1
|
Li C, Jiang M, Chen Z, Hu Q, Liu Z, Wang J, Yin X, Wang J, Wu M. The neuroprotective effects of normobaric oxygen therapy after stroke. CNS Neurosci Ther 2024; 30:e14858. [PMID: 39009510 PMCID: PMC11250159 DOI: 10.1111/cns.14858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Revised: 06/29/2024] [Accepted: 07/03/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND Stroke, including ischemic and hemorrhagic stroke, is a severe and prevalent acute cerebrovascular disease. The development of hypoxia following stroke can trigger a cascade of pathological events, including mitochondrial dysfunction, energy deficiency, oxidative stress, neuroinflammation, and excitotoxicity, all of which are often associated with unfavorable prognosis. Nonetheless, a noninvasive intervention, referred to as normobaric hyperoxia (NBO), is known to have neuroprotective effects against stroke. RESULTS NBO can exert neuroprotective effects through various mechanisms, such as the rescue of hypoxic tissues, preservation of the blood-brain barrier, reduction of brain edema, alleviation of neuroinflammation, improvement of mitochondrial function, mitigation of oxidative stress, reduction of excitotoxicity, and inhibition of apoptosis. These mechanisms may help improve the prognosis of stroke patients. CONCLUSIONS This review summarizes the mechanism by which hypoxia causes brain injury and how NBO can act as a neuroprotective therapy to treat stroke. We conclude that NBO has significant potential for treating stroke and may represent a novel therapeutic strategy.
Collapse
Affiliation(s)
- Chuan Li
- Department of Medical LaboratoryAffiliated Hospital of Jiujiang UniversityJiujiangJiangxiChina
| | - Min Jiang
- Jiujiang Clinical Precision Medicine Research CenterJiujiangJiangxiChina
| | - Zhiying Chen
- Department of NeurologyAffiliated Hospital of Jiujiang UniversityJiujiangJiangxiChina
| | - Qiongqiong Hu
- Department of NeurologyZhengzhou Central Hospital, Zhengzhou UniversityZhengzhouHenanChina
| | - Ziying Liu
- Department of Medical LaboratoryAffiliated Hospital of Jiujiang UniversityJiujiangJiangxiChina
| | - Junmin Wang
- Department of Human AnatomySchool of Basic Medical Sciences, Zhengzhou UniversityZhengzhouHenanChina
| | - Xiaoping Yin
- Department of NeurologyAffiliated Hospital of Jiujiang UniversityJiujiangJiangxiChina
| | - Jian Wang
- Department of Human AnatomySchool of Basic Medical Sciences, Zhengzhou UniversityZhengzhouHenanChina
| | - Moxin Wu
- Department of Medical LaboratoryAffiliated Hospital of Jiujiang UniversityJiujiangJiangxiChina
- Jiujiang Clinical Precision Medicine Research CenterJiujiangJiangxiChina
| |
Collapse
|
2
|
Hu W, Li W, Mangal R, Jia M, Ji X, Ding Y. Normobaric Hyperoxia (NBHO): An Adjunctive Therapy to Cerebrovascular Recanalization in Ischemic Stroke. Aging Dis 2023; 14:1483-1487. [PMID: 37196114 PMCID: PMC10529751 DOI: 10.14336/ad.2023.0227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/26/2023] [Indexed: 05/19/2023] Open
Abstract
Acute ischemic stroke (AIS) is a serious neurological disease. Normobaric hyperoxia (NBHO) is both a non-invasive and easy method that seems to be able to improve outcomes after cerebral ischemia/reperfusion. In clinical trials, normal low-flow oxygen has been shown to be ineffective, but NBHO has been shown to have a transient brain-protective effect. Today, NBHO combined with recanalization is the best treatment available. NBHO combined with thrombolysis is considered to improve neurological scores and long-term outcomes. Large randomized controlled trials (RCTs), however, are still needed to determine the role they will have in stroke treatment. RCTs of NBHO combined with thrombectomy have both improved infarct volume at 24 hours and the long-term prognosis. These two mechanisms most likely play key roles in the neuroprotective actions of NBHO after recanalization, including the increase in penumbra oxygen supply and the integrity of the blood-brain barrier (BBB). Considering the mechanism of action of NBHO, oxygen should be given as early as possible to increase the duration of oxygen therapy before recanalization is initiated. NBHO can further prolong the existence time of penumbra, so that more patients may benefit from it. Overall, however, recanalization therapy is still essential.
Collapse
Affiliation(s)
- Wenbo Hu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.
| | - Weili Li
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital, Capital Medical University, Beijing, China.
- Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China.
| | - Ruchi Mangal
- Department of Neurosurgery, Wayne State University School of Medicine, Michigan, USA.
| | - Milan Jia
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.
| | - Xunming Ji
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.
- Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China.
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China.
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Michigan, USA.
- John D. Dingell VA Medical Center, Detroit, Michigan, USA.
| |
Collapse
|
3
|
Li W, Wei M, Liu L, Lan J, Wu C, Zhao W, Li C, Chen J, Hou C, Ma Q, Ji X. Normobaric Hyperoxia Combined with Endovascular Treatment in Patients with Acute Ischemic Stroke (OPENS-2) Trial: Protocol for a Prospective, Multicenter, Randomized Controlled Study. Cerebrovasc Dis 2023; 53:346-353. [PMID: 39250887 DOI: 10.1159/000530004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/27/2022] [Indexed: 09/11/2024] Open
Abstract
Normobaric hyperoxia (NBO) is a potentially promising stroke treatment strategy that could protect the ischemic penumbra and could be administered as an adjunct before vascular recanalization. However, the efficacy and safety of NBO have not been confirmed by randomized controlled trials. The study aims to assess the efficacy and safety of NBO for ischemic stroke due to large artery occlusion (LVO) of acute anterior circulation among patients who had endovascular treatment (EVT) and were randomized within 6 h from symptom onset. Based on the data of the modified Rankin Scale (mRS) score at 90 days from the normobaric hyperoxia combined with EVT for acute ischemic stroke (OPENS: NCT03620370) trial, 284 patients will be included to achieve a 90% power by using Wilcoxon-Mann-Whitney test and the proportional odds model to calculate the sample size. The study is a prospective, multicenter, blinded, randomized controlled trial. The NBO group is administered with mask oxygen therapy of 10 L/min, while the sham NBO group is with that of 1 L/min. The primary outcome is the mRS score at 90 days. Secondary endpoints include cerebral infarct volume at 24-48 h, functional independence (mRS ≤2) at 90 days, and improvement in neurological function at 24 h. Safety outcomes include 90-day mortality, oxygen-related adverse events, and serious adverse events. This study will indicate whether NBO combined with EVT is superior to EVT alone for acute ischemic stroke caused by LVO in subjects randomized within 6 h from symptom onset and will provide some evidence for NBO intervention as an adjunct to thrombectomy for acute stroke.
Collapse
Affiliation(s)
- Weili Li
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Ming Wei
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Lan Liu
- School of Statistics, University of Minnesota at Twin Cities, Minneapolis, Minnesota, USA
| | - Jing Lan
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Wenbo Zhao
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Chuanhui Li
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jian Chen
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Chengbei Hou
- Center for Evidence-Based Medicine, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Qingfeng Ma
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Xunming Ji
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| |
Collapse
|
4
|
Rodríguez-Vázquez A, Laredo C, Renú A, Rudilosso S, Llull L, Amaro S, Obach V, Vera V, Páez A, Oleaga L, Urra X, Chamorro Á. Optimizing the Definition of Ischemic Core in CT Perfusion: Influence of Infarct Growth and Tissue-Specific Thresholds. AJNR Am J Neuroradiol 2022; 43:1265-1270. [PMID: 35981763 PMCID: PMC9451632 DOI: 10.3174/ajnr.a7601] [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: 03/28/2022] [Accepted: 06/20/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE CTP allows estimating ischemic core in patients with acute stroke. However, these estimations have limited accuracy compared with MR imaging. We studied the effect of applying WM- and GM-specific thresholds and analyzed the infarct growth from baseline imaging to reperfusion. MATERIALS AND METHODS This was a single-center cohort of consecutive patients (n = 113) with witnessed strokes due to proximal carotid territory occlusions with baseline CT perfusion, complete reperfusion, and follow-up DWI. We segmented GM and WM, coregistered CTP with DWI, and compared the accuracy of the different predictions for each voxel on DWI through receiver operating characteristic analysis. We assessed the yield of different relative CBF thresholds to predict the final infarct volume and an estimated infarct growth-corrected volume (subtracting the infarct growth from baseline imaging to complete reperfusion) for a single relative CBF threshold and GM- and WM-specific thresholds. RESULTS The fixed threshold underestimated lesions in GM and overestimated them in WM. Double GM- and WM-specific thresholds of relative CBF were superior to fixed thresholds in predicting infarcted voxels. The closest estimations of the infarct on DWI were based on a relative CBF of 25% for a single threshold, 35% for GM, and 20% for WM, and they decreased when correcting for infarct growth: 20% for a single threshold, 25% for GM, and 15% for WM. The combination of 25% for GM and 15% for WM yielded the best prediction. CONCLUSIONS GM- and WM-specific thresholds result in different estimations of ischemic core in CTP and increase the global accuracy. More restrictive thresholds better estimate the actual extent of the infarcted tissue.
Collapse
Affiliation(s)
- A Rodríguez-Vázquez
- From the Comprehensive Stroke Center (A.R.-V., C.L., A.R., S.R., L.L., S.A., V.O., V.V., X.U., A.C.), Functional Unit of Cerebrovascular Diseases
| | - C Laredo
- From the Comprehensive Stroke Center (A.R.-V., C.L., A.R., S.R., L.L., S.A., V.O., V.V., X.U., A.C.), Functional Unit of Cerebrovascular Diseases
| | - A Renú
- From the Comprehensive Stroke Center (A.R.-V., C.L., A.R., S.R., L.L., S.A., V.O., V.V., X.U., A.C.), Functional Unit of Cerebrovascular Diseases
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (A.R., S.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
- University of Barcelona (A.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
| | - S Rudilosso
- From the Comprehensive Stroke Center (A.R.-V., C.L., A.R., S.R., L.L., S.A., V.O., V.V., X.U., A.C.), Functional Unit of Cerebrovascular Diseases
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (A.R., S.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
| | - L Llull
- From the Comprehensive Stroke Center (A.R.-V., C.L., A.R., S.R., L.L., S.A., V.O., V.V., X.U., A.C.), Functional Unit of Cerebrovascular Diseases
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (A.R., S.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
- University of Barcelona (A.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
| | - S Amaro
- From the Comprehensive Stroke Center (A.R.-V., C.L., A.R., S.R., L.L., S.A., V.O., V.V., X.U., A.C.), Functional Unit of Cerebrovascular Diseases
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (A.R., S.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
- University of Barcelona (A.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
| | - V Obach
- From the Comprehensive Stroke Center (A.R.-V., C.L., A.R., S.R., L.L., S.A., V.O., V.V., X.U., A.C.), Functional Unit of Cerebrovascular Diseases
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (A.R., S.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
- University of Barcelona (A.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
| | - V Vera
- From the Comprehensive Stroke Center (A.R.-V., C.L., A.R., S.R., L.L., S.A., V.O., V.V., X.U., A.C.), Functional Unit of Cerebrovascular Diseases
| | - A Páez
- Radiology Department (A.P., L.O.), Hospital Clínic, Barcelona, Spain
| | - L Oleaga
- Radiology Department (A.P., L.O.), Hospital Clínic, Barcelona, Spain
| | - X Urra
- From the Comprehensive Stroke Center (A.R.-V., C.L., A.R., S.R., L.L., S.A., V.O., V.V., X.U., A.C.), Functional Unit of Cerebrovascular Diseases
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (A.R., S.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
- University of Barcelona (A.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
| | - Á Chamorro
- From the Comprehensive Stroke Center (A.R.-V., C.L., A.R., S.R., L.L., S.A., V.O., V.V., X.U., A.C.), Functional Unit of Cerebrovascular Diseases
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (A.R., S.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
- University of Barcelona (A.R., L.L., S.A., V.O., X.U., A.C.), Barcelona, Spain
| |
Collapse
|
5
|
Li W, Qi Z, Ma Q, Ding J, Wu C, Song H, Yang Q, Duan J, Liu L, Kang H, Wu L, Ji K, Zhao W, Li C, Sun C, Li N, Fisher M, Ji X, Liu KJ. Normobaric Hyperoxia Combined With Endovascular Treatment for Patients With Acute Ischemic Stroke: A Randomized Controlled Clinical Trial. Neurology 2022; 99:e824-e834. [PMID: 35715198 DOI: 10.1212/wnl.0000000000200775] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 04/08/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To investigate the safety and efficacy of normobaric hyperoxia (NBO) combined with endovascular treatment (EVT) in patients with acute ischemic stroke (AIS). METHODS In this single-center, proof-of-concept, assessor-blinded, randomized, controlled pilot study, patients with AIS in the acute anterior circulation with large vessel occlusion who had an indication for EVT were randomly assigned to the EVT group or the NBO + EVT group. The NBO + EVT group was given 100% oxygen through a face mask initiated before vascular recanalization (10L/min for 4 hours), while the EVT group was given room air. The primary endpoint was infarct volume measured by MRI within 24-48 hours after randomization. RESULTS A total of 231 patients were screened, and 86 patients were randomized into a ratio of 1:1 (EVT group, n = 43; NBO + EVT group, n = 43). The median infarction volume of the NBO + EVT group at 24-48 hours after randomization was significantly smaller than that of the EVT group (median 20.1 vs 37.7 mL, p < 0.01). The median mRS score at 90 days was 2 for the NBO + EVT group when compared with 3 for the EVT group (adjusted value 1.8, 95% CI 1.3-4.2; p = 0.038). Compared with the EVT group, the NBO + EVT group had a lower incidence of symptomatic intracranial hemorrhagic (7% vs 12%), mortality (9% vs 16%), and adverse events (33% vs 42%); however, such a difference was not statistically significant. DISCUSSION NBO in combination with EVT seems to be a safe and feasible treatment strategy that could significantly reduce infarct volume, improve short-term neurobehavioral test score, and enhance clinical outcomes at 90 days when compared with EVT alone in patients with AIS. These observations need to be further confirmed by a large, multicenter, randomized clinical trial. CLINICAL TRIALS REGISTRATION NCT03620370. CLASSIFICATION OF EVIDENCE This pilot study provides Class I evidence that NBO combined with standard EVT decreases infarction volume in patients with acute anterior circulation stroke.
Collapse
Affiliation(s)
- Weili Li
- From the Cerebrovascular Diseases Research Institute (W.L., Z.Q., X.J.) and the Departments of Neurology (Q.M., Jiayue Ding, C.W., H.S., L.W., K.J., W.Z., C.S., N.L.), Radiology (Q.Y.), Emergency (Jiangang Duan, C.L.), and Neurosurgery (X.J.), Xuanwu Hospital of Capital Medical University, Beijing; Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology (W.L., X.J.), Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China; School of Statistics (L.L.), University of Minnesota at Twin Cities, Minneapolis; Department of Internal Medicine (H.K.), University of New Mexico, Albuquerque; Department of Neurology (M.F.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Pharmaceutical Sciences (K.J.L.), University of New Mexico Health Sciences Center, Albuquerque
| | - Zhifeng Qi
- From the Cerebrovascular Diseases Research Institute (W.L., Z.Q., X.J.) and the Departments of Neurology (Q.M., Jiayue Ding, C.W., H.S., L.W., K.J., W.Z., C.S., N.L.), Radiology (Q.Y.), Emergency (Jiangang Duan, C.L.), and Neurosurgery (X.J.), Xuanwu Hospital of Capital Medical University, Beijing; Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology (W.L., X.J.), Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China; School of Statistics (L.L.), University of Minnesota at Twin Cities, Minneapolis; Department of Internal Medicine (H.K.), University of New Mexico, Albuquerque; Department of Neurology (M.F.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Pharmaceutical Sciences (K.J.L.), University of New Mexico Health Sciences Center, Albuquerque
| | - Qingfeng Ma
- From the Cerebrovascular Diseases Research Institute (W.L., Z.Q., X.J.) and the Departments of Neurology (Q.M., Jiayue Ding, C.W., H.S., L.W., K.J., W.Z., C.S., N.L.), Radiology (Q.Y.), Emergency (Jiangang Duan, C.L.), and Neurosurgery (X.J.), Xuanwu Hospital of Capital Medical University, Beijing; Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology (W.L., X.J.), Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China; School of Statistics (L.L.), University of Minnesota at Twin Cities, Minneapolis; Department of Internal Medicine (H.K.), University of New Mexico, Albuquerque; Department of Neurology (M.F.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Pharmaceutical Sciences (K.J.L.), University of New Mexico Health Sciences Center, Albuquerque
| | - Jiayue Ding
- From the Cerebrovascular Diseases Research Institute (W.L., Z.Q., X.J.) and the Departments of Neurology (Q.M., Jiayue Ding, C.W., H.S., L.W., K.J., W.Z., C.S., N.L.), Radiology (Q.Y.), Emergency (Jiangang Duan, C.L.), and Neurosurgery (X.J.), Xuanwu Hospital of Capital Medical University, Beijing; Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology (W.L., X.J.), Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China; School of Statistics (L.L.), University of Minnesota at Twin Cities, Minneapolis; Department of Internal Medicine (H.K.), University of New Mexico, Albuquerque; Department of Neurology (M.F.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Pharmaceutical Sciences (K.J.L.), University of New Mexico Health Sciences Center, Albuquerque
| | - Chuanjie Wu
- From the Cerebrovascular Diseases Research Institute (W.L., Z.Q., X.J.) and the Departments of Neurology (Q.M., Jiayue Ding, C.W., H.S., L.W., K.J., W.Z., C.S., N.L.), Radiology (Q.Y.), Emergency (Jiangang Duan, C.L.), and Neurosurgery (X.J.), Xuanwu Hospital of Capital Medical University, Beijing; Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology (W.L., X.J.), Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China; School of Statistics (L.L.), University of Minnesota at Twin Cities, Minneapolis; Department of Internal Medicine (H.K.), University of New Mexico, Albuquerque; Department of Neurology (M.F.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Pharmaceutical Sciences (K.J.L.), University of New Mexico Health Sciences Center, Albuquerque
| | - Haiqing Song
- From the Cerebrovascular Diseases Research Institute (W.L., Z.Q., X.J.) and the Departments of Neurology (Q.M., Jiayue Ding, C.W., H.S., L.W., K.J., W.Z., C.S., N.L.), Radiology (Q.Y.), Emergency (Jiangang Duan, C.L.), and Neurosurgery (X.J.), Xuanwu Hospital of Capital Medical University, Beijing; Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology (W.L., X.J.), Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China; School of Statistics (L.L.), University of Minnesota at Twin Cities, Minneapolis; Department of Internal Medicine (H.K.), University of New Mexico, Albuquerque; Department of Neurology (M.F.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Pharmaceutical Sciences (K.J.L.), University of New Mexico Health Sciences Center, Albuquerque
| | - Qi Yang
- From the Cerebrovascular Diseases Research Institute (W.L., Z.Q., X.J.) and the Departments of Neurology (Q.M., Jiayue Ding, C.W., H.S., L.W., K.J., W.Z., C.S., N.L.), Radiology (Q.Y.), Emergency (Jiangang Duan, C.L.), and Neurosurgery (X.J.), Xuanwu Hospital of Capital Medical University, Beijing; Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology (W.L., X.J.), Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China; School of Statistics (L.L.), University of Minnesota at Twin Cities, Minneapolis; Department of Internal Medicine (H.K.), University of New Mexico, Albuquerque; Department of Neurology (M.F.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Pharmaceutical Sciences (K.J.L.), University of New Mexico Health Sciences Center, Albuquerque
| | - Jiangang Duan
- From the Cerebrovascular Diseases Research Institute (W.L., Z.Q., X.J.) and the Departments of Neurology (Q.M., Jiayue Ding, C.W., H.S., L.W., K.J., W.Z., C.S., N.L.), Radiology (Q.Y.), Emergency (Jiangang Duan, C.L.), and Neurosurgery (X.J.), Xuanwu Hospital of Capital Medical University, Beijing; Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology (W.L., X.J.), Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China; School of Statistics (L.L.), University of Minnesota at Twin Cities, Minneapolis; Department of Internal Medicine (H.K.), University of New Mexico, Albuquerque; Department of Neurology (M.F.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Pharmaceutical Sciences (K.J.L.), University of New Mexico Health Sciences Center, Albuquerque
| | - Lan Liu
- From the Cerebrovascular Diseases Research Institute (W.L., Z.Q., X.J.) and the Departments of Neurology (Q.M., Jiayue Ding, C.W., H.S., L.W., K.J., W.Z., C.S., N.L.), Radiology (Q.Y.), Emergency (Jiangang Duan, C.L.), and Neurosurgery (X.J.), Xuanwu Hospital of Capital Medical University, Beijing; Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology (W.L., X.J.), Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China; School of Statistics (L.L.), University of Minnesota at Twin Cities, Minneapolis; Department of Internal Medicine (H.K.), University of New Mexico, Albuquerque; Department of Neurology (M.F.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Pharmaceutical Sciences (K.J.L.), University of New Mexico Health Sciences Center, Albuquerque
| | - Huining Kang
- From the Cerebrovascular Diseases Research Institute (W.L., Z.Q., X.J.) and the Departments of Neurology (Q.M., Jiayue Ding, C.W., H.S., L.W., K.J., W.Z., C.S., N.L.), Radiology (Q.Y.), Emergency (Jiangang Duan, C.L.), and Neurosurgery (X.J.), Xuanwu Hospital of Capital Medical University, Beijing; Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology (W.L., X.J.), Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China; School of Statistics (L.L.), University of Minnesota at Twin Cities, Minneapolis; Department of Internal Medicine (H.K.), University of New Mexico, Albuquerque; Department of Neurology (M.F.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Pharmaceutical Sciences (K.J.L.), University of New Mexico Health Sciences Center, Albuquerque
| | - Longfei Wu
- From the Cerebrovascular Diseases Research Institute (W.L., Z.Q., X.J.) and the Departments of Neurology (Q.M., Jiayue Ding, C.W., H.S., L.W., K.J., W.Z., C.S., N.L.), Radiology (Q.Y.), Emergency (Jiangang Duan, C.L.), and Neurosurgery (X.J.), Xuanwu Hospital of Capital Medical University, Beijing; Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology (W.L., X.J.), Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China; School of Statistics (L.L.), University of Minnesota at Twin Cities, Minneapolis; Department of Internal Medicine (H.K.), University of New Mexico, Albuquerque; Department of Neurology (M.F.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Pharmaceutical Sciences (K.J.L.), University of New Mexico Health Sciences Center, Albuquerque
| | - Kangxiang Ji
- From the Cerebrovascular Diseases Research Institute (W.L., Z.Q., X.J.) and the Departments of Neurology (Q.M., Jiayue Ding, C.W., H.S., L.W., K.J., W.Z., C.S., N.L.), Radiology (Q.Y.), Emergency (Jiangang Duan, C.L.), and Neurosurgery (X.J.), Xuanwu Hospital of Capital Medical University, Beijing; Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology (W.L., X.J.), Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China; School of Statistics (L.L.), University of Minnesota at Twin Cities, Minneapolis; Department of Internal Medicine (H.K.), University of New Mexico, Albuquerque; Department of Neurology (M.F.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Pharmaceutical Sciences (K.J.L.), University of New Mexico Health Sciences Center, Albuquerque.
| | - Wenbo Zhao
- From the Cerebrovascular Diseases Research Institute (W.L., Z.Q., X.J.) and the Departments of Neurology (Q.M., Jiayue Ding, C.W., H.S., L.W., K.J., W.Z., C.S., N.L.), Radiology (Q.Y.), Emergency (Jiangang Duan, C.L.), and Neurosurgery (X.J.), Xuanwu Hospital of Capital Medical University, Beijing; Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology (W.L., X.J.), Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China; School of Statistics (L.L.), University of Minnesota at Twin Cities, Minneapolis; Department of Internal Medicine (H.K.), University of New Mexico, Albuquerque; Department of Neurology (M.F.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Pharmaceutical Sciences (K.J.L.), University of New Mexico Health Sciences Center, Albuquerque
| | - Chuanhui Li
- From the Cerebrovascular Diseases Research Institute (W.L., Z.Q., X.J.) and the Departments of Neurology (Q.M., Jiayue Ding, C.W., H.S., L.W., K.J., W.Z., C.S., N.L.), Radiology (Q.Y.), Emergency (Jiangang Duan, C.L.), and Neurosurgery (X.J.), Xuanwu Hospital of Capital Medical University, Beijing; Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology (W.L., X.J.), Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China; School of Statistics (L.L.), University of Minnesota at Twin Cities, Minneapolis; Department of Internal Medicine (H.K.), University of New Mexico, Albuquerque; Department of Neurology (M.F.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Pharmaceutical Sciences (K.J.L.), University of New Mexico Health Sciences Center, Albuquerque
| | - Chenghe Sun
- From the Cerebrovascular Diseases Research Institute (W.L., Z.Q., X.J.) and the Departments of Neurology (Q.M., Jiayue Ding, C.W., H.S., L.W., K.J., W.Z., C.S., N.L.), Radiology (Q.Y.), Emergency (Jiangang Duan, C.L.), and Neurosurgery (X.J.), Xuanwu Hospital of Capital Medical University, Beijing; Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology (W.L., X.J.), Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China; School of Statistics (L.L.), University of Minnesota at Twin Cities, Minneapolis; Department of Internal Medicine (H.K.), University of New Mexico, Albuquerque; Department of Neurology (M.F.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Pharmaceutical Sciences (K.J.L.), University of New Mexico Health Sciences Center, Albuquerque
| | - Na Li
- From the Cerebrovascular Diseases Research Institute (W.L., Z.Q., X.J.) and the Departments of Neurology (Q.M., Jiayue Ding, C.W., H.S., L.W., K.J., W.Z., C.S., N.L.), Radiology (Q.Y.), Emergency (Jiangang Duan, C.L.), and Neurosurgery (X.J.), Xuanwu Hospital of Capital Medical University, Beijing; Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology (W.L., X.J.), Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China; School of Statistics (L.L.), University of Minnesota at Twin Cities, Minneapolis; Department of Internal Medicine (H.K.), University of New Mexico, Albuquerque; Department of Neurology (M.F.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Pharmaceutical Sciences (K.J.L.), University of New Mexico Health Sciences Center, Albuquerque
| | - Marc Fisher
- From the Cerebrovascular Diseases Research Institute (W.L., Z.Q., X.J.) and the Departments of Neurology (Q.M., Jiayue Ding, C.W., H.S., L.W., K.J., W.Z., C.S., N.L.), Radiology (Q.Y.), Emergency (Jiangang Duan, C.L.), and Neurosurgery (X.J.), Xuanwu Hospital of Capital Medical University, Beijing; Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology (W.L., X.J.), Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China; School of Statistics (L.L.), University of Minnesota at Twin Cities, Minneapolis; Department of Internal Medicine (H.K.), University of New Mexico, Albuquerque; Department of Neurology (M.F.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Pharmaceutical Sciences (K.J.L.), University of New Mexico Health Sciences Center, Albuquerque
| | - Xunming Ji
- From the Cerebrovascular Diseases Research Institute (W.L., Z.Q., X.J.) and the Departments of Neurology (Q.M., Jiayue Ding, C.W., H.S., L.W., K.J., W.Z., C.S., N.L.), Radiology (Q.Y.), Emergency (Jiangang Duan, C.L.), and Neurosurgery (X.J.), Xuanwu Hospital of Capital Medical University, Beijing; Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology (W.L., X.J.), Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China; School of Statistics (L.L.), University of Minnesota at Twin Cities, Minneapolis; Department of Internal Medicine (H.K.), University of New Mexico, Albuquerque; Department of Neurology (M.F.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Pharmaceutical Sciences (K.J.L.), University of New Mexico Health Sciences Center, Albuquerque.
| | - Ke Jian Liu
- From the Cerebrovascular Diseases Research Institute (W.L., Z.Q., X.J.) and the Departments of Neurology (Q.M., Jiayue Ding, C.W., H.S., L.W., K.J., W.Z., C.S., N.L.), Radiology (Q.Y.), Emergency (Jiangang Duan, C.L.), and Neurosurgery (X.J.), Xuanwu Hospital of Capital Medical University, Beijing; Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology (W.L., X.J.), Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China; School of Statistics (L.L.), University of Minnesota at Twin Cities, Minneapolis; Department of Internal Medicine (H.K.), University of New Mexico, Albuquerque; Department of Neurology (M.F.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Pharmaceutical Sciences (K.J.L.), University of New Mexico Health Sciences Center, Albuquerque
| |
Collapse
|
6
|
González RG. Diffusion MR Imaging of Large Vessel Occlusion Ischemic Stroke for Treatment Selection. Magn Reson Imaging Clin N Am 2022; 30:363-369. [PMID: 35995467 DOI: 10.1016/j.mric.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
The role of MR imaging in the evaluation and management of ischemic stroke patients is large, and to cover it all is far beyond the scope of one article. Thus, the focus will be on the role of MR imaging in the great leap forward in stroke therapy: endovascular thrombectomy of large vessel occlusions (LVOs). Diffusion MR imaging has played a key role in the research leading to the current standard of care for LVO stroke because it is the most sensitive and reliable method for the early delineation of the ischemic core.
Collapse
Affiliation(s)
- Ramon Gilberto González
- Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, GRB 273A, Boston, MA 02114, USA.
| |
Collapse
|
7
|
Gwak DS, Park HK, Jung C, Kim JH, Lee J, Kim BJ, Han MK, Bae HJ. Infarct growth patterns may vary in acute stroke due to large vessel occlusion and recanalization with endovascular therapy. Eur Radiol 2020; 30:6432-6440. [PMID: 32676782 DOI: 10.1007/s00330-020-07068-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/27/2020] [Accepted: 07/03/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES This study aimed to investigate infarct growth patterns in stroke patients with large vessel occlusion (LVO) and successful recanalization by endovascular therapy (EVT). METHODS A total of 135 patients with LVO of the internal carotid artery or proximal segment of the middle cerebral artery admitted within 12 h after onset, having baseline National Institute of Health Stroke Scale score ≥ 5 points, and successfully recanalized by EVT were enrolled. Infarct growth pattern models were developed based on infarct volumes on diffusion-weighted imaging before and after reperfusion. Single pattern models of linear, logarithmic, and exponential shapes were initially tested. Their appropriateness was predetermined. If none of these patterns was suitable, the best pattern model, which was the most suitable pattern among the three shapes selected for each individual, was tested. Clinical correlates were explored. RESULTS Each single pattern model was tested for their suitability. However, none of the single pattern models successfully represented infarct growth curves: Of all subjects, only 63.7%, 62.2%, and 54.1% of patients were explained by the logarithmic, linear, and exponential model, respectively. Compared with the single pattern models, the best pattern model explained 80.7% of the subjects. The linear shape fit best in 40 patients, the logarithmic in 51, and the exponential in 44. Those fit best for the logarithmic pattern showed more favorable outcomes at discharge (31.4%) than did the others (linear, 10.0%; exponential, 9.1%; p = 0.01). CONCLUSIONS Infarct growth patterns may vary among individual patients with acute stroke due to LVO and successful treatment with EVT. KEY POINTS • Infarct growth during the acute stage of stroke is highly dynamic and the exact shape remains unknown. • Infarct growth pattern models were developed based on infarct volumes on diffusion-weighted imaging before and after reperfusion. • Infarct growth patterns may not be singular, rather various among individual patients with acute stroke due to LVO and successful treatment with EVT.
Collapse
Affiliation(s)
- Dong-Seok Gwak
- Department of Neurology, Kyungpook National University Hospital, Daegu, South Korea
| | - Hong-Kyun Park
- Department of Neurology, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, South Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Jae Hyoung Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, South Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea.
| |
Collapse
|
8
|
González RG, Silva GS, He J, Sadaghiani S, Wu O, Singhal AB. Identifying Severe Stroke Patients Likely to Benefit From Thrombectomy Despite Delays of up to a Day. Sci Rep 2020; 10:4008. [PMID: 32132644 PMCID: PMC7055266 DOI: 10.1038/s41598-020-60933-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 02/17/2020] [Indexed: 12/25/2022] Open
Abstract
Selected patients with large vessel occlusions (LVO) can benefit from thrombectomy up to 24 hours after onset. Identifying patients who might benefit from late intervention after transfer from community hospitals to thrombectomy-capable centers would be valuable. We searched for presentation biomarkers to identify such patients. Frequent MR imaging over 2 days of 38 untreated LVO patients revealed logarithmic growth of the ischemic infarct core. In 24 patients with terminal internal carotid artery or the proximal middle cerebral artery occlusions we found that an infarct core growth rate (IGR) <4.1 ml/hr and initial infarct core volumes (ICV) <19.9 ml had accuracies >89% for identifying patients who would still have a core of <50 ml 24 hours after stroke onset, a core size that should predict favorable outcomes with thrombectomy. Published reports indicate that up to half of all LVO stroke patients have an IGR <4.1 ml/hr. Other potentially useful biomarkers include the NIHSS and the perfusion measurements MTT and Tmax. We conclude that many LVO patients have a stroke physiology that is favorable for late intervention, and that there are biomarkers that can accurately identify them at early time points as suitable for transfer for intervention.
Collapse
Affiliation(s)
- R Gilberto González
- Neuroradiology Division, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA.
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA.
| | - Gisele Sampaio Silva
- Stroke Service,Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA
| | - Julian He
- Neuroradiology Division, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA
| | - Saloomeh Sadaghiani
- Stroke Service,Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA
| | - Ona Wu
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA
| | - Aneesh B Singhal
- Stroke Service,Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA
| |
Collapse
|
9
|
Aoki J, Suzuki K, Kanamaru T, Kutsuna A, Katano T, Takayama Y, Nishi Y, Takeshi Y, Nakagami T, Numao S, Abe A, Suda S, Nishiyama Y, Kimura K. Association between initial NIHSS score and recanalization rate after endovascular thrombectomy. J Neurol Sci 2019; 403:127-132. [DOI: 10.1016/j.jns.2019.06.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 06/12/2019] [Accepted: 06/28/2019] [Indexed: 11/15/2022]
|
10
|
Jiang B, Ball RL, Michel P, Li Y, Zhu G, Ding V, Su B, Naqvi Z, Eskandari A, Desai M, Wintermark M. Factors influencing infarct growth including collateral status assessed using computed tomography in acute stroke patients with large artery occlusion. Int J Stroke 2019; 14:603-612. [PMID: 31096871 DOI: 10.1177/1747493019851278] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In major ischemic stroke caused by a large artery occlusion, neuronal loss varies considerably across individuals without revascularization. This study aims to identify which patient characteristics are most highly associated with this variability. Demographic and clinical information were retrospectively collected on a registry of 878 patients. Imaging biomarkers including Alberta Stroke Program Early CT score, noncontrast head computed tomography infarct volume, perfusion computed tomography infarct core and penumbra, occlusion site, collateral score, and recanalization status were evaluated on the baseline and early follow-up computed tomography images. Infarct growth rates were calculated by dividing infarct volumes by the time elapsed between the computed tomography scan and the symptom onset. Collateral score was graded into four levels (0, 1, 2, and 3) in comparison with the normal side. Correlation of perfusion computed tomography and noncontrast head computed tomography infarct volumes and infarct growth rates were estimated with the nonparametric Spearman's rank correlation. Conditional inference trees were used to identify the clinical and imaging biomarkers that were most highly associated with the infarct growth rate and modified Rankin Scale at 90 days. Two hundred and thirty-two patients met the inclusion criteria for this study. The median infarct growth rates for perfusion computed tomography and noncontrast head computed tomography were 11.2 and 6.2 ml/log(min) in logarithmic model, and 18.9 and 10.4 ml/h in linear model, respectively. Noncontrast head computed tomography and perfusion computed tomography infarct volumes and infarct growth rates were significantly correlated (rho=0.53; P < 0.001). Collateral status was the strongest predictor for infarct growth rates. For collateral=0, the perfusion computed tomography and noncontrast head computed tomography infarct growth rate were 31.56 and 16.86 ml/log(min), respectively. Patients who had collateral >0 and penumbra volumes>92 ml had the lowest predicted perfusion computed tomography infarct growth rates (6.61 ml/log(min)). Collateral status was closely related to the diversity of infarct growth rates, poor collaterals were associated with a faster infarct growth rates and vice versa.
Collapse
Affiliation(s)
- Bin Jiang
- 1 Department of Radiology, Neuroradiology Section, Stanford University School of Medicine, Stanford, USA
| | - Robyn L Ball
- 2 Department of Medicine, Quantitative Sciences Unit, Stanford University, Stanford, USA
| | - Patrik Michel
- 3 Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Ying Li
- 1 Department of Radiology, Neuroradiology Section, Stanford University School of Medicine, Stanford, USA
| | - Guangming Zhu
- 1 Department of Radiology, Neuroradiology Section, Stanford University School of Medicine, Stanford, USA
| | - Victoria Ding
- 2 Department of Medicine, Quantitative Sciences Unit, Stanford University, Stanford, USA
| | - Bochao Su
- 1 Department of Radiology, Neuroradiology Section, Stanford University School of Medicine, Stanford, USA
| | - Zack Naqvi
- 1 Department of Radiology, Neuroradiology Section, Stanford University School of Medicine, Stanford, USA
| | - Ashraf Eskandari
- 3 Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Manisha Desai
- 2 Department of Medicine, Quantitative Sciences Unit, Stanford University, Stanford, USA
| | - Max Wintermark
- 1 Department of Radiology, Neuroradiology Section, Stanford University School of Medicine, Stanford, USA
| |
Collapse
|
11
|
Thamm T, Zweynert S, Piper SK, Madai VI, Livne M, Martin SZ, Herzig CX, Mutke MA, Siebert E, Liebig T, Sobesky J. Diagnostic and prognostic benefit of arterial spin labeling in subacute stroke. Brain Behav 2019; 9:e01271. [PMID: 30912272 PMCID: PMC6520295 DOI: 10.1002/brb3.1271] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 01/31/2019] [Accepted: 02/25/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND PURPOSE Brain perfusion measurement in the subacute phase of stroke may support therapeutic decisions. We evaluated whether arterial spin labeling (ASL), a noninvasive perfusion imaging technique based on magnetic resonance imaging (MRI), adds diagnostic and prognostic benefit to diffusion-weighted imaging (DWI) in subacute stroke. METHODS In a single-center imaging study, patients with DWI lesion(s) in the middle cerebral artery (MCA) territory were included. Onset to imaging time was ≤7 days and imaging included ASL and DWI sequences. Qualitative (standardized visual analysis) and quantitative perfusion analyses (region of interest analysis) were performed. Dichotomized early outcome (modified Rankin Scale [mRS] 0-2 vs. 3-6) was analyzed in two logistic regression models. Model 1 included DWI lesion volume, age, vascular pathology, admission NIHSS, and acute stroke treatment as covariates. Model 2 added the ASL-based perfusion pattern to Model 1. Receiver-operating-characteristic (ROC) and area-under-the-curve (AUC) were calculated for both models to assess their predictive power. The likelihood-ratio-test compared both models. RESULTS Thirty-eight patients were included (median age 70 years, admission NIHSS 4, onset to imaging time 67 hr, discharge mRS 2). Qualitative perfusion analysis yielded additional diagnostic information in 84% of the patients. In the quantitative analysis, AUC for outcome prediction was 0.88 (95% CI 0.77-0.99) for Model 1 and 0.97 (95% CI 0.91-1.00) for Model 2. Inclusion of perfusion data significantly improved performance and outcome prediction (p = 0.002) of stroke imaging. CONCLUSIONS In patients with subacute stroke, our study showed that adding perfusion imaging to structural imaging and clinical data significantly improved outcome prediction. This highlights the usefulness of ASL and noninvasive perfusion biomarkers in stroke diagnosis and management.
Collapse
Affiliation(s)
- Thoralf Thamm
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sarah Zweynert
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sophie K Piper
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Vince I Madai
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Michelle Livne
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Steve Z Martin
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Cornelius X Herzig
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Matthias A Mutke
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Eberhard Siebert
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Thomas Liebig
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neuroradiology, Ludwig-Maximilian-University, Munich, Germany
| | - Jan Sobesky
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Johanna-Etienne-Hospital, Neuss, Germany
| |
Collapse
|
12
|
Leslie-Mazwi TM, Lev MH, Schaefer PW, Hirsch JA, González RG. MR Imaging Selection of Acute Stroke Patients with Emergent Large Vessel Occlusions for Thrombectomy. Neuroimaging Clin N Am 2018; 28:573-584. [PMID: 30322594 DOI: 10.1016/j.nic.2018.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Acute stroke caused by large vessel occlusions (LVOs) are common. The time window to treat is up to 24 hours, and the most important factor is the size of the ischemic core. If the core is small (<70-100 mL), the penumbra must be large; penumbral imaging is unnecessary. MR imaging is precise in measuring the core, and superior to alternatives. The necessary sequences are obtainable rapidly, comparable to computed tomography scans. Available evidence suggests that most patients with LVOs are slow progressors defined as having a small core 6 hours or more after ictus onset.
Collapse
Affiliation(s)
- Thabele M Leslie-Mazwi
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, WAC-7-745, MGH, 15 Parkman Street, Boston, MA 02114-3117, USA; Neurocritical Care, Massachusetts General Hospital, Harvard Medical School, WAC-7-745, MGH, 15 Parkman Street, Boston, MA 02114-3117, USA; Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, WAC-7-745, MGH, 15 Parkman Street, Boston, MA 02114-3117, USA; Department of Neurology, Massachusetts General Hospital, Harvard Medical School, WAC-7-745, MGH, 15 Parkman Street, Boston, MA 02114-3117, USA
| | - Michael H Lev
- Emergency Radiology, Massachusetts General Hospital, Harvard Medical School, BLK-SB-0038 MGH, 55 Fruit Street, Boston, MA 02114, USA
| | - Pamela W Schaefer
- Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Founders 228 MGH, 55 Fruit Street, Boston, MA 02114, USA; Radiology, Massachusetts General Hospital, Harvard Medical School, Founders 228 MGH, 55 Fruit Street, Boston, MA 02114, USA
| | - Joshua A Hirsch
- NeuroInterventional Radiology, Massachusetts General Hospital, Harvard Medical School, Gray 241 MGH, 55 Fruit Street, Boston, MA 02114, USA; Interventional Radiology, Massachusetts General Hospital, Harvard Medical School, Gray 241 MGH, 55 Fruit Street, Boston, MA 02114, USA
| | - R Gilberto González
- Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Gray 241 MGH, 55 Fruit Street, Boston, MA 02114, USA.
| |
Collapse
|
13
|
Gomez CR. Time Is Brain: The Stroke Theory of Relativity. J Stroke Cerebrovasc Dis 2018; 27:2214-2227. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.04.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 04/04/2018] [Indexed: 01/24/2023] Open
|
14
|
Manning NW, Wenderoth J, Alsahli K, Cordato D, Cappelen-Smith C, McDougall A, Zagami AS, Cheung A. Endovascular Thrombectomy >24-hr From Stroke Symptom Onset. Front Neurol 2018; 9:501. [PMID: 30026722 PMCID: PMC6041982 DOI: 10.3389/fneur.2018.00501] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 06/08/2018] [Indexed: 12/24/2022] Open
Abstract
Background: Trials have demonstrated efficacy for endovascular thrombectomy (EVT) for anterior circulation acute ischaemic stroke (AIS) up to 24-h from symptom onset. The magnitude of effect suggests benefit may exist beyond 24-h. Objectives: To perform a retrospective review of all patients undergoing EVT for anterior circulation LVO stroke beyond 24-h from symptom onset and assess safety and efficacy. Methods:A prospectively maintained database of EVT patients treated at two comprehensive stroke centers between January 2016 and December 2017 was retrospectively screened. Patients undergoing EVT for anterior circulation AIS >24-h from symptom onset were selected. Results: A total of 429 AIS patient underwent EVT in the study period. Five patients treated >24-h from symptom onset were identified. The median age was 72 (range 42–84); median ASPECTS 8 (range 6–8); median baseline-NIHSS 9 (range 4–17); and median time from symptom onset to groin puncture 44 h and 55 min (range 25:07-90:10). One patient underwent CT perfusion imaging. The remaining four patients were selected based on non-contrast CT brain and CT-angiography. Two patients had tandem cervical carotid lesions and underwent acute stenting. Modified thrombolysis in cerebral ischaemia (mTICI) 3 reperfusion was achieved in four patients. No hemorrhagic transformation occurred. All patients were alive at 90-day follow-up. Four patients achieved functional independence at 90-days (mRS 0-2). Conclusion: Endovascular thrombectomy for AIS patients beyond 24-h from symptom onset appears to be safe and effective in this limited study. There is a need for further evidence-based trials of benefit vs. risk in very prolonged time windows.
Collapse
Affiliation(s)
- Nathan W Manning
- Department of Interventional Neuroradiology, Institute of Neurological Sciences, Prince of Wales Hospital, Randwick, NSW, Australia.,Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, NSW, Australia.,Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia.,Florey Institute of Neuroscience, Parkville, VIC, Australia
| | - Jason Wenderoth
- Department of Interventional Neuroradiology, Institute of Neurological Sciences, Prince of Wales Hospital, Randwick, NSW, Australia.,Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, NSW, Australia.,Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Khalid Alsahli
- Department of Radiology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Dennis Cordato
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Cecilia Cappelen-Smith
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Alan McDougall
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Alessandro S Zagami
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia.,Department of Neurology, Institute of Neurological Sciences, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Andrew Cheung
- Department of Interventional Neuroradiology, Institute of Neurological Sciences, Prince of Wales Hospital, Randwick, NSW, Australia.,Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, NSW, Australia.,Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
| |
Collapse
|
15
|
Ding J, Zhou D, Sui M, Meng R, Chandra A, Han J, Ding Y, Ji X. The effect of normobaric oxygen in patients with acute stroke: a systematic review and meta-analysis. Neurol Res 2018; 40:433-444. [PMID: 29600891 DOI: 10.1080/01616412.2018.1454091] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Normobaric oxygen (NBO) has received considerable attention due to controversial data in brain protection in patients with acute stroke. This study aims to analyze current data of NBO on brain protection as used in the clinic. Methods We searched for and reviewed relevant articles and references from Pubmed, Medline, Embase, Cochrane, and Clincialtrials.gov that were published prior to October 2017. Data from prospective studies were processed using RevMan5.0 software, provided by Cochrane collaboration and transformed using relevant formulas. Results A total of 11 prospective RCT studies including 6366 patients with acute stroke (NBO group, 3207; control group, 3159) were enrolled in this analysis. △NIHSS represented the values of NIHSS at 4, 24 h, or 7 days post-stroke minus baseline NIHSS. Compared to controls, there was a minor trend toward NBO benefits in short-term prognostic indices, as indicated by decreased ΔNIHSS at our defined time points. By contrast, NBO decreased Barthel Index scores between 3 and 7 months, and increased death rates at 3, 6 months, and 1 year, whereas, modified Rankin Scale scores between 3 and 6 months were unchanged. Conclusions The existing trends toward benefits revealed in this meta-analysis help us appreciate the promising value of NBO, although current evidence of NBO on improving clinical outcomes of stroke is insufficient. Well-designed multi-center clinical trials are encouraged and urgently needed to further explore the efficacy of NBO on brain protection.
Collapse
Affiliation(s)
- Jiayue Ding
- a Department of Neurology , Xuanwu Hospital, Capital Medical University , Beijing , China.,b Beijing Institute for Brain Disorders , Beijing , China
| | - Da Zhou
- a Department of Neurology , Xuanwu Hospital, Capital Medical University , Beijing , China.,b Beijing Institute for Brain Disorders , Beijing , China
| | - Meng Sui
- c Department of Economics , Fordham University , Bronx , NY , USA
| | - Ran Meng
- a Department of Neurology , Xuanwu Hospital, Capital Medical University , Beijing , China.,b Beijing Institute for Brain Disorders , Beijing , China
| | - Ankush Chandra
- d Department of Neurosurgery , Wayne State University School of Medicine , Detroit , MI , USA.,e Department of Neurosurgery , University of California San Francisco , San Francisco, CA , USA
| | - Jie Han
- f Department of Neurology , The First Affiliated Hospital of Dalian Medical University , Dalian , China
| | - Yuchuan Ding
- d Department of Neurosurgery , Wayne State University School of Medicine , Detroit , MI , USA
| | - Xunming Ji
- b Beijing Institute for Brain Disorders , Beijing , China.,g Department of Neurosurgery , Xuanwu Hospital, Capital Medical University , Beijing , China
| |
Collapse
|
16
|
Albers GW. Late Window Paradox. Stroke 2018; 49:768-771. [PMID: 29367336 DOI: 10.1161/strokeaha.117.020200] [Citation(s) in RCA: 143] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 12/03/2017] [Accepted: 12/05/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Gregory W Albers
- From the Department of Neurology, Stanford University, Palo Alto, CA.
| |
Collapse
|
17
|
Lu SS, Ge S, Su CQ, Xie J, Mao J, Shi HB, Hong XN. MRI of plaque characteristics and relationship with downstream perfusion and cerebral infarction in patients with symptomatic middle cerebral artery stenosis. J Magn Reson Imaging 2017; 48:66-73. [PMID: 29083523 DOI: 10.1002/jmri.25879] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 10/10/2017] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Intracranial plaque characteristics are associated with stroke events. Differences in plaque features may explain the disconnect between stenosis severity and the presence of ischemic stroke. PURPOSE To investigate the relationship between plaque characteristics and downstream perfusion changes, and their contribution to the occurrence of cerebral infarction beyond luminal stenosis. STUDY TYPE Case control. SUBJECTS Forty-six patients with symptomatic middle cerebral artery (MCA) stenosis (with acute cerebral infarction, n = 30; without acute cerebral infarction, n = 16). FIELD STRENGTH/SEQUENCE 3.0T with 3D turbo spin echo sequence (3D-SPACE). ASSESSMENT Luminal stenosis grade, plaque features including lesion T2 and T1 hyperintense components, plaque enhancement grade, and plaque distribution were assessed. Brain perfusion was evaluated on mean transient time maps based on the Alberta Stroke Program Early CT score (MTT-ASPECTS). STATISTICAL TESTS Plaque features, grade of luminal stenosis, and MTT-ASPECTS were compared between two groups. The association between plaque features and MTT-ASPECTS were assessed using Spearman's correlation analysis. Multivariate logistic regression and receiver operating characteristic (ROC) curves were constructed to assess the effect of significant variables alone and their combination in determining the occurrence of cerebral infarction. RESULTS Stronger enhanced plaques were associated with downstream lower MTT-ASPECTS (P = 0.010). Plaque enhancement grade (P = 0.039, odds ratio [OR] 5.9, 95% confidence interval [CI] 1.1-32) and MTT-ASPECTS (P = 0.003, OR 2.6, 95% CI 1.4-4.7) were associated with a recent cerebral infarction, whereas luminal stenosis grade was not (P = 0.128). The combination of MTT-ASPECTS and plaque enhancement grade provided incremental information beyond luminal stenosis grade alone. The area under the receiver operating characteristic curve (AUC) improved from 0.535 to 0.921 (P < 0.05). DATA CONCUSION Strongly enhanced plaques are associated with a higher likelihood of downstream perfusion impairment. Plaque enhancement and perfusion evaluation may play a complementary role to luminal stenosis in determining the occurrence of acute cerebral infarction. LEVEL OF EVIDENCE 4 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2017.
Collapse
Affiliation(s)
- Shan-Shan Lu
- Department of Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, P.R. China
| | - Song Ge
- Department of Neurology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, P.R. China
| | - Chun-Qiu Su
- Department of Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, P.R. China
| | - Jun Xie
- Department of Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, P.R. China
| | - Jian Mao
- Siemens Healthineers, Shanghai, P.R. China
| | - Hai-Bin Shi
- Department of Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, P.R. China
| | - Xun-Ning Hong
- Department of Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, P.R. China
| |
Collapse
|
18
|
Kamran S, Akhtar N, Alboudi A, Kamran K, Ahmad A, Inshasi J, Salam A, Shuaib A, Qidwai U. Prediction of infarction volume and infarction growth rate in acute ischemic stroke. Sci Rep 2017; 7:7565. [PMID: 28790400 PMCID: PMC5548812 DOI: 10.1038/s41598-017-08044-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 06/28/2017] [Indexed: 12/01/2022] Open
Abstract
The prediction of infarction volume after stroke onset depends on the shape of the growth dynamics of the infarction. To understand growth patterns that predict lesion volume changes, we studied currently available models described in literature and compared the models with Adaptive Neuro-Fuzzy Inference System [ANFIS], a method previously unused in the prediction of infarction growth and infarction volume (IV). We included 67 patients with malignant middle cerebral artery [MMCA] stroke who underwent decompressive hemicraniectomy. All patients had at least three cranial CT scans prior to the surgery. The rate of growth and volume of infarction measured on the third CT was predicted with ANFIS without statistically significant difference compared to the ground truth [P = 0.489]. This was not possible with linear, logarithmic or exponential methods. ANFIS was able to predict infarction volume [IV3] over a wide range of volume [163.7–600 cm3] and time [22–110 hours]. The cross correlation [CRR] indicated similarity between the ANFIS-predicted IV3 and original data of 82% for ANFIS, followed by logarithmic 70%, exponential 63% and linear 48% respectively. Our study shows that ANFIS is superior to previously defined methods in the prediction of infarction growth rate (IGR) with reasonable accuracy, over wide time and volume range.
Collapse
Affiliation(s)
- Saadat Kamran
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Medical Corporation, Doha, Qatar. .,Weill Cornell School of Medicine, Doha, Qatar.
| | - Naveed Akhtar
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Medical Corporation, Doha, Qatar.,Weill Cornell School of Medicine, Doha, Qatar
| | | | - Kainat Kamran
- School of Liberal Arts, University of Illinois, Chicago, USA
| | | | | | - Abdul Salam
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Medical Corporation, Doha, Qatar
| | - Ashfaq Shuaib
- The Neuroscience Institute (Stroke Center of Excellence), Hamad General Hospital, Medical Corporation, Doha, Qatar.,Stroke Program, Department of Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - Uvais Qidwai
- KINDI Center for Computing Research, Qatar University, Doha, Qatar
| |
Collapse
|
19
|
Regenhardt RW, Das AS, Stapleton CJ, Chandra RV, Rabinov JD, Patel AB, Hirsch JA, Leslie-Mazwi TM. Blood Pressure and Penumbral Sustenance in Stroke from Large Vessel Occlusion. Front Neurol 2017; 8:317. [PMID: 28717354 PMCID: PMC5494536 DOI: 10.3389/fneur.2017.00317] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 06/16/2017] [Indexed: 12/11/2022] Open
Abstract
The global burden of stroke remains high, and of the various subtypes of stroke, large vessel occlusions (LVOs) account for the largest proportion of stroke-related death and disability. Several randomized controlled trials in 2015 changed the landscape of stroke care worldwide, with endovascular thrombectomy (ET) now the standard of care for all eligible patients. With the proven success of this therapy, there is a renewed focus on penumbral sustenance. In this review, we describe the ischemic penumbra, collateral circulation, autoregulation, and imaging assessment of the penumbra. Blood pressure goals in acute stroke remain controversial, and we review the current data and suggest an approach for induced hypertension in the acute treatment of patients with LVOs. Finally, in addition to reperfusion and enhanced perfusion, efforts focused on developing therapeutic targets that afford neuroprotection and augment neural repair will gain increasing importance. ET has revolutionized stroke care, and future emphasis will be placed on promoting penumbral sustenance, which will increase patient eligibility for this highly effective therapy and reduce overall stroke-related death and disability.
Collapse
Affiliation(s)
- Robert W. Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Alvin S. Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Christopher J. Stapleton
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Ronil V. Chandra
- Interventional Neuroradiology, Monash Imaging, Monash Health, Monash University, Melbourne, VIC, Australia
| | - James D. Rabinov
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Aman B. Patel
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Joshua A. Hirsch
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Thabele M. Leslie-Mazwi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| |
Collapse
|
20
|
Shi SH, Qi ZF, Luo YM, Ji XM, Liu KJ. Normobaric oxygen treatment in acute ischemic stroke: a clinical perspective. Med Gas Res 2016; 6:147-153. [PMID: 27867482 PMCID: PMC5110139 DOI: 10.4103/2045-9912.191360] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Acute ischemic stroke is a common and serious neurological disease. Oxygen therapy has been shown to increase oxygen supply to ischemic tissues and improve outcomes after cerebral ischemia/reperfusion. Normobaric hyperoxia (NBO), an easily applicable and non-invasive method, shows protective effects on acute ischemic stroke animals and patients in pilot studies. However, many critical scientific questions are still unclear, such as the therapeutic time window of NBO, the long-term effects and the benefits of NBO in large clinic trials. In this article, we review the current literatures on NBO treatment of acute ischemic stroke in preclinical and clinical studies and try to analyze and identify the key gaps or unknowns in our understanding about NBO. Based on these analyses, we provide suggestions for future studies.
Collapse
Affiliation(s)
- Shu-Hai Shi
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing, China; Pediatric Intensive Care, First Affiliated Hospital of Baotou Medical College, Baotou, Inner Mongolia Autonomous Region, China
| | - Zhi-Feng Qi
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Yu-Min Luo
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Xun-Ming Ji
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Ke Jian Liu
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing, China; Department of Pharmaceutical Sciences, College of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| |
Collapse
|
21
|
Akbik F, Hirsch JA, Cougo-Pinto PT, Chandra RV, Simonsen CZ, Leslie-Mazwi T. The Evolution of Mechanical Thrombectomy for Acute Stroke. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:32. [PMID: 26932587 DOI: 10.1007/s11936-016-0457-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OPINION STATEMENT The natural history of an acute ischemic stroke from a large vessel occlusion (LVO) is poor and has long challenged stroke therapy. Recently, endovascular therapy has demonstrated superiority to medical management in appropriately selected patients. This advance has revolutionized acute care for LVO and mandates a reevaluation of the entire chain of stroke care delivery, including patient selection, intervention, and post-procedural care. Since endovascular therapy is a therapy specifically targeting LVO, its application should be restricted to those patients only. Clinical and radiologic parameters need to be considered in patient selection. Data supports that all patients over the age of 18 years presenting with a National Institutes of Health Stroke Scale (NIHSS) of 6 or greater within 6 hours of symptom onset should be considered for emergent endovascular therapy. Radiologically, those with a LVO of the internal carotid artery (ICA) or middle cerebral artery (MCA) M1 portion, intermediate or good collaterals and without large established infarct should be considered endovascular candidates. Selection beyond these parameters remains an open question and is being actively evaluated. In all cases, revascularization should be attempted with a new generation device (stentriever or direct aspiration), as these techniques are most likely to deliver adequate reperfusion. Post-revascularization, patients are closely monitored in an intensive care setting followed by discharge to rehabilitation, if required, or directly home. Patients should be evaluated in delayed fashion to assess recovery (typically at 3 months post-treatment). Ultimately, the poor natural history of ischemic stroke from LVO and the potential significant benefit from endovascular therapy over medical management alone necessitate a national response to ensure we identify and treat all eligible patients as rapidly and effectively as possible.
Collapse
Affiliation(s)
- Feras Akbik
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Joshua A Hirsch
- Neuroendovascular Service, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Pedro Telles Cougo-Pinto
- Department of Neurosciences and Behavior Sciences, Ribeirão Preto Medical School, Ribeirão Preto, SP, Brazil
| | - Ronil V Chandra
- Interventional Neuroradiology, Monash Health, Monash University, Melbourne, Australia
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Thabele Leslie-Mazwi
- Neuroendovascular Service, Massachusetts General Hospital, Boston, MA, 02114, USA.
| |
Collapse
|
22
|
Early CT perfusion mismatch in acute stroke is not time-dependent but relies on collateralization grade. Neuroradiology 2016; 58:357-65. [DOI: 10.1007/s00234-016-1643-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 01/06/2016] [Indexed: 10/22/2022]
|
23
|
Ejaz S, Emmrich JV, Sitnikov SL, Hong YT, Sawiak SJ, Fryer TD, Aigbirhio FI, Williamson DJ, Baron JC. Normobaric hyperoxia markedly reduces brain damage and sensorimotor deficits following brief focal ischaemia. Brain 2016; 139:751-64. [PMID: 26767570 DOI: 10.1093/brain/awv391] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 11/16/2015] [Indexed: 01/02/2023] Open
Abstract
'True' transient ischaemic attacks are characterized not only clinically, but also radiologically by a lack of corresponding changes on magnetic resonance imaging. During a transient ischaemic attack it is assumed that the affected tissue is penumbral but rescued by early spontaneous reperfusion. There is, however, evidence from rodent studies that even brief focal ischaemia not resulting in tissue infarction can cause extensive selective neuronal loss associated with long-lasting sensorimotor impairment but normal magnetic resonance imaging. Selective neuronal loss might therefore contribute to the increasingly recognized cognitive impairment occurring in patients with transient ischaemic attacks. It is therefore relevant to consider treatments to reduce brain damage occurring with transient ischaemic attacks. As penumbral neurons are threatened by markedly constrained oxygen delivery, improving the latter by increasing arterial O2 content would seem logical. Despite only small increases in arterial O2 content, normobaric oxygen therapy experimentally induces significant increases in penumbral O2 pressure and by such may maintain the penumbra alive until reperfusion. Nevertheless, the effects of normobaric oxygen therapy on infarct volume in rodent models have been conflicting, although duration of occlusion appeared an important factor. Likewise, in the single randomized trial published to date, early-administered normobaric oxygen therapy had no significant effect on clinical outcome despite reduced diffusion-weighted imaging lesion growth during therapy. Here we tested the hypothesis that normobaric oxygen therapy prevents both selective neuronal loss and sensorimotor deficits in a rodent model mimicking true transient ischaemic attack. Normobaric oxygen therapy was applied from the onset and until completion of 15 min distal middle cerebral artery occlusion in spontaneously hypertensive rats, a strain representative of the transient ischaemic attack-prone population. Whereas normoxic controls showed normal magnetic resonance imaging but extensive cortical selective neuronal loss associated with microglial activation (present both at Day 14 in vivo and at Day 28 post-mortem) and marked and long-lasting sensorimotor deficits, normobaric oxygen therapy completely prevented sensorimotor deficit (P < 0.02) and near-completely Day 28 selective neuronal loss (P < 0.005). Microglial activation was substantially reduced at Day 14 and completely prevented at Day 28 (P = 0.002). Our findings document that normobaric oxygen therapy administered during ischaemia nearly completely prevents the neuronal death, microglial inflammation and sensorimotor impairment that characterize this rodent true transient ischaemic attack model. Taken together with the available literature, normobaric oxygen therapy appears a promising therapy for short-lasting ischaemia, and is attractive clinically as it could be started at home in at-risk patients or in the ambulance in subjects suspected of transient ischaemic attack/early stroke. It may also be a straightforward adjunct to reperfusion therapies, and help prevent subtle brain damage potentially contributing to long-term cognitive and sensorimotor impairment in at-risk populations.
Collapse
Affiliation(s)
- Sohail Ejaz
- 1 Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Julius V Emmrich
- 1 Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, UK 2 Department of Neurology, Charité - Universitätsmedizin Berlin, Germany
| | - Sergey L Sitnikov
- 1 Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Young T Hong
- 3 Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Stephen J Sawiak
- 3 Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Tim D Fryer
- 3 Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Franklin I Aigbirhio
- 3 Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, UK
| | - David J Williamson
- 3 Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Jean-Claude Baron
- 1 Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, UK 4 INSERM U894, Hôpital Sainte-Anne, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| |
Collapse
|
24
|
Abstract
Acute ischemic stroke is common and often treatable, but treatment requires reliable information on the state of the brain that may be provided by modern neuroimaging. Critical information includes: the presence of hemorrhage; the site of arterial occlusion; the size of the early infarct "core"; and the size of underperfused, potentially threatened brain parenchyma, commonly referred to as the "penumbra." In this chapter we review the major determinants of outcomes in ischemic stroke patients, and the clinical value of various advanced computed tomography and magnetic resonance imaging methods that may provide key physiologic information in these patients. The focus is on major strokes due to occlusions of large arteries of the anterior circulation, the most common cause of a severe stroke syndrome. The current evidence-based approach to imaging the acute stroke patient at the Massachusetts General Hospital is presented, which is applicable for all stroke types. We conclude with new information on time and stroke evolution that imaging has revealed, and how it may open the possibilities of treating many more patients.
Collapse
Affiliation(s)
- R Gilberto González
- Neuroradiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| |
Collapse
|
25
|
Lansberg MG, Cereda CW, Mlynash M, Mishra NK, Inoue M, Kemp S, Christensen S, Straka M, Zaharchuk G, Marks MP, Bammer R, Albers GW. Response to endovascular reperfusion is not time-dependent in patients with salvageable tissue. Neurology 2015; 85:708-14. [PMID: 26224727 PMCID: PMC4553034 DOI: 10.1212/wnl.0000000000001853] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 04/03/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate whether time to treatment modifies the effect of endovascular reperfusion in stroke patients with evidence of salvageable tissue on MRI. METHODS Patients from the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution 2 (DEFUSE 2) cohort study with a perfusion-diffusion target mismatch were included. Reperfusion was defined as a decrease in the perfusion lesion volume of at least 50% between baseline and early follow-up. Good functional outcome was defined as a modified Rankin Scale score ≤2 at day 90. Lesion growth was defined as the difference between the baseline and the early follow-up diffusion-weighted imaging lesion volumes. RESULTS Among 78 patients with the target mismatch profile (mean age 66 ± 16 years, 54% women), reperfusion was associated with increased odds of good functional outcome (adjusted odds ratio 3.7, 95% confidence interval 1.2-12, p = 0.03) and attenuation of lesion growth (p = 0.02). Time to treatment did not modify these effects (p value for the time × reperfusion interaction is 0.6 for good functional outcome and 0.3 for lesion growth). Similarly, in the subgroup of patients with reperfusion (n = 46), time to treatment was not associated with good functional outcome (p = 0.2). CONCLUSION The association between endovascular reperfusion and improved functional and radiologic outcomes is not time-dependent in patients with a perfusion-diffusion mismatch. Proof that patients with mismatch benefit from endovascular therapy in the late time window should come from a randomized placebo-controlled trial.
Collapse
Affiliation(s)
- Maarten G Lansberg
- From the Stanford Stroke Center (M.G.L., C.W.C., M.M., N.K.M., M.I., S.K., S.C., M.S., G.Z., M.P.M., R.B., G.W.A.), Department of Neurology, Stanford University, Palo Alto, CA; and Stroke Center (C.W.C.), Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland.
| | - Carlo W Cereda
- From the Stanford Stroke Center (M.G.L., C.W.C., M.M., N.K.M., M.I., S.K., S.C., M.S., G.Z., M.P.M., R.B., G.W.A.), Department of Neurology, Stanford University, Palo Alto, CA; and Stroke Center (C.W.C.), Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland
| | - Michael Mlynash
- From the Stanford Stroke Center (M.G.L., C.W.C., M.M., N.K.M., M.I., S.K., S.C., M.S., G.Z., M.P.M., R.B., G.W.A.), Department of Neurology, Stanford University, Palo Alto, CA; and Stroke Center (C.W.C.), Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland
| | - Nishant K Mishra
- From the Stanford Stroke Center (M.G.L., C.W.C., M.M., N.K.M., M.I., S.K., S.C., M.S., G.Z., M.P.M., R.B., G.W.A.), Department of Neurology, Stanford University, Palo Alto, CA; and Stroke Center (C.W.C.), Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland
| | - Manabu Inoue
- From the Stanford Stroke Center (M.G.L., C.W.C., M.M., N.K.M., M.I., S.K., S.C., M.S., G.Z., M.P.M., R.B., G.W.A.), Department of Neurology, Stanford University, Palo Alto, CA; and Stroke Center (C.W.C.), Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland
| | - Stephanie Kemp
- From the Stanford Stroke Center (M.G.L., C.W.C., M.M., N.K.M., M.I., S.K., S.C., M.S., G.Z., M.P.M., R.B., G.W.A.), Department of Neurology, Stanford University, Palo Alto, CA; and Stroke Center (C.W.C.), Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland
| | - Søren Christensen
- From the Stanford Stroke Center (M.G.L., C.W.C., M.M., N.K.M., M.I., S.K., S.C., M.S., G.Z., M.P.M., R.B., G.W.A.), Department of Neurology, Stanford University, Palo Alto, CA; and Stroke Center (C.W.C.), Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland
| | - Matus Straka
- From the Stanford Stroke Center (M.G.L., C.W.C., M.M., N.K.M., M.I., S.K., S.C., M.S., G.Z., M.P.M., R.B., G.W.A.), Department of Neurology, Stanford University, Palo Alto, CA; and Stroke Center (C.W.C.), Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland
| | - Greg Zaharchuk
- From the Stanford Stroke Center (M.G.L., C.W.C., M.M., N.K.M., M.I., S.K., S.C., M.S., G.Z., M.P.M., R.B., G.W.A.), Department of Neurology, Stanford University, Palo Alto, CA; and Stroke Center (C.W.C.), Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland
| | - Michael P Marks
- From the Stanford Stroke Center (M.G.L., C.W.C., M.M., N.K.M., M.I., S.K., S.C., M.S., G.Z., M.P.M., R.B., G.W.A.), Department of Neurology, Stanford University, Palo Alto, CA; and Stroke Center (C.W.C.), Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland
| | - Roland Bammer
- From the Stanford Stroke Center (M.G.L., C.W.C., M.M., N.K.M., M.I., S.K., S.C., M.S., G.Z., M.P.M., R.B., G.W.A.), Department of Neurology, Stanford University, Palo Alto, CA; and Stroke Center (C.W.C.), Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland
| | - Gregory W Albers
- From the Stanford Stroke Center (M.G.L., C.W.C., M.M., N.K.M., M.I., S.K., S.C., M.S., G.Z., M.P.M., R.B., G.W.A.), Department of Neurology, Stanford University, Palo Alto, CA; and Stroke Center (C.W.C.), Department of Neurology, Neurocenter (EOC) of Southern Switzerland, Lugano, Switzerland
| |
Collapse
|
26
|
Abstract
OPINION STATEMENT With the recent publication of multiple trials demonstrating the superiority of the endovascular treatment of patients presenting with stroke from large vessel occlusion (LVO) over medical management, the emergent care of these patients is entering a new era. This realization justifies an aggressive treatment approach with these stroke patients, given the poor natural history of the disease. In general, treatment should occur as quickly as is reasonably possible. Patients with NIHSS >8 should be considered, and if <6 h from onset imaging selection achieved with CT and CTA. Those with ASPECTS >5, LVO and intermediate or good collaterals should be treated emergently. For patients with clinical deficits presenting in later timeframes MRI should be used to define core infarct size and therefore treatment eligibility. MRI might also be considered for the workup of stroke patients in centers that can offer it rapidly. Recanalization should be attempted with a stentriever or using a direct aspiration technique, with the patient under conscious sedation rather than general anesthesia, if that is a safe option. Angiographically, the goal is reperfusion of mTICI 2b/3. Post-procedure, the patient should be admitted to an intensive care setting and assessed for inpatient rehabilitation placement as soon as stable. Continuous institutional process improvement ensures that optimization of treatment times and logistics is an ongoing endeavor. Finally, patient outcomes should be assessed at three months, most commonly using the modified Rankin score.
Collapse
|
27
|
Wheeler HM, Mlynash M, Inoue M, Tipirnini A, Liggins J, Bammer R, Lansberg MG, Kemp S, Zaharchuk G, Straka M, Albers GW. The growth rate of early DWI lesions is highly variable and associated with penumbral salvage and clinical outcomes following endovascular reperfusion. Int J Stroke 2015; 10:723-9. [PMID: 25580662 DOI: 10.1111/ijs.12436] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Accepted: 10/29/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND The degree of variability in the rate of early diffusion-weighted imaging expansion in acute stroke has not been well characterized. AIM We hypothesized that patients with slowly expanding diffusion-weighted imaging lesions would have more penumbral salvage and better clinical outcomes following endovascular reperfusion than patients with rapidly expanding diffusion-weighted imaging lesions. METHODS In the first part of this substudy of DEFUSE 2, growth curves were constructed for patients with >90% reperfusion and <10% reperfusion. Next, the initial growth rate was determined in all patients with a clearly established time of symptom onset, assuming a lesion volume of 0 ml just prior to symptom onset. Patients who achieved reperfusion (>50% reduction in perfusion-weighted imaging after endovascular therapy) were categorized into tertiles according to their initial diffusion-weighted imaging growth rates. For each tertile, penumbral salvage [comparison of final volume to the volume of perfusion-weighted imaging (Tmax > 6 s)/diffusion-weighted imaging mismatch prior to endovascular therapy], favorable clinical response (National Institutes of Health Stroke Scale improvement of ≥8 points or 0-1 at 30 days), and good functional outcome (90-day modified Rankin score of ≤2) were calculated. A multivariate model assessed whether infarct growth rates were an independent predictor of clinical outcomes. RESULTS Sixty-five patients were eligible for this study; the median initial growth rate was 3·1 ml/h (interquartile range 0·7-10·7). Target mismatch patients (n = 42) had initial growth rates that were significantly slower than the growth rates in malignant profile (n = 9 patients, P < 0·001). In patients who achieved reperfusion (n = 38), slower early diffusion-weighted imaging growth rates were associated with better clinical outcomes (P < 0·05) and a trend toward more penumbral salvage (n = 31, P = 0·103). A multivariate model demonstrated that initial diffusion-weighted imaging growth rate was an independent predictor of achieving a 90-day modified Rankin score of ≤2. CONCLUSIONS The growth rate of early diffusion-weighted imaging lesions in acute stroke patients is highly variable; malignant profile patients have higher growth rates than patients with target mismatch. A slower rate of early diffusion-weighted imaging growth is associated with a greater degree of penumbral salvage and improved clinical outcomes following endovascular reperfusion.
Collapse
Affiliation(s)
- Hayley M Wheeler
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Mlynash
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Manabu Inoue
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Aaryani Tipirnini
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
| | - John Liggins
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Roland Bammer
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Maarten G Lansberg
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Stephanie Kemp
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Greg Zaharchuk
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Matus Straka
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Gregory W Albers
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
| | | |
Collapse
|
28
|
Aoki J, Tateishi Y, Cummings CL, Cheng-Ching E, Ruggieri P, Hussain MS, Uchino K. Collateral flow and brain changes on computed tomography angiography predict infarct volume on early diffusion-weighted imaging. J Stroke Cerebrovasc Dis 2014; 23:2845-2850. [PMID: 25440366 DOI: 10.1016/j.jstrokecerebrovasdis.2014.07.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 06/21/2014] [Accepted: 07/09/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND We investigated whether a computed tomography (CT)-based score could predict a large infarct (≥ 80 mL) on early diffusion-weighted magnetic resonance imaging (DWI). METHODS Acute stroke patients considered for endovascular therapy within 8 hours of the onset of symptoms were included. The Alberta Stroke Program Early Computed Tomography Score (ASPECTS) was determined on noncontrast CT and computed tomography angiography source images (CTA-SI). Limited collateral flow was defined as less than 50% collateral filling on CTA-SI. RESULTS Fifty-six patients were analyzed. National Institutes of Health Stroke Scale score was 20 (15-24) in the large infarct group and 16 (11-20) in the small infarct group (P = .049). ASPECTS on noncontrast CT and CTA-SI was 5 (3-8) and 3 (2-6) in the large infarct group and 9 (8-10) and 8 (7-9) in the small infarct group (both P < .001), respectively. Limited collateral flow was frequent in the large infarct group than in the small infarct group (92% vs. 11%, P < .001). Multivariate analysis found that CTA-SI ASPECTS less than or equal to 5 (odds ratio [OR], 40.55; 95% confidence interval [CI], 1.10-1493.44; P = .044) and limited collateral flow (OR, 114.64; 95% CI, 1.93-6812.79; P = .023) were associated with a large infarct. Absence of ASPECTS less than or equal to 5 and limited collateral flow on CTA-SI predicted absence of a large infarct with a sensitivity of .89, specificity of 1.00, positive predictive value of 1.00, and negative predictive value of .71. CONCLUSIONS Assessment of ASPECTS and collateral flow on CTA-SI may be able to exclude a patient with large infarct on early DWI.
Collapse
Affiliation(s)
- Junya Aoki
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Yohei Tateishi
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Esteban Cheng-Ching
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Paul Ruggieri
- Center for Neuroimaging, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
29
|
Hakimelahi R, Vachha BA, Copen WA, Papini GDE, He J, Higazi MM, Lev MH, Schaefer PW, Yoo AJ, Schwamm LH, González RG. Time and diffusion lesion size in major anterior circulation ischemic strokes. Stroke 2014; 45:2936-41. [PMID: 25190444 DOI: 10.1161/strokeaha.114.005644] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Major anterior circulation ischemic strokes caused by occlusion of the distal internal carotid artery or proximal middle cerebral artery or both account for about one third of ischemic strokes with mostly poor outcomes. These strokes are treatable by intravenous tissue-type plasminogen activator and endovascular methods. However, dynamics of infarct growth in these strokes are poorly documented. The purpose was to help understand infarct growth dynamics by measuring acute infarct size with diffusion-weighted imaging (DWI) at known times after stroke onset in patients with documented internal carotid artery/middle cerebral artery occlusions. METHODS Retrospectively, we included 47 consecutive patients with documented internal carotid artery/middle cerebral artery occlusions who underwent DWI within 30 hours of stroke onset. Prospectively, 139 patients were identified using the same inclusion criteria. DWI lesion volumes were measured and correlated to time since stroke onset. Perfusion data were reviewed in those who underwent perfusion imaging. RESULTS Acute infarct volumes ranged from 0.41 to 318.3 mL. Infarct size and time did not correlate (R2=0.001). The majority of patients had DWI lesions that were <25% the territory at risk (<70 mL) whether they were imaged <8 or >8 hours after stroke onset. DWI lesions corresponded to areas of greatly reduced perfusion. CONCLUSIONS Poor correlation between infarct volume and time after stroke onset suggests that there are factors more powerful than time in determining infarct size within the first 30 hours. The observations suggest that highly variable cerebral perfusion via the collateral circulation may primarily determine infarct growth dynamics. If verified, clinical implications include the possibility of treating many patients outside traditional time windows.
Collapse
Affiliation(s)
- Reza Hakimelahi
- From the Neuroradiology Division and the Stroke Service, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Behroze A Vachha
- From the Neuroradiology Division and the Stroke Service, Massachusetts General Hospital, Harvard Medical School, Boston
| | - William A Copen
- From the Neuroradiology Division and the Stroke Service, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Giacomo D E Papini
- From the Neuroradiology Division and the Stroke Service, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Julian He
- From the Neuroradiology Division and the Stroke Service, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Mahmoud M Higazi
- From the Neuroradiology Division and the Stroke Service, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Michael H Lev
- From the Neuroradiology Division and the Stroke Service, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Pamela W Schaefer
- From the Neuroradiology Division and the Stroke Service, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Albert J Yoo
- From the Neuroradiology Division and the Stroke Service, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Lee H Schwamm
- From the Neuroradiology Division and the Stroke Service, Massachusetts General Hospital, Harvard Medical School, Boston
| | - R Gilberto González
- From the Neuroradiology Division and the Stroke Service, Massachusetts General Hospital, Harvard Medical School, Boston.
| |
Collapse
|
30
|
Aoki J, Tateishi Y, Cummings CL, Cheng-Ching E, Ruggieri P, Hussain MS, Uchino K. Diffusion-weighted imaging volume as the best predictor of the diffusion-perfusion mismatch in acute stroke patients within 8 hours of onset. J Neuroimaging 2014; 25:217-225. [PMID: 24593841 DOI: 10.1111/jon.12107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 11/02/2013] [Accepted: 12/26/2013] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Diagnostic accuracies of standard NCCT, CTA, CTA-SI, FLAIR, and DWI to detect the diffusion-perfusion mismatch (DPM) were compared. METHODS Stroke patients considered for endovascular therapy within 8 hours of onset were enrolled. DPM was defined as at least 160% mismatch between DWI and PWI volume. RESULTS DPM was seen in 35 (71%) of 49 patients. ASPECTS on NCCT, CTA-SI, and DWI was 9 (8-9), 8 (6-9), and 7 (5-9) in mismatch group, and 6 (4-9), 6 (2-7), 5 (2-6) in nonmismatch group, respectively (P = .027, .006, and .001). Ischemic volume on CTA-SI and DWI was 4.6 (.2-13.0) cm(3) and 21.5 (9.7-44.0) cm(3) in mismatch group, and 61.5 (6.6-101.1) cm(3) and 94.9 (45.7-139.8) cm(3) in nonmismatch group (P = .003 and <.001). Significant collateralization on CTA-SI and FLAIR was seen in 80% and 88% in mismatch group, and 42% and 58% in nonmismatch group (P = .026 and .039). Odds ratios (95% CI) of DWI volume of ≤ 70 cm(3) to predict the mismatch was 30.17 (2.06-442.41) after adjusting for ASPECTSs on NCCT, CTA-SI, and DWI, 44.90 (2.75-732.73) for ischemic volume on CTA-SI, and 42.80 (3.05-601.41) for significant collateralization on CTA-SI and FLAIR (P = .013, .008, and .005). CONCLUSIONS DWI volume was the best predictor of DPM.
Collapse
Affiliation(s)
- Junya Aoki
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Ohio
| | - Yohei Tateishi
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Ohio
| | | | | | - Paul Ruggieri
- Neuroradiology, Imaging Institute, Cleveland Clinic, Ohio
| | | | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Ohio
| |
Collapse
|
31
|
Stability of ischemic core volume during the initial hours of acute large vessel ischemic stroke in a subgroup of mechanically revascularized patients. Neuroradiology 2014; 56:325-32. [DOI: 10.1007/s00234-014-1329-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 01/15/2014] [Indexed: 10/25/2022]
|
32
|
Abstract
The most important service that imaging provides to patients with ischemic stroke is to rapidly identify those patients who are most likely to benefit from immediate treatment. This group includes patients who have severe neurological symptoms due to an occlusion of a major artery, and who are candidates for recanalization using intravenous thrombolysis or intra-arterial intervention to remove the occlusion. Outcomes for these patients are determined by symptom severity, the artery that is occluded, the size of the infarct at the time of presentation, and the effect of treatment. MRI provides key physiological information through MR angiography and diffusion MRI that has been proven to be of high clinical value in identify patients who are in need of immediate treatment. Perfusion MRI provides information about the ischemic penumbra, but its clinical value is unproven. In current clinical practice, the time since stroke onset is dominant over physiologic information provided by MRI in treatment decisions. This will change only when clinical trials prove that stroke physiology as revealed by MRI is superior to time from stroke onset in promoting good clinical outcomes.
Collapse
|
33
|
Abstract
In ischemic stroke, positron-emission tomography (PET) established the imaging-based concept of penumbra. It defines hypoperfused, but functionally impaired, tissue with preserved viability that can be rescued by timely reperfusion. Diffusion-weighted and perfusion-weighted (PW) magnetic resonance imaging (MRI) translated the concept of penumbra to the concept of mismatch. However, the use of mismatch-based patient stratification for reperfusion therapy remains a matter of debate. The equivalence of mismatch and penumbra, as well as the validity of the classical mismatch concept is questioned for several reasons. First, methodological differences between PET and MRI lead to different definitions of the tissue at risk. Second, the mismatch concept is still poorly standardized among imaging facilities causing relevant variability in stroke research. Third, relevant conceptual issues (e.g., the choice of the adequate perfusion measure, the best quantitative approach to perfusion maps, and the required size of the mismatch) need further refinement. Fourth, the use of single thresholds does not account for the physiological heterogeneity of the penumbra and probabilistic approaches may be more promising. The implementation of this current knowledge into an optimized state-of-the-art mismatch model and its validation in clinical stroke studies remains a major challenge for future stroke research.
Collapse
Affiliation(s)
- Jan Sobesky
- Department of Neurology and Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin, Berlin, Germany.
| |
Collapse
|
34
|
Chen F, Ni YC. Magnetic resonance diffusion-perfusion mismatch in acute ischemic stroke: An update. World J Radiol 2012; 4:63-74. [PMID: 22468186 PMCID: PMC3314930 DOI: 10.4329/wjr.v4.i3.63] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 02/22/2012] [Accepted: 03/01/2012] [Indexed: 02/06/2023] Open
Abstract
The concept of magnetic resonance perfusion-diffusion mismatch (PDM) provides a practical and approximate measure of the tissue at risk and has been increasingly applied for the evaluation of hyperacute and acute stroke in animals and patients. Recent studies demonstrated that PDM does not optimally define the ischemic penumbra; because early abnormality on diffusion-weighted imaging overestimates the infarct core by including part of the penumbra, and the abnormality on perfusion weighted imaging overestimates the penumbra by including regions of benign oligemia. To overcome these limitations, many efforts have been made to optimize conventional PDM. Various alternatives beyond the PDM concept are under investigation in order to better define the penumbra. The PDM theory has been applied in ischemic stroke for at least three purposes: to be used as a practical selection tool for stroke treatment; to test the hypothesis that patients with PDM pattern will benefit from treatment, while those without mismatch pattern will not; to be a surrogate measure for stroke outcome. The main patterns of PDM and its relation with clinical outcomes were also briefly reviewed. The conclusion was that patients with PDM documented more reperfusion, reduced infarct growth and better clinical outcomes compared to patients without PDM, but it was not yet clear that thrombolytic therapy is beneficial when patients were selected on PDM. Studies based on a larger cohort are currently under investigation to further validate the PDM hypothesis.
Collapse
|
35
|
Wu O, Benner T, Roccatagliata L, Zhu M, Schaefer PW, Sorensen AG, Singhal AB. Evaluating effects of normobaric oxygen therapy in acute stroke with MRI-based predictive models. Med Gas Res 2012; 2:5. [PMID: 22404875 PMCID: PMC3388462 DOI: 10.1186/2045-9912-2-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 03/09/2012] [Indexed: 12/04/2022] Open
Abstract
Background Voxel-based algorithms using acute multiparametric-MRI data have been shown to accurately predict tissue outcome after stroke. We explored the potential of MRI-based predictive algorithms to objectively assess the effects of normobaric oxygen therapy (NBO), an investigational stroke treatment, using data from a pilot study of NBO in acute stroke. Methods The pilot study of NBO enrolled 11 patients randomized to NBO administered for 8 hours, and 8 Control patients who received room-air. Serial MRIs were obtained at admission, during gas therapy, post-therapy, and pre-discharge. Diffusion/perfusion MRI data acquired at admission (pre-therapy) was used in generalized linear models to predict the risk of lesion growth at subsequent time points for both treatment scenarios: NBO or Control. Results Lesion volume sizes 'during NBO therapy' predicted by Control-models were significantly larger (P = 0.007) than those predicted by NBO models, suggesting that ischemic lesion growth is attenuated during NBO treatment. No significant difference was found between the predicted lesion volumes at later time-points. NBO-treated patients, despite showing larger lesion volumes on Control-models than NBO-models, tended to have reduced lesion growth. Conclusions This study shows that NBO has therapeutic potential in acute ischemic stroke, and demonstrates the feasibility of using MRI-based algorithms to evaluate novel treatments in early-phase clinical trials.
Collapse
Affiliation(s)
- Ona Wu
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston MA 02114, USA.
| | | | | | | | | | | | | |
Collapse
|