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Xu H, Zheng M, Liu W, Peng W, Qiu J, Huang W, Zhang J, Xin E, Xia N, Lin R, Qiu C, Cao G, Chen W, Yang Y, Qian Y, Chen J. Enhanced Prediction of Malignant Cerebral Edema in Large Vessel Occlusion with Successful Recanalization Through Automated Weighted Net Water Uptake. World Neurosurg 2024:S1878-8750(24)00864-7. [PMID: 38796145 DOI: 10.1016/j.wneu.2024.05.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Accepted: 05/16/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Malignant cerebral edema (MCE) is associated with both net water uptake (NWU) and infarct volume. We hypothesized that NWU weighted by the affected Alberta Stroke Program Early Computed Tomography Score (ASPECTS) regions could serve as a quantitative imaging biomarker of aggravated edema development in acute ischemic stroke with large vessel occlusion (LVO). The aim of this study was to evaluate the performance of weighted NWU (wNWU) to predict MCE in patients with mechanical thrombectomy (MT). METHODS We retrospectively analyzed consecutive patients who underwent MT due to LVO. NWU was computed from nonenhanced computed tomography scans upon admission using automated ASPECTS software. wNWU was derived by multiplying NWU with the number of affected ASPECTS regions in the ischemic hemisphere. Predictors of MCE were assessed through multivariate logistic regression analysis and receiver operating characteristic curves. RESULTS NWU and wNWU were significantly higher in MCE patients than in non-MCE patients. Vessel recanalization status influenced the performance of wNWU in predicting MCE. In patients with successful recanalization, wNWU was an independent predictor of MCE (adjusted odds ratio 1.61; 95% confidence interval [CI] 1.24-2.09; P < 0.001). The model integrating wNWU, National Institutes of Health Stroke Scale, and collateral score exhibited an excellent performance in predicting MCE (area under the curve 0.80; 95% CI 0.75-0.84). Among patients with unsuccessful recanalization, wNWU did not influence the development of MCE (adjusted odds ratio 0.99; 95% CI 0.60-1.62; P = 0.953). CONCLUSIONS This study revealed that wNWU at admission can serve as a quantitative predictor of MCE in LVO with successful recanalization after MT and may contribute to the decision for early intervention.
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Affiliation(s)
- Haoli Xu
- Suzhou Medical College of Soochow University, Suzhou, Jiangsu, China; Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Mo Zheng
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Wenhui Liu
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Weili Peng
- Cancer Center, Department of Interventional Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Jiamei Qiu
- Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Wangle Huang
- Department of Nuclear Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jiaqi Zhang
- Cancer Center, Department of Interventional Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Enhui Xin
- Department of Research and Development, Shanghai United Imaging Intelligence Co., Ltd., Shanghai, China
| | - Nengzhi Xia
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Ru Lin
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Chaomin Qiu
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Guoquan Cao
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Weijian Chen
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yunjun Yang
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; Department of Nuclear Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yinfeng Qian
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Jun Chen
- Suzhou Medical College of Soochow University, Suzhou, Jiangsu, China; Cancer Center, Department of Interventional Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China.
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Wang H, Xu C, Xiao Y, Shen P, Guo S, Shang Y, Chen X, Xu J, Li C, Tan M, Zhang S, Geng Y. A dynamic nomogram for predict individual risk of malignant brain edema after endovascular thrombectomy in acute ischemic stroke. Sci Rep 2024; 14:9529. [PMID: 38664433 PMCID: PMC11045849 DOI: 10.1038/s41598-024-60083-w] [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: 01/28/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
The aim of this study was to develop a dynamic nomogram combining clinical and imaging data to predict malignant brain edema (MBE) after endovascular thrombectomy (EVT) in patients with large vessel occlusion stroke (LVOS). We analyzed the data of LVOS patients receiving EVT at our center from October 2018 to February 2023, and divided a 7:3 ratio into the training cohort and internal validation cohort, and we also prospectively collected patients from another stroke center for external validation. MBE was defined as a midline shift or pineal gland shift > 5 mm, as determined by computed tomography (CT) scans obtained within 7 days after EVT. A nomogram was constructed using logistic regression analysis, and its receiver operating characteristic curve (ROC) and calibration were assessed in three cohorts. A total of 432 patients were enrolled in this study, with 247 in the training cohort, 100 in the internal validation cohort, and 85 in the external validation cohort. MBE occurred in 24% (59) in the training cohort, 16% (16) in the internal validation cohort and 14% (12) in the external validation cohort. After adjusting for various confounding factors, we constructed a nomogram including the clot burden score (CBS), baseline neutrophil count, core infarct volume on CTP before EVT, collateral index, and the number of retrieval attempts. The AUCs of the training cohorts were 0.891 (95% CI 0.840-0.942), the Hosmer-Lemeshow test showed good calibration of the nomogram (P = 0.879). And our nomogram performed well in both internal and external validation data. Our nomogram demonstrates promising potential in identifying patients at elevated risk of MBE following EVT for LVOS.
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Affiliation(s)
- Huiyuan Wang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
- School of Clinical Medicine, Graduate School, Bengbu Medical College, Bengbu, China
| | - Chenghua Xu
- Department of Neurology, Taizhou First People's Hospital, Taizhou, Zhejiang, China
| | - Yu Xiao
- Department of Neurology, Taizhou First People's Hospital, Taizhou, Zhejiang, China
| | - Panpan Shen
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
- Department of the Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Shunyuan Guo
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
| | - Yafei Shang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
- School of Clinical Medicine, Graduate School, Bengbu Medical College, Bengbu, China
| | - Xinyi Chen
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
- Department of the Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jie Xu
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
- Department of the Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Chunrong Li
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
| | - Mingming Tan
- Department of Quality Management, Zhejiang Provincial People's Hospital, Hangzhou, 310014, Zhejiang, China
| | - Sheng Zhang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China.
| | - Yu Geng
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China.
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Simard JM, Wilhelmy B, Tsymbalyuk N, Shim B, Stokum JA, Evans M, Gaur A, Tosun C, Keledjian K, Ciryam P, Serra R, Gerzanich V. Brain Swelling versus Infarct Size: A Problematizing Review. Brain Sci 2024; 14:229. [PMID: 38539619 PMCID: PMC10968884 DOI: 10.3390/brainsci14030229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/21/2024] [Accepted: 02/24/2024] [Indexed: 05/16/2024] Open
Abstract
In human stroke, brain swelling is an important predictor of neurological outcome and mortality, yet treatments to reduce or prevent brain swelling are extremely limited, due in part to an inadequate understanding of mechanisms. In preclinical studies on cerebroprotection in animal models of stroke, historically, the focus has been on reducing infarct size, and in most studies, a reduction in infarct size has been associated with a corresponding reduction in brain swelling. Unfortunately, such findings on brain swelling have little translational value for treating brain swelling in patients with stroke. This is because, in humans, brain swelling usually becomes evident, either symptomatically or radiologically, days after the infarct size has stabilized, requiring that the prevention or treatment of brain swelling target mechanism(s) that are independent of a reduction in infarct size. In this problematizing review, we highlight the often-neglected concept that brain edema and brain swelling are not simply secondary, correlative phenomena of stroke but distinct pathological entities with unique molecular and cellular mechanisms that are worthy of direct targeting. We outline the advances in approaches for the study of brain swelling that are independent of a reduction in infarct size. Although straightforward, the approaches reviewed in this study have important translational relevance for identifying novel treatment targets for post-ischemic brain swelling.
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Affiliation(s)
- J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Bradley Wilhelmy
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Natalya Tsymbalyuk
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Bosung Shim
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Jesse A. Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Madison Evans
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Anandita Gaur
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Cigdem Tosun
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Kaspar Keledjian
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Prajwal Ciryam
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Riccardo Serra
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
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Elkhayyat ON, Froehler MT, Good BC. Analysis of frictional forces in experimental models of stent retriever mechanical thrombectomy. J Biomech 2024; 164:111971. [PMID: 38309134 DOI: 10.1016/j.jbiomech.2024.111971] [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: 09/14/2023] [Revised: 01/21/2024] [Accepted: 01/28/2024] [Indexed: 02/05/2024]
Abstract
Acute ischemic stroke (AIS) and mechanical thrombectomy (MT) are commonly studied in vitro using cerebral artery models made of nonbiological materials. However, these models often report higher recanalization rates than those observed clinically, suggesting a discrepancy between experimental models and clinical settings. We believe this may be partly due to the frictional interactions between blood clots, stent retrievers (SRs), and the vessel walls. Experiments were performed to measure the coefficients of static and kinetic friction between blood clots, common nonbiological model materials, and bovine carotid arteries (CAs). Additional friction testing was performed with nitinol SRs. Coefficients of static friction between blood clots and nonbiological materials were found to range from 0.1 to 0.2, increasing with decreasing clot hematocrit, but were significantly higher between blood clots and CAs (1.49, 0.57, and 0.46 for 0, 20, and 40% hematocrit clots, respectively). For 0% and 40% hematocrit clots, the coefficients of kinetic friction with nonbiological materials were less than 0.1, while significantly higher with CAs (0.26 and 0.23 for 0% and 40% hematocrit clots, respectively). However, no significant differences in the coefficients of kinetic friction were found between the different hematocrit clots. Testing with the nitinol SR showed no significant differences in the coefficients of kinetic friction for CAs (0.73) and silicone (0.78), suggesting that silicone could be a suitable model material for evaluating SR-vessel interactions in vitro. Overall, it is evident that discrepancies exist in the frictional forces between materials commonly used in experimental models of AIS and MT and those seen in vivo. The individual contributions of clot-artery, SR-artery, and clot-SR interactions during blood clot removal merit further investigation.
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Affiliation(s)
- Omar N Elkhayyat
- Department of Mechanical, Aerospace, and Biomedical Engineering, University of Tennessee, Knoxville, TN, United States
| | - Michael T Froehler
- Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Bryan C Good
- Department of Mechanical, Aerospace, and Biomedical Engineering, University of Tennessee, Knoxville, TN, United States.
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