceptibility contrast perfusion-weighted imaging; and (3) ER evaluated ≤3 hours from IVT start on either first angiographic run or noninvasive imaging. A collateral flow map derived from perfusion-weighted imaging source data was automatically generated, replicating a previously validated method. Thrombus length was measured on T2*-based susceptibility vessel sign.
Results—
Of 224 eligible patients, 37 (16%) experienced ER. ER occurred in 10 of 83 (12%), 17 of 116 (15%), and 10 of 25 (40%) patients with poor/moderate, good, and excellent collaterals, respectively. In multivariable analysis, better collaterals were independently associated with ER (
P
=0.029), together with shorter thrombus (
P
<0.001) and more distal occlusion site (
P
=0.010).
Conclusions—
In our sample of patients with stroke imaged with perfusion-weighted imaging before IVT and intended for thrombectomy, better collaterals were independently associated with post-IVT recanalization, supporting our hypothesis. These findings strengthen the idea that advanced imaging may play a key role for personalized medicine in identifying patients with large vessel occlusion most likely to benefit from IVT in the thrombectomy era.
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Affiliation(s)
- Pierre Seners
- From the Department of Neurology (P.S., G.T., J.-L.M., J.-C.B.), Sainte-Anne Hospital, INSERM U894, University Paris Descartes, France
| | - Pauline Roca
- Department of Radiology (P.R., L.L., W.B.H., O.N., S.L., C. Oppenheim), Sainte-Anne Hospital, INSERM U894, University Paris Descartes, France
| | - Laurence Legrand
- Department of Radiology (P.R., L.L., W.B.H., O.N., S.L., C. Oppenheim), Sainte-Anne Hospital, INSERM U894, University Paris Descartes, France
| | - Guillaume Turc
- From the Department of Neurology (P.S., G.T., J.-L.M., J.-C.B.), Sainte-Anne Hospital, INSERM U894, University Paris Descartes, France
| | - Jean-Philippe Cottier
- Department of Neuroradiology (J.-P.C.), Bretonneau Hospital, University of Tours, France
| | - Tae-Hee Cho
- Department of Stroke Medicine (T.-H.C.), Hospices Civils de Lyon, Université Lyon 1, CREATIS, CNRS UMR 5220-INSERM U1044, France
| | - Caroline Arquizan
- Department of Neurology (C.A.), CHRU Gui de Chauliac, Montpellier, France
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, INSERM U947, France (S.B.)
| | - Canan Ozsancak
- Department of Neurology (C. Ozsancak), Orleans Hospital, France
| | - Wagih Ben Hassen
- Department of Radiology (P.R., L.L., W.B.H., O.N., S.L., C. Oppenheim), Sainte-Anne Hospital, INSERM U894, University Paris Descartes, France
| | - Olivier Naggara
- Department of Radiology (P.R., L.L., W.B.H., O.N., S.L., C. Oppenheim), Sainte-Anne Hospital, INSERM U894, University Paris Descartes, France
| | - Stéphanie Lion
- Department of Radiology (P.R., L.L., W.B.H., O.N., S.L., C. Oppenheim), Sainte-Anne Hospital, INSERM U894, University Paris Descartes, France
| | - Séverine Debiais
- Department of Neurology (S.D.), Bretonneau Hospital, University of Tours, France
| | - Yves Berthezene
- Department of Neuroradiology (Y.B.), Hospices Civils de Lyon, Université Lyon 1, CREATIS, CNRS UMR 5220-INSERM U1044, France
| | - Vincent Costalat
- Department of Interventional Neuroradiology (V.C.), CHRU Gui de Chauliac, Montpellier, France
| | - Sébastien Richard
- Department of Neurology, University Hospital of Nancy, France (S.R.)
| | | | - Jean-Louis Mas
- From the Department of Neurology (P.S., G.T., J.-L.M., J.-C.B.), Sainte-Anne Hospital, INSERM U894, University Paris Descartes, France
| | - Jean-Claude Baron
- From the Department of Neurology (P.S., G.T., J.-L.M., J.-C.B.), Sainte-Anne Hospital, INSERM U894, University Paris Descartes, France
| | - Catherine Oppenheim
- Department of Radiology (P.R., L.L., W.B.H., O.N., S.L., C. Oppenheim), Sainte-Anne Hospital, INSERM U894, University Paris Descartes, France
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48
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Heiss WD, Zaro-Weber O. Extension of therapeutic window in ischemic stroke by selective mismatch imaging. Int J Stroke 2019; 14:351-358. [DOI: 10.1177/1747493019840936] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The concept of the ischemic penumbra was formulated on the basis of animal experiments showing functional impairment and electrophysiologic disturbances with decreasing flow to the brain below defined values (the threshold for function) and irreversible tissue damage with blood supply further decreased (the threshold for infarction). The perfusion range between these thresholds was termed the “penumbra,” and restitution of flow above the functional threshold was able to reverse the deficits without permanent damage. In further experiments, the dependency of the development of irreversible lesions on the interaction of the severity and the duration of critically reduced blood flow was established, proving that the lower the flow, the shorter the time for efficient reperfusion. As a consequence, infarction develops from the core of ischemia to the areas of less severe hypoperfusion. The translation of this experimental concept as the basis for the efficient treatment of stroke requires methods by which regional flow and energy metabolism can be repeatedly investigated to demonstrate penumbra tissue, which can benefit from therapeutic interventions. Positron emission tomography allows the quantification of regional cerebral blood flow, the regional oxygen extraction fraction, and the regional metabolic rate for oxygen. With these variables, clear definitions of irreversible tissue damage and of critically hypoperfused but potentially salvageable tissue (i.e. the penumbra) in stroke patients can be achieved. However, positron emission tomography is a research tool, and its complex logistics limit clinical routine applications. Perfusion-weighted or diffusion-weighted magnetic resonance imaging is a widely applicable clinical tool, and the “mismatch” between perfusion-weighted and diffusion-weighted abnormalities serves as an indicator of the penumbra. Also computed tomography angiography and computed tomography perfusion imaging can be used to detect areas suspicious of penumbra. The findings with both methods should be validated by positron emission tomography measurements. Several studies included the selection of patients for intravenous thrombolysis on the basis of a perfusion-weighted imaging–diffusion-weighted imaging mismatch or computed tomography perfusion studies. A meta-analysis of several mismatch-based thrombolysis studies of delayed treatment from the DIAS, DIAS-2, DEDAS, EPITHET, and DEFUSE trials revealed increased recanalization. However, this analysis did not confirm an improvement in clinical outcome with delayed thrombolysis. Randomized controlled trials that did enroll patients based on the presence of a target mismatch on multimodal imaging demonstrated a higher benefit of revascularization treatment by comparison with those who did not and demonstrated for the first time that revascularization treatment for occlusion of an internal carotid artery (ICA) or a proximal middle cerebral artery (MCA) was still beneficial from 6 to 24 h after onset among patients in whom the clinical examination and the multimodal brain imaging indicate a persistent penumbra. On this background, the yield of imaging for the selection of patients for a revascularization therapy will be discussed.
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Affiliation(s)
- Wolf-Dieter Heiss
- Max Planck Institute for Metabolism Research, Cologne, Germany
- Max Planck Institute for Neurological Research, Cologne, Germany
| | - Olivier Zaro-Weber
- Max Planck Institute for Metabolism Research, Cologne, Germany
- Max Planck Institute for Neurological Research, Cologne, Germany
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49
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Affiliation(s)
- Shashvat M. Desai
- From the Department of Neurology (S.M.D., M.R., T.G.J., A.P.J.), University of Pittsburgh Medical Center, PA
| | - Marcelo Rocha
- From the Department of Neurology (S.M.D., M.R., T.G.J., A.P.J.), University of Pittsburgh Medical Center, PA
| | - Tudor G. Jovin
- From the Department of Neurology (S.M.D., M.R., T.G.J., A.P.J.), University of Pittsburgh Medical Center, PA
- Department of Neurosurgery (T.G.J., A.P.J.), University of Pittsburgh Medical Center, PA
| | - Ashutosh P. Jadhav
- From the Department of Neurology (S.M.D., M.R., T.G.J., A.P.J.), University of Pittsburgh Medical Center, PA
- Department of Neurosurgery (T.G.J., A.P.J.), University of Pittsburgh Medical Center, PA
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