1
|
Orscelik A, Senol YC, Bilgin C, Kobeissi H, Ghozy S, Musmar B, Bilgin GB, Zandpazandi S, Pakkam M, Arul S, Brinjikji W, Kallmes DF. Outcomes of mechanical thrombectomy in M1 occlusion patients with or without hyperdense middle cerebral artery sign: A systematic review and meta-analysis. Neuroradiol J 2024; 37:454-461. [PMID: 38146685 PMCID: PMC11366193 DOI: 10.1177/19714009231224446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND The comparison of mechanical thrombectomy (MT) outcomes between patients with the hyperdense middle cerebral artery sign (HMCAS) and non-HMCAS is important to evaluate the impact of this radiological finding on treatment efficacy. This meta-analysis aimed to assess the association between HMCAS and clinical outcomes in patients undergoing thrombectomy, comparing the outcomes over non-HMCAS. METHODS A systematic literature search was conducted in PubMed, Ovid Embase, Google Scholar, and Cochrane Library to identify studies on MT outcomes for M1 occlusions of HMCAS over non-HMCAS. Inclusion criteria encompassed modified Rankin Scale (mRS) score, mortality, symptomatic intracranial hemorrhage (sICH), and successful recanalization. Using R software version 4.1.2, we calculated pooled odds ratios (ORs) and their corresponding 95% confidence intervals (CI). RESULTS The meta-analysis was performed for 5 studies with 724 patients. There was no association found between presence of HMCAS and achieving mRS 0-2 (OR = 0.65, 95% CI: 0.29-1.47; p = .544). Mortality analysis also showed no significant association with presence of HMCAS (OR = 0.78, 95% CI: 0.37-1.65; p = .520). No significant difference in sICH risk (OR = 1.54, 95% CI: 0.24-9.66; p = .646) was found between groups. Recanalization analysis showed a non-significant positive association (OR = 1.23, 95% CI: 0.67-2.28; p = .501). Heterogeneity was observed in all analyses. CONCLUSION Our findings showed that there is no statistically significant difference in mRS scores, mortality, sICH, and recanalization success rates between the HMCAS and non-HMCAS groups.
Collapse
Affiliation(s)
- Atakan Orscelik
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Yigit Can Senol
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - Basel Musmar
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Sara Zandpazandi
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Madona Pakkam
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Santhosh Arul
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | | |
Collapse
|
2
|
Zhang L, Li J, Yang B, Li W, Wang X, Zou M, Song H, Shi L, Duan Y. The risk and outcome of malignant brain edema in post-mechanical thrombectomy: acute ischemic stroke by anterior circulation occlusion. Eur J Med Res 2023; 28:435. [PMID: 37833809 PMCID: PMC10571427 DOI: 10.1186/s40001-023-01414-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 09/30/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND AND PURPOSE Malignant brain edema (MBE) occurring after mechanical thrombectomy (MT) in acute ischemic stroke (AIS) could lead to severe disability and mortality. We aimed to investigate the incidence, predictors, and clinical outcomes of MBE in patients with AIS after MT. METHODS The clinical and imaging data of 155 patients with AIS of anterior circulation after MT were studied. Standard non-contrast CT was used to evaluate baseline imaging characteristics at admission. Clinical outcomes were measured using the 90-day modified Rankin Scale (mRS) score. Based on the follow-up CT scans performed within 72 h after MT, the patients were classified into MBE and non-MBE group. MBE was defined as a midline shift of ≥ 5 mm with signs of local brain swelling. Univariate and multivariate regression analyses were used to analyze the relationship between MBE and clinical outcomes and identify the predictors that correlate with MBE. RESULTS MBE was observed in 19.4% of the patients who underwent MT and was associated with a lower rate of favorable 90-day clinical outcomes. Significant differences were observed in both MBE and non-MBE groups: baseline Alberta Stroke Program Early CT (ASPECT) score, hyperdense middle cerebral artery sign (HMCAS), baseline signs of early infarct, angiographic favorable collaterals, number of retrieval attempts, and revascularization rate. Multivariate analysis indicated that low baseline ASPECT score, absent HMCAS, angiographic poor collaterals, more retrieval attempt count, and poor revascularization independently influenced the occurrence of MBE in AIS patients with anterior circulation after MT. CONCLUSION MBE was associated with a lower rate of favorable 90-day clinical outcomes. Low baseline ASPECT score, absent HMCAS, angiographic poor collaterals, more retrieval attempt count and poor revascularization were independently associated with MBE after MT.
Collapse
Affiliation(s)
- Luojin Zhang
- Center for Neuroimaging, Department of Radiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenhe District, Shenyang, China
- Department of Radiology, Shanxi Fenyang Hospital, Shanxi, China
| | - Jinze Li
- Center for Neuroimaging, Department of Radiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenhe District, Shenyang, China
- Northern Theater Command Postgraduate Training Base of Jinzhou Medical University General Hospital, Shenyang, China
| | - Benqiang Yang
- Department of Radiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Wei Li
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Xinrui Wang
- Center for Neuroimaging, Department of Radiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenhe District, Shenyang, China
| | - Mingyu Zou
- Center for Neuroimaging, Department of Radiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenhe District, Shenyang, China
| | - Hongyan Song
- Center for Neuroimaging, Department of Radiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenhe District, Shenyang, China
| | - Lin Shi
- Center for Neuroimaging, Department of Radiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenhe District, Shenyang, China
| | - Yang Duan
- Center for Neuroimaging, Department of Radiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenhe District, Shenyang, China.
| |
Collapse
|
3
|
Schwarz R, Bier G, Wilke V, Wilke C, Taubmann O, Ditt H, Hempel JM, Ernemann U, Horger M, Gohla G. Automated Intracranial Clot Detection: A Promising Tool for Vascular Occlusion Detection in Non-Enhanced CT. Diagnostics (Basel) 2023; 13:2863. [PMID: 37761230 PMCID: PMC10527571 DOI: 10.3390/diagnostics13182863] [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: 07/31/2023] [Revised: 08/30/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
(1) Background: to test the diagnostic performance of a fully convolutional neural network-based software prototype for clot detection in intracranial arteries using non-enhanced computed tomography (NECT) imaging data. (2) Methods: we retrospectively identified 85 patients with stroke imaging and one intracranial vessel occlusion. An automated clot detection prototype computed clot location, clot length, and clot volume in NECT scans. Clot detection rates were compared to the visual assessment of the hyperdense artery sign by two neuroradiologists. CT angiography (CTA) was used as the ground truth. Additionally, NIHSS, ASPECTS, type of therapy, and TOAST were registered to assess the relationship between clinical parameters, image results, and chosen therapy. (3) Results: the overall detection rate of the software was 66%, while the human readers had lower rates of 46% and 24%, respectively. Clot detection rates of the automated software were best in the proximal middle cerebral artery (MCA) and the intracranial carotid artery (ICA) with 88-92% followed by the more distal MCA and basilar artery with 67-69%. There was a high correlation between greater clot length and interventional thrombectomy and between smaller clot length and rather conservative treatment. (4) Conclusions: the automated clot detection prototype has the potential to detect intracranial arterial thromboembolism in NECT images, particularly in the ICA and MCA. Thus, it could support radiologists in emergency settings to speed up the diagnosis of acute ischemic stroke, especially in settings where CTA is not available.
Collapse
Affiliation(s)
- Ricarda Schwarz
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University of Tuebingen, D-72076 Tuebingen, Germany; (R.S.); (M.H.)
| | - Georg Bier
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls University of Tuebingen, D-72076 Tuebingen, Germany; (G.B.); (J.-M.H.); (U.E.)
- Radiologie Salzstraße, D-48143 Muenster, Germany
| | - Vera Wilke
- Department of Neurology & Stroke, Eberhard Karls University of Tuebingen, D-72076 Tuebingen, Germany;
- Centre for Neurovascular Diseases Tübingen, D-72076 Tuebingen, Germany
| | - Carlo Wilke
- Division Translational Genomics of Neurodegenerative Diseases, Hertie Institute for Clinical Brain Research, Center of Neurology, University of Tuebingen, D-72076 Tuebingen, Germany;
- German Center for Neurodegenerative Diseases (DZNE), D-72076 Tuebingen, Germany
| | - Oliver Taubmann
- Siemens Healthcare GmbH, Computed Tomography, D-91301 Forchheim, Germany; (O.T.); (H.D.)
| | - Hendrik Ditt
- Siemens Healthcare GmbH, Computed Tomography, D-91301 Forchheim, Germany; (O.T.); (H.D.)
| | - Johann-Martin Hempel
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls University of Tuebingen, D-72076 Tuebingen, Germany; (G.B.); (J.-M.H.); (U.E.)
| | - Ulrike Ernemann
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls University of Tuebingen, D-72076 Tuebingen, Germany; (G.B.); (J.-M.H.); (U.E.)
| | - Marius Horger
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University of Tuebingen, D-72076 Tuebingen, Germany; (R.S.); (M.H.)
| | - Georg Gohla
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls University of Tuebingen, D-72076 Tuebingen, Germany; (G.B.); (J.-M.H.); (U.E.)
| |
Collapse
|
4
|
Bala F, Kappelhof M, Ospel JM, Cimflova P, Qiu W, Singh N, Zhu K, Kim BJ, Wadhwa A, Almekhlafi MA, Menon BK, Arrarte Terreros N, Marquering H, Majoie C, Hill MD, Goyal M. Distal Embolization in Relation to Radiological Thrombus Characteristics, Treatment Details, and Functional Outcome. Stroke 2023; 54:448-456. [PMID: 36689583 DOI: 10.1161/strokeaha.122.040542] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 11/23/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Distal embolization (DE) is a common complication of endovascular treatment (EVT). We investigated the association of radiological thrombus characteristics and treatment details with DE. METHODS Patients with thin-slice (≤2.5 mm) baseline noncontrast computed tomography and computed tomography angiography from the ESCAPE-NA1 trial (Efficacy and Safety of Nerinetide for the Treatment of Acute Ischemic Stroke) were included. Thrombus annotation was performed manually on coregistered scans by experienced readers. We assessed thrombus location, distance from internal carotid artery terminus, length, perviousness, absolute attenuation, and hyperdense artery sign. In addition, we evaluated balloon guide catheter use during EVT, first-line EVT approach, the number of thrombectomy passes, and prior intravenous thrombolysis administration. DE was defined as the occurrence of emboli distal to the target artery or in new territories during EVT. The association between thrombus characteristics, treatment details, and DE was evaluated using descriptive statistics and multivariable mixed-effects logistic regression, resulting in adjusted odds ratios (aOR) with 95% CI. Interaction between IVT and radiological thrombus characteristics was assessed by adding interaction terms in separate models. RESULTS In total, 496 out of 1105 (44.9%) ESCAPE-NA1 patients were included. DE was detected in 251 out of 496 patients (50.6%). Patients with DE had longer thrombi (median, 28.5 [interquartile range, 20.8-42.3] mm versus 24.4 [interquartile range, 17.1-32.4] mm; P<0.01). There were no statistically significant differences in the other thrombus characteristics. Factors associated with DE were thrombus length (aOR, 1.02 [95% CI, 1.01-1.04]), balloon guide catheter use (aOR, 0.49 [95% CI, 0.29-0.85]), and number of passes (aOR, 1.24 [95% CI, 1.04-1.47]). In patients with hyperdense artery sign, IVT was associated with reduced odds of DE (aOR, 0.55 [95% CI, 0.31-0.97]), P for interaction=0.04. CONCLUSIONS DE was associated with longer thrombi, no balloon guide catheter use, and more EVT passes. IVT was associated with a reduced risk of DE in patients with hyperdense artery sign. These findings may support treatment decisions on IVT and EVT approaches.
Collapse
Affiliation(s)
- Fouzi Bala
- Department of Clinical Neurosciences and Diagnostic Imaging (F.B., J.M.O., P.C., W.Q., N.S., K.Z., A.W., M.A.A., B.K.M., M.D.H., M.G.), University of Calgary, Canada
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, France (F.B.)
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine (M.K., N.A.T., H.M., C.M.), Amsterdam UMC location University of Amsterdam, the Netherlands
| | - Johanna M Ospel
- Department of Clinical Neurosciences and Diagnostic Imaging (F.B., J.M.O., P.C., W.Q., N.S., K.Z., A.W., M.A.A., B.K.M., M.D.H., M.G.), University of Calgary, Canada
- Department of Radiology, University Hospital of Basel, Switzerland (J.M.O.)
| | - Petra Cimflova
- Department of Clinical Neurosciences and Diagnostic Imaging (F.B., J.M.O., P.C., W.Q., N.S., K.Z., A.W., M.A.A., B.K.M., M.D.H., M.G.), University of Calgary, Canada
- Department of Radiology (P.C., M.A.A., B.K.M., M.D.H.), University of Calgary, Canada
- Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.)
| | - Wu Qiu
- Department of Clinical Neurosciences and Diagnostic Imaging (F.B., J.M.O., P.C., W.Q., N.S., K.Z., A.W., M.A.A., B.K.M., M.D.H., M.G.), University of Calgary, Canada
- School of Life Science and Technology, Huazhong University of Science and Technology (W.Q.)
| | - Nishita Singh
- Department of Clinical Neurosciences and Diagnostic Imaging (F.B., J.M.O., P.C., W.Q., N.S., K.Z., A.W., M.A.A., B.K.M., M.D.H., M.G.), University of Calgary, Canada
| | - Kairan Zhu
- Department of Clinical Neurosciences and Diagnostic Imaging (F.B., J.M.O., P.C., W.Q., N.S., K.Z., A.W., M.A.A., B.K.M., M.D.H., M.G.), University of Calgary, Canada
| | - Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea (B.J.K.)
| | - Ankur Wadhwa
- Department of Clinical Neurosciences and Diagnostic Imaging (F.B., J.M.O., P.C., W.Q., N.S., K.Z., A.W., M.A.A., B.K.M., M.D.H., M.G.), University of Calgary, Canada
| | - Mohammed A Almekhlafi
- Department of Clinical Neurosciences and Diagnostic Imaging (F.B., J.M.O., P.C., W.Q., N.S., K.Z., A.W., M.A.A., B.K.M., M.D.H., M.G.), University of Calgary, Canada
- Department of Radiology (P.C., M.A.A., B.K.M., M.D.H.), University of Calgary, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences and Diagnostic Imaging (F.B., J.M.O., P.C., W.Q., N.S., K.Z., A.W., M.A.A., B.K.M., M.D.H., M.G.), University of Calgary, Canada
- Department of Radiology (P.C., M.A.A., B.K.M., M.D.H.), University of Calgary, Canada
| | - Nerea Arrarte Terreros
- Department of Radiology and Nuclear Medicine (M.K., N.A.T., H.M., C.M.), Amsterdam UMC location University of Amsterdam, the Netherlands
- Department of Biomedical Engineering and Physics (N.A.T., H.M.), Amsterdam UMC location University of Amsterdam, the Netherlands
| | - Henk Marquering
- Department of Radiology and Nuclear Medicine (M.K., N.A.T., H.M., C.M.), Amsterdam UMC location University of Amsterdam, the Netherlands
- Department of Biomedical Engineering and Physics (N.A.T., H.M.), Amsterdam UMC location University of Amsterdam, the Netherlands
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine (M.K., N.A.T., H.M., C.M.), Amsterdam UMC location University of Amsterdam, the Netherlands
| | - Michael D Hill
- Department of Clinical Neurosciences and Diagnostic Imaging (F.B., J.M.O., P.C., W.Q., N.S., K.Z., A.W., M.A.A., B.K.M., M.D.H., M.G.), University of Calgary, Canada
- Department of Radiology (P.C., M.A.A., B.K.M., M.D.H.), University of Calgary, Canada
| | - Mayank Goyal
- Department of Clinical Neurosciences and Diagnostic Imaging (F.B., J.M.O., P.C., W.Q., N.S., K.Z., A.W., M.A.A., B.K.M., M.D.H., M.G.), University of Calgary, Canada
| |
Collapse
|
5
|
Hyperdense middle cerebral artery sign predicts favorable outcome in patients undergoing mechanical thrombectomy. J Thromb Thrombolysis 2023; 55:312-321. [PMID: 36434302 DOI: 10.1007/s11239-022-02731-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2022] [Indexed: 11/26/2022]
Abstract
Non-contrast computer tomography detects the presence of hyperdense middle cerebral artery sign (HMCAS). Studies on the prognostic value of HMCAS among patients undergoing mechanical thrombectomy (MT) are conflicting. A retrospective analysis of consecutive patients with acute ischemic stroke due to middle cerebral artery occlusion, presenting with or without HMCAS, who underwent MT, was performed. We enrolled 191 patients (HMCAS +, n = 140; HMCAS -, n = 51). Prevalence of successful recanalization was significantly higher in patients with HMCAS than in those without HMCAS (92.1% versus 74.5%, p = 0.001). Patients with HMCAS had a better clinical outcome than those HMCAS - (54.3% versus 37.3%, p = 0.037, for three-month favorable outcome; 62.9% versus 39.3%, p = 0.004, for major neurological improvement at discharge; 8.6% versus 19.6%, p = 0.035, for in-hospital mortality; 14.3% versus 27.5%, p = 0.035, for intracranial hemorrhage; 2.9% versus 17.6%, p = 0.001, for symptomatic intracranial hemorrhage). Multivariate analyses confirmed that HMCAS represents an independent predictor of three-month favorable outcome (OR 2.48, 95% CI 1.10-5.58, p = 0.028), major neurological improvement at discharge (OR 2.40, 95% CI 1.09-5.20, p = 0.030), in-hospital mortality (OR 0.29, 95% CI 0.010-0.81, p = 0.018), presence of ICH (OR 0.49, 95% CI 0.25-0.97, p = 0.042) and presence of SICH (OR 0.16, 95% CI 0.04-0.63, p = 0.009). HMCAS presence predicts favorable outcome in patients undergoing MT. This result may indicate that hyperdense clots are more likely to respond to MT than isodense ones. This effect is mediated by reduction in hemorrhagic transformation.
Collapse
|
6
|
Wu Q, Wei C, Liu J, Wang Y, Liu M. Effects of Hyperferritinemia on Functional Outcome in Acute Ischemic Stroke Patients with Admission Hyperglycemia. Cerebrovasc Dis 2022; 52:511-518. [PMID: 36516789 DOI: 10.1159/000527860] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 10/26/2022] [Indexed: 10/04/2023] Open
Abstract
INTRODUCTION Hyperferritinemia, presented as elevated serum ferritin level, is an indicator of high iron status which plays roles in secondary brain injury after acute ischemic stroke (AIS). However, the effects of hyperferritinemia and poor outcomes remain uncertain. Additionally, admission hyperglycemia quite frequently accompanies AIS patients, which is associated with unfavorable outcome. Thus, we aimed to investigate the effects of hyperferritinemia on 3-month and 1-year functional outcomes in AIS patients and especially those with admission hyperglycemia. METHODS AIS patients within 24 h of onset were enrolled at West China Hospital from October 2016 to December 2019. Serum ferritin and blood glucose levels were tested on admission. Poor functional outcome at 3 months and 1 year was defined as modified Rankin Scale score ≥3. Multivariable analysis was used to investigate the associations between hyperferritinemia and 3-month and 1-year outcomes. Subgroup analysis was performed in patients with and without hyperglycemia. RESULTS Of 723 patients (mean age 68.11 years, 60.6% males) finally included, 347 (48.0%) had hyperferritinemia. The incidence of poor outcome was 45.2% at 3 months and 41.2% at 1 year. Patients with hyperferritinemia had a higher frequency of poor 3-month outcome (51.8% vs. 39.2%, p = 0.001) and poor 1-year outcome (46.8% vs. 36.1%, p = 0.004). In all AIS patients, hyperferritinemia was not independently associated with poor functional outcome at 3 months or 1 year after adjusting for confounders (all p > 0.05). In AIS patients with hyperglycemia, hyperferritinemia was an independent factor correlated with poor 3-month outcome (OR = 1.711, 95% CI 1.093-2.681, p = 0.019) but not with poor 1-year outcome (p > 0.05). CONCLUSIONS High iron status, presented as hyperferritinemia, is associated with poor 3-month functional outcome in AIS patients with hyperglycemia. Evaluating serum ferritin level may be conducive to assess the risk of short-term poor outcome in AIS patients with hyperglycemia. Further studies will be required to confirm our findings.
Collapse
Affiliation(s)
- Qian Wu
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, China,
| | - Chenchen Wei
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Junfeng Liu
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, China
| | - Yanan Wang
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, China
| | - Ming Liu
- Department of Neurology, Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
7
|
Chen J, Li J, Xu Z, Zhang L, Qi S, Yang B, Chen Z, Wang X, Duan Y. Prediction model of early biomarkers of massive cerebral infarction caused by anterior circulation occlusion: Establishment and evaluation. Front Neurol 2022; 13:903730. [PMID: 36062018 PMCID: PMC9433650 DOI: 10.3389/fneur.2022.903730] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/26/2022] [Indexed: 11/14/2022] Open
Abstract
Objective The purpose of this study is to establish and evaluate an early biomarker prediction model of massive cerebral infarction caused by anterior circulation occlusion. Methods One hundred thirty-four patients with acute cerebral infarction from January 2018 to October 2020 were selected to establish the development cohort for the internal test of the nomogram. Ninety-one patients with acute cerebral infarction hospitalized in our hospital from December 2020 to December 2021 were constituted the validation cohort for the external validation. All patients underwent baseline computed tomography (CT) scans within 12 h of onset and early imaging signs (hyperdense middle cerebral artery sign, obscuration of the lentiform nucleus, insular ribbon sign) of acute cerebral infarction were identified on CT by two neurologists. Based on follow-up CT images, patients were then divided into a massive cerebral infarction group and a non-massive cerebral infarction group. The nomogram model was constructed based on logistic regression analysis with R language. The nomogram was subsequently validated in an independent external validation cohort. Accuracy and discrimination of the prediction model were evaluated by a calibration chart, receiver operating characteristic (ROC) curve, and decision curve. Results The indicators, including insular ribbon sign, reperfusion therapy, National Institutes of Health Stroke Scale (NHISS) score, previous cerebral infarction, and atrial fibrillation, were entered into the prediction model through binary logistic regression analysis. The prediction model showed good predictive ability. The area under the ROC curve of the prediction model was 0.848. The specificity, sensitivity, and Youden index were 0.864, 0.733, and 0.597, respectively. This nomogram to the validation cohort also showed good discrimination (AUC = 0.940, 95% CI 0.894–0.985) and calibration. Conclusion Demonstrating favorable predictive efficacy and reproducibility, this study successfully established a prediction model of CT imaging signs and clinical data as early biomarkers of massive cerebral infarction caused by anterior circulation occlusion.
Collapse
Affiliation(s)
- Jingshu Chen
- Center for Neuroimaging, Department of Radiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Jinze Li
- Center for Neuroimaging, Department of Radiology, General Hospital of Northern Theater Command, Shenyang, China
- Center for Neuroimaging, Northern Theater Command Postgraduate Training Base of Jinzhou Medical University General Hospital, Shenyang, China
| | - Zhihua Xu
- Department of Radiology, Tong De Hospital of Zhejiang Province, Hangzhou, China
| | - Luojin Zhang
- Center for Neuroimaging, Department of Radiology, General Hospital of Northern Theater Command, Shenyang, China
- Center for Neuroimaging, Northern Theater Command Postgraduate Training Base of Dalian Medical University General Hospital, Shenyang, China
| | - Shouliang Qi
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang, China
| | - Benqiang Yang
- Department of Radiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Zimeng Chen
- Boston University College of Art and Science, Boston, MA, United States
| | - Xinrui Wang
- Department of Radiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yang Duan
- Center for Neuroimaging, Department of Radiology, General Hospital of Northern Theater Command, Shenyang, China
- *Correspondence: Yang Duan
| |
Collapse
|
8
|
Zhou Y, Jing Y, Ospel J, Goyal M, McDonough R, Yue X, Ren Y, Sun Y, Li B, Yu W, Yang P, Zhang Y, Zhang L, Li Z, Duan G, Ye X, Hong B, Shi H, Han H, Li S, Liu S, Liu J. CT Hyperdense Artery Sign and the Effect of Alteplase in Endovascular Thrombectomy after Acute Stroke. Radiology 2022; 305:410-418. [PMID: 35819327 DOI: 10.1148/radiol.212358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Recent evidence suggests that presence of an intracranial arterial thrombus with a hyperdense artery sign (HAS) at noncontrast CT (NCCT) is associated with better response to intravenous alteplase. Patients with HAS may benefit more from combined intravenous alteplase and endovascular treatment (EVT). Purpose To investigate whether HAS at NCCT modifies the treatment effect of adding intravenous alteplase on clinical outcome in patients with acute large-vessel occlusion undergoing EVT. Materials and Methods This study is a secondary analysis of a prospective randomized trial (Direct Intra-arterial thrombectomy in order to Revascularize AIS patients with large-vessel occlusion Efficiently in Chinese Tertiary hospitals: A Multicenter randomized clinical Trial [DIRECT-MT]), which compared adding alteplase to EVT versus EVT alone in participants with acute large-vessel occlusion between February 2018 and July 2019. Participants with catheter angiograms and adequate NCCT for HAS evaluation were included. HAS was determined visually by two independent investigators at baseline NCCT. Treatment effect of intravenous alteplase administration according to presence of HAS on the primary clinical outcome (modified Rankin Scale [mRS] score at 90 days) and secondary and safety outcomes were assessed using adjusted multivariable regression models. Results Among 633 included participants (356 men [56%]; median age, 69 years), HAS was observed in 283 participants (45%): 142 of 313 participants (45%) in the EVT-only group and 141 of 320 participants (44%) in the group with added intravenous alteplase. Treatment-by-HAS interaction was observed for the primary outcome (P < .001), whereby a shift in favor of better outcomes with added intravenous alteplase occurred in participants with HAS (adjusted odds ratio [OR]: 1.82; 95% CI: 1.18, 2.79), while an adverse effect was seen in participants without HAS (adjusted OR: 0.62; 95% CI: 0.42, 0.91). This also held true for three secondary outcomes (excellent outcome [mRS score of 0-1 at 90 days], P = .005; good outcome [mRS score of 0-2 at 90 days], P = .008; final successful reperfusion, P = .04) in the adjusted models. Conclusion After acute ischemic stroke, presence of hyperdense artery sign (HAS) at baseline noncontrast CT indicated better outcomes when alteplase was added to endovascular treatment, but adding alteplase to endovascular treatment resulted in worse outcomes in participants without HAS. Clinical trial registration no. NCT03469206 © RSNA, 2022 Online supplemental material is available for this article.
Collapse
Affiliation(s)
- Yu Zhou
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| | - Yantao Jing
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| | - Johanna Ospel
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| | - Mayank Goyal
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| | - Rosalie McDonough
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| | - Xincan Yue
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| | - Yuwei Ren
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| | - Yan Sun
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| | - Biao Li
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| | - Wenkai Yu
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| | - Pengfei Yang
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| | - Yongwei Zhang
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| | - Lei Zhang
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| | - Zifu Li
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| | - Guoli Duan
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| | - Xiaofei Ye
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| | - Bo Hong
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| | - Huaizhang Shi
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| | - Hongxing Han
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| | - Shuai Li
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| | - Sheng Liu
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| | - Jianmin Liu
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| | -
- From the Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, P.Y., Y. Zhang, L.Z., Z.L., G.D., B.H., J.L.); Neurosurgery Intensive Care Unit, ZhouKou Center Hospital, He'nan, China (Y.J., X. Yue, Y.R., Y.S., B.L., W.Y., S. Li); Department of Radiology, University Hospital Basel, Basel, Switzerland (J.O.); Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Canada (M.G., R.M.); Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany (R.M.); Health Statistics Department, Naval Medical University, Shanghai, China (X. Ye); Department of Neurosurgery, First Hospital Affiliate to Harbin Medical University, Harbin, China (H.S.); Department of Neurology, Linyi People's Hospital, Shandong, China (H.H.); Department of Radiology, Jiangsu People's Hospital, Jiangsu, China (S. Liu)
| |
Collapse
|
9
|
Prognosis with non-contrast CT and CT Perfusion imaging in thrombolysis-treated acute ischemic stroke. Eur J Radiol 2022; 149:110217. [DOI: 10.1016/j.ejrad.2022.110217] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/13/2022] [Accepted: 02/10/2022] [Indexed: 11/21/2022]
|
10
|
LaGrange DD, Wanke I, Machi P, Bernava G, Vargas M, Botta D, Berberat J, Muster M, Platon A, Poletti PA, Lövblad KO. Multimodality Characterization of the Clot in Acute Stroke. Front Neurol 2022; 12:760148. [PMID: 34970209 PMCID: PMC8712945 DOI: 10.3389/fneur.2021.760148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/17/2021] [Indexed: 11/26/2022] Open
Abstract
Aim: Current treatment of occluded cerebral vessels can be done by a variety of endovascular techniques. Sometimes, the clot responds in varying degrees to the treatment chosen. The Ex vivo characterization of the clot occluding the arteries in acute ischemic stroke can help in understanding the underlying imaging features obtained from pre-treatment brain scans. For this reason, we explored the potential of microCT when combined with electron microscopy for clot characterization. Results were compared to the clinical CT findings. Methods: 16 patients (9 males, 8 females, age range 54–93 years) who were referred to our institution for acute stroke underwent dual-source CT. Results: Clinical CT clots were seen as either iso or hyperdense. This was corroborated with micro-CT, and electron microscopy can show the detailed composition. Conclusion: MicroCT values can be used as an indicator for red blood cells-rich composition of clots. Meaningful information regarding the clot composition and modalities of embedding along the stent retrievers can be obtained through a combination of microCT and electron microscopy.
Collapse
Affiliation(s)
- Daniela Dumitriu LaGrange
- Division of Diagnostic and Interventional Neuroradiology, Diagnostic Department, HUG Geneva University Hospitals, Genève, Switzerland
| | - Isabel Wanke
- Division of Neuroradiology, Zentrum für Neuroradiologie, Klinik Hirslanden, Zurich, Switzerland.,Swiss Neuroradiology Institute, Zurich, Switzerland.,Division of Neuroradiology, Institute of Diagnostic and Interventional Radiology and Neuroradiology, University of Essen, Essen, Germany
| | - Paolo Machi
- Division of Diagnostic and Interventional Neuroradiology, Diagnostic Department, HUG Geneva University Hospitals, Genève, Switzerland
| | - Gianmarco Bernava
- Division of Diagnostic and Interventional Neuroradiology, Diagnostic Department, HUG Geneva University Hospitals, Genève, Switzerland
| | - Maria Vargas
- Division of Diagnostic and Interventional Neuroradiology, Diagnostic Department, HUG Geneva University Hospitals, Genève, Switzerland
| | - Daniele Botta
- Division of Radiology, Diagnostic Department, Geneva University Hospitals, Genève, Switzerland
| | - Jatta Berberat
- Division of Neuroradiology, Zentrale Medizinische Dienste, Kantonsspital Aarau, Aarau, Switzerland
| | - Michel Muster
- Division of Diagnostic and Interventional Neuroradiology, Diagnostic Department, HUG Geneva University Hospitals, Genève, Switzerland
| | - Alexandra Platon
- Division of Radiology, Diagnostic Department, Geneva University Hospitals, Genève, Switzerland
| | | | - Karl-Olof Lövblad
- Division of Diagnostic and Interventional Neuroradiology, Diagnostic Department, HUG Geneva University Hospitals, Genève, Switzerland
| |
Collapse
|
11
|
Wei C, Liu J, Guo W, Jin Y, Song Q, Wang Y, Ye C, Li J, Zhang S, Liu M. Development and Validation of a Predictive Model for Spontaneous Hemorrhagic Transformation After Ischemic Stroke. Front Neurol 2021; 12:747026. [PMID: 34867730 PMCID: PMC8634397 DOI: 10.3389/fneur.2021.747026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 09/30/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Hemorrhagic transformation (HT) after reperfusion therapy for acute ischemic stroke (AIS) has been well studied; however, there is scarce research focusing on spontaneous HT (sHT). Spontaneous HT is no less important with a relatively high incidence and could be associated with neurological worsening. We aimed to develop and validate a simple and practical model to predict sHT after AIS (SHAIS) and compared the predictive value of the SHAIS score against the models of post-Reperfusion HT for sHT. Methods: Patients with AIS admitted within 24 h of onset were prospectively screened to develop and validate the SHAIS score. The primary outcome was sHT during hospitalization (within 30 days after onset), and the secondary outcomes were symptomatic sHT and parenchymal hematoma (PH). Clinical information, laboratory, and neuroimaging data were screened to construct the SHAIS score. We selected six commonly used scales for predicting HT after reperfusion therapy and compared their predictive ability for sHT with the SHAIS score using Delong's test. Results: The derivation cohort included 539 patients (mean age, 68.1 years; men, 61.4%), of whom 91 (16.9%) patients developed sHT with 25.3% (23/91) being symptomatic sHT and 62.6% (57/91) being PH. Five variables (atrial fibrillation, NIHSS score ≥ 10, hypodensity > 1/3 of middle cerebral artery territory, hyperdense artery sign, and anterior circulation infarction) composed the SHAIS score, which ranged from 0 to 11 points. The area under the receiver-operating characteristic curve (AUC) was 0.86 (95% CI 0.82–0.91, p < 0.001) for the overall sHT, 0.85 (95% CI 0.76–0.92, p < 0.001) for symptomatic sHT, and 0.89 (95% CI 0.85–0.94, p < 0.001) for PH. No evidence of miscalibration of the SHAIS score was found to predict the overall sHT (p = 0.19), symptomatic sHT (p = 0.44), and PH (p = 0.22). The internal (n = 245) and external validation cohorts (n = 200) depicted similar predictive performance compared to the derivation cohort. The SHAIS score had a higher AUC to predict sHT than any of the six pre-Existing models (p < 0.05). Conclusions: The SHAIS score provides an easy-to-use model to predict sHT, which could help providers with decision-making about treatments with high bleeding risk, and to counsel patients and families on the baseline risk of HT, aligning expectations with probable outcomes.
Collapse
Affiliation(s)
- Chenchen Wei
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China.,Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Junfeng Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Wen Guo
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Yuxi Jin
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Quhong Song
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Yanan Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Chen Ye
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Li
- Department of Neurology, The First People's Hospital of Ziyang, Ziyang, China
| | - Shanshan Zhang
- Department of Neurology, Mianyang Central Hospital, Mianyang, China
| | - Ming Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
12
|
Joundi RA, Menon BK. Thrombus Composition, Imaging, and Outcome Prediction in Acute Ischemic Stroke. Neurology 2021; 97:S68-S78. [PMID: 34785606 DOI: 10.1212/wnl.0000000000012796] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES New imaging techniques have advanced our ability to capture thrombus characteristics and burden in real time. An improved understanding of recanalization rates with thrombolysis and endovascular thrombectomy based on thrombus characteristics has spurred interest in new therapies for acute stroke. METHODS AND RESULTS This article reviews the biochemical, structural, and imaging characteristics of intracranial thrombi in acute ischemic stroke; the relationship between thrombus composition and response to lytic and endovascular therapies; and current and future directions for improving outcomes in patients with acute stroke based on thrombus characteristics. DISCUSSION Thrombus composition, size, location, and timing from stroke onset correlate with imaging findings in acute ischemic stroke and are associated with clinical outcome. Further research across multiple domains could assist in better applying our knowledge of thrombi to patient selection and individualization of acute therapies.
Collapse
Affiliation(s)
- Raed A Joundi
- From the Department of Neurosciences and Community Health Sciences, Calgary Stroke Program (R.J.), and Department of Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute (B.K.M.), Cumming School of Medicine, University of Calgary, Canada
| | - Bijoy K Menon
- From the Department of Neurosciences and Community Health Sciences, Calgary Stroke Program (R.J.), and Department of Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute (B.K.M.), Cumming School of Medicine, University of Calgary, Canada.
| |
Collapse
|
13
|
Baykal T, Unal Akoglu E, Akoglu T, Cimilli Ozturk T, Akoglu H. The middle cerebral artery density and ratio for the diagnosis of acute ischaemic stroke in the Emergency Department. Int J Clin Pract 2021; 75:e14799. [PMID: 34482600 DOI: 10.1111/ijcp.14799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/31/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Non-contrast computed tomography (ncCT) is the first-line imaging modality for acute ischaemic stroke diagnosis. Recognition of the early diagnostic signs of a stroke on computed tomography (CT) is crucial. The hyperdense middle cerebral artery (MCA) sign is one of these findings. We investigated the diagnostic utility of absolute MCA density (MCAD) in patients with acute MCA stroke confirmed with diffusion-weighted magnetic resonance imaging (dwMRI). METHODS We retrospectively included all patients who presented to the Emergency Department with symptoms related to an acute stroke and confirmed with a dwMRI and ncCT to this diagnostic case-control study. An expert radiologist with more than four years of experience in neuroradiology re-evaluated all ncCT images. The evaluation of MCAD and ratio were measured on axial images in Hounsfield units (HU). RESULTS We included 407 patients in our study (MCA infarction: 55%, n = 225; Control: 45%, n = 182). We calculated the threshold for the highest sensitivity (20%) and specificity (94%) as 49 HU with the Youden J index test for MCAD and as 1.1 for MCAD ratio (sensitivity 20% and specificity 95%). MCAD >49 HU or MCAD ratio >1.1 alone or joint use of MCAD >47 HU and MCAD ratio >1.1 are useful markers to confirm the diagnosis of MCA AIS with a specificity of at least 94%. Higher MCAD values are associated with larger infarction volumes. CONCLUSION MCAD and MCAD ratio can be used to identify patients who need early treatment, especially in situations where computed tomography angiogram or dwMRI are not readily available.
Collapse
Affiliation(s)
- Taygun Baykal
- Emergency Service, Bursa Karacabey State Hospital, Bursa, Turkey
| | - Ebru Unal Akoglu
- Department of Emergency Medicine, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Tayfun Akoglu
- Department of Radiology, MEDAR Hospital, Kocaeli, Turkey
| | | | - Haldun Akoglu
- Department of Emergency Medicine, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| |
Collapse
|
14
|
Hou J, Sun Y, Duan Y, Zhang L, Xing D, Lee X, Yang B. Hyperdense middle cerebral artery sign in large cerebral infarction. Brain Behav 2021; 11:e02116. [PMID: 33764692 PMCID: PMC8119806 DOI: 10.1002/brb3.2116] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/23/2021] [Accepted: 03/03/2021] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES To evaluate if the hyperdense middle cerebral artery sign (HMCAS) is an imaging biomarker for hemorrhagic transformation (HT) and the functional outcome of patients with large cerebral infarctions without thrombolytic therapy. MATERIALS AND METHODS The clinical and imaging data of 312 patients with large cerebral infarction without thrombolytic therapy were retrospectively analyzed. They were divided into patients who presented with HMCAS (n = 121) and those who did not (non-HMCAS[n = 168] patients), and the clinical data of the 2 groups were compared. This was a retrospective study. RESULTS Of the 289 patients, 83(28.7%) developed HT. The incidence of atrial fibrillation, high homocysteine and admission NIHSS score at the time of admission was significantly higher in the HMCAS patients than in non-HMCAS patients (p < .05). The ASPECTS was significantly lower in HMCAS patients (t = -5.835, p < .001). The incidence of PH-2 and 3-month mRS score was also statistically significant higher in HMCAS patients (χ2 = 3.971, p = .046; χ2 = 5.653, p < .001, respectively). A sub-analysis showed HMCAS patients with HT were significantly older than non-HMCAS patients with HT (t = 2.473, p = .015). The incidence of atrial fibrillation and the 3-month mortality rate were higher in HMCAS patients with HT than in non-HMCAS patients with HT (χ2 = 3.944, p = .047; χ2 = 6.043, p = .014, respectively). Multiple logistic regression analysis showed HT was independently associated with HMCAS (adjusted OR/95% CI/p = 2.762/1.571-4.854/p < .001) and admission NIHSS score (adjusted OR/95% CI/p = 1.081/1.026-1.139/0.003). And HMCAS with HT was independently associated with length of HMCAS (adjusted OR/95% CI/p = 1.216/1.076-1.374/0.002). CONCLUSIONS HMCAS in patients with a large cerebral infarction without thrombolytic therapy is an independent biomarker of HT. Length of HMCAS is also a marker of HT with lower ASPECTS in HMCAS patients.
Collapse
Affiliation(s)
- Jie Hou
- Department of Radiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yu Sun
- Department of Radiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yang Duan
- Department of Radiology, Center for Neuroimaging, General Hospital of Northern Theater Command, Shenyang, China
| | - Libo Zhang
- Department of Radiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Dengxiang Xing
- Department of Medicine Data, General Hospital of Northern Theater Command, Shenyang, China
| | - Xiaoqiu Lee
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Benqiang Yang
- Department of Radiology, General Hospital of Northern Theater Command, Shenyang, China
| |
Collapse
|
15
|
Algeo C, Beh S, McDonald L, MacLeod AD, Reid JM. Examining Outcomes following Thrombolysis in An Increasingly Older and Dependent Stroke Population. J R Coll Physicians Edinb 2020; 50:372-378. [DOI: 10.4997/jrcpe.2020.405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background Thrombolysis for acute ischaemic stroke (AIS) patients aged ≥80 years is evidence based, although its use in previously dependent patients is controversial. Methods Data from 831 thrombolysed AIS patients in our centre from 2009–2017 were used to compare demographic trends and outcomes (haemorrhage, mortality, three-month independence) in patients aged <80 and ≥80 years and with prior dependency. Comparison with UK and world registry data regarding age and pre-stroke dependency was made. Results The percentage of treated patients aged ≥80 years increased year-on-year, doubling from 25% to 50% (p<0.01), with increasing average age and pre-stroke dependency in world centres. Patients ≥80 years had higher (p<0.001) stroke severity, symptomatic intracerebral haemorrhage (5% vs. 1.5%), mortality (35% vs. 13%) and lower three month independent survival (24% vs. 60%). Patients with pre-stroke dependency had especially higher three month mortality (57–71%, OR 3.75 [95% CI 1.97–7.15]) in both age groups. Conclusion Patients aged ≥80 years and with dependency increasingly receive thrombolysis. Given poorer outcomes thrombolysis trials are needed in pre-stroke dependent patients.
Collapse
Affiliation(s)
- Charlotte Algeo
- Foundation Year 2 Doctor, Acute Stroke Unit, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Sean Beh
- Foundation Year 2 Doctor, Acute Stroke Unit, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Lindsey McDonald
- ST6 in Geriatric Medicine, Acute Stroke Unit, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Angus D MacLeod
- Senior Clinical Lecturer in Neurology, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Consultant Neurologist, Acute Stroke Unit, Aberdeen Royal Infirmary, Aberdeen, UK
| | - John M Reid
- Consultant Neurologist, Acute Stroke Unit, Aberdeen Royal Infirmary, Aberdeen, UK
| |
Collapse
|
16
|
Wu S, Mair G, Cohen G, Morris Z, von Heijne A, Bradey N, Cala L, Peeters A, Farrall AJ, Adami A, Potter G, Liu M, Lindley RI, Sandercock PAG, Wardlaw JM. Hyperdense artery sign, symptomatic infarct swelling and effect of alteplase in acute ischaemic stroke. Stroke Vasc Neurol 2020; 6:238-243. [PMID: 33246970 PMCID: PMC8258046 DOI: 10.1136/svn-2020-000569] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/10/2020] [Accepted: 10/07/2020] [Indexed: 02/05/2023] Open
Abstract
Background Alteplase improves functional outcomes of patients with acute ischaemic stroke, but its effects on symptomatic infarct swelling, an adverse complication of stroke and the influence of CT hyperdense artery sign (HAS) are unclear. This substudy of the Third International Stroke Trial aimed to investigate the association between HAS and symptomatic infarct swelling and effect of intravenous alteplase on this association. Methods We included stroke patients whose prerandomisation scan was non-contrast CT. Raters, masked to clinical information, assessed baseline (prerandomisation) and follow-up (24–48 hours postrandomisation) CT scans for HAS, defined as an intracranial artery appearing denser than contralateral arteries. Symptomatic infarct swelling was defined as clinically significant neurological deterioration ≤7 days after stroke with radiological evidence of midline shift, effacement of basal cisterns or uncal herniation. Results Among 2961 patients, HAS presence at baseline was associated with higher risk of symptomatic infarct swelling (OR 2.21; 95% CI 1.42 to 3.44). Alteplase increased the risk of swelling (OR 1.69; 95% CI 1.11 to 2.57), with no difference between patients with and those without baseline HAS (p=0.49). In patients with baseline HAS, alteplase reduced the proportion with HAS at follow-up (OR 0.67; 95% CI 0.50 to 0.91), where HAS disappearance was associated with reduced risk of swelling (OR 0.25, 95% CI 0.14 to 0.47). Conclusion Although alteplase was associated with increased risk of symptomatic infarct swelling in patients with or without baseline HAS, it was also associated with accelerated clearance of HAS, which in return reduced swelling, providing further mechanistic insights to underpin the benefits of alteplase.
Collapse
Affiliation(s)
- Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Grant Mair
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Geoff Cohen
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Zoe Morris
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Anders von Heijne
- Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
| | - Nick Bradey
- Neuroradiology, James Cook University Hospital, South Tees Hospital NHS Trust, Middlesbrough, UK
| | - Lesley Cala
- Division of Pathology and Laboratory Medicine, School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Andre Peeters
- Department of Neurology, Cliniques universitaires Saint-Luc, Bruxelles, Belgium
| | - Andrew J Farrall
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | | | - Gillian Potter
- Department of Neuroradiology, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, Manchester, UK
| | - Ming Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Richard I Lindley
- Westmead Applied Research Centre, Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,The George Institute for Global Health, Newtown, New South Wales, Australia
| | | | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK .,UK Dementia Research Institute Centre at the University of Edinburgh, Edinburgh, UK
| | | |
Collapse
|
17
|
Mohammaden MH, Haussen DC, Perry da Camara C, Pisani L, Olive Gadea M, Al-Bayati AR, Liberato B, Rangaraju S, Frankel MR, Nogueira RG. Hyperdense vessel sign as a potential guide for the choice of stent retriever versus contact aspiration as first-line thrombectomy strategy. J Neurointerv Surg 2020; 13:599-604. [PMID: 32737205 DOI: 10.1136/neurintsurg-2020-016005] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 06/10/2020] [Accepted: 06/14/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND The first-pass effect (FPE) has emerged as a key metric for efficacy in mechanical thrombectomy (MT). The hyperdense vessel sign (HDVS) on non-contrast head CT (NCCT) indicates a higher clot content of red blood cells. OBJECTIVE To assess whether the HDVS could serve as an imaging biomarker for guiding first-line device selection in MT. METHODS A prospective MT database was reviewed for consecutive patients with anterior circulation large vessel occlusion stroke who underwent thrombectomy with stent retriever (SR) or contact aspiration (CA) as first-line therapy between January 2012 and November 2018. Pretreatment NCCT scans were evaluated for the presence of HDVS. The primary outcome was FPE (modified Thrombolysis in Cerebral Infarction score 2c/3). The primary analysis was the interaction between HDVS and thrombectomy modality on FPE. Secondary analyses aimed to evaluate the predictors of FPE. RESULTS A total of 779 patients qualified for the analysis. HDVS and FPE were reported in 473 (60.7%) and 286 (36.7%) patients, respectively. The presence of HDVS significantly modified the effect of thrombectomy modality on FPE (p=0.01), with patients with HDVS having a significantly higher rate of FPE with a SR (41.3% vs 22.2%, p=0.001; adjusted OR 2.11 (95% CI 1.20 to 3.70), p=0.009) and non-HDVS patients having a numerically better response to CA (41.4% vs 33.9%, p=0.28; adjusted OR 0.58 (95% CI 0.311 to 1.084), p=0.088). Age (OR 1.01 (95% CI 1.00 to 1.02), p=0.04) and balloon guide catheter (OR 2.08 (95% CI 1.24 to 3.47), p=0.005) were independent predictors of FPE in the overall population. CONCLUSION Our data suggest that patients with HDVS may have a better response to SRs than CA for the FPE. Larger confirmatory prospective studies are warranted.
Collapse
Affiliation(s)
- Mahmoud H Mohammaden
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Catarina Perry da Camara
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Leonardo Pisani
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Marta Olive Gadea
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Alhamza R Al-Bayati
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Bernardo Liberato
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Srikant Rangaraju
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Michael R Frankel
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA .,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA
| |
Collapse
|
18
|
Wadhwa A, Joundi RA, Menon B. Clinical considerations and assessment of risk factors when choosing endovascular thrombectomy for acute stroke. Expert Rev Cardiovasc Ther 2020; 18:541-556. [PMID: 32686967 DOI: 10.1080/14779072.2020.1798229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The advent of endovascular thrombectomy (EVT) has been a game changer for the management of acute ischemic stroke due to large vessel occlusion. However, the selection of suitable candidates for EVT remains a significant challenge. AREAS COVERED This review focuses on the clinical, radiological, and procedural considerations for EVT in acute stroke that assist in optimal patient selection. EXPERT OPINION All patients presenting with significant clinical deficits with treatable occlusions, who have salvageable brain tissue at presentation might benefit from treatment up to twenty-four hours from symptom onset. Neuroimaging tools form the backbone for this decision making.
Collapse
Affiliation(s)
- Ankur Wadhwa
- Calgary Stroke Program, University of Calgary, Foot Hills Medical Center , Calgary, AB, Canada
| | - Raed A Joundi
- Calgary Stroke Program, University of Calgary, Foot Hills Medical Center , Calgary, AB, Canada
| | - Bijoy Menon
- Clinical Neurosciences, University of Calgary, Foot Hills Medical Center , Calgary, AB, Canada
| |
Collapse
|
19
|
Abstract
Acute stroke is the clinical manifestation of disrupted blood flow or bleeding in the central nervous system. Imaging supports the clinical diagnosis and can aide in acute treatment decision making and guide information on prognosis. Features that are delineated include the parenchyma and the blood vessels. Parenchymal characteristics include early ischemic changes, established infarct and tissue at risk (penumbra), and hemorrhage. Vessel pathology includes arterial and venous steno-occlusive disease and vascular malformations. In the presence of a vessel occlusion, vessel imaging can assess collateral flow. This article outlines the role of neuroimaging as applied to patients presenting with acute stroke.
Collapse
Affiliation(s)
- Ashutosh P Jadhav
- Neurology, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15222, USA.
| | - Shashvat M Desai
- Neurology, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15222, USA
| | - David S Liebeskind
- Neurology, University of California Los Angeles, 635 Charles E Young Drive South, Suite 225, Los Angeles, CA 90095, USA
| | - Lawrence R Wechsler
- Neurology, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15222, USA
| |
Collapse
|
20
|
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019; 50:e344-e418. [PMID: 31662037 DOI: 10.1161/str.0000000000000211] [Citation(s) in RCA: 3408] [Impact Index Per Article: 681.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.
Collapse
|
21
|
Imaging Clot Characteristics in Stroke and its Possible Implication on Treatment. Clin Neuroradiol 2019; 30:27-35. [DOI: 10.1007/s00062-019-00841-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 09/17/2019] [Indexed: 12/11/2022]
|
22
|
Broocks G, Kniep H, Kemmling A, Flottmann F, Nawabi J, Elsayed S, Schön G, Thomalla G, Fiehler J, Hanning U. Effect of intravenous alteplase on ischaemic lesion water homeostasis. Eur J Neurol 2019; 27:376-383. [PMID: 31529738 DOI: 10.1111/ene.14088] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 09/03/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Intravenous (IV) lysis with alteplase is known to increase biomarkers of blood-brain barrier breakdown and has therefore been associated with secondary injuries such as hemorrhagic transformation. The impact of alteplase on brain edema formation, however, has not been investigated yet. The purpose was to examine the effects of IV alteplase on ischaemic lesion water homeostasis differentiated from final tissue infarct in patients with and without successful endovascular therapy (sET). METHODS In all, 232 middle cerebral artery stroke patients were analyzed. 147 patients received IV alteplase, of whom 106 patients received subsequent sET. Out of 85 patients without IV alteplase, 50 received sET. Ischaemic brain edema was quantified at admission and follow-up computed tomography using quantitative lesion net water uptake (NWU) and its difference was calculated (ΔNWU). The relationship of alteplase on ΔNWU and edema-corrected final infarct volume was analyzed using univariate and multivariate linear regression models. RESULTS The mean ΔNWU was 11.8% (SD 7.9) in patients with alteplase and 11.5% (SD 8.3) in patients without alteplase (P = 0.8). Alteplase was not associated with lowered ΔNWU whilst being associated with reduced edema-corrected tissue infarct volume [-27.4 ml, 95% confidence interval (CI) -49.4 to -5.4 ml; P = 0.02], adjusted for the Alberta Stroke Program Early Computed Tomography Score and recanalization status. In patients with sET, ΔNWU was 10.5% (95% CI 6.3%-10.5%) for patients with IV alteplase and 8.4% (95% CI 9.1%-12.0%) for patients without IV alteplase. CONCLUSION The application of IV alteplase did not significantly alter ischaemic lesion water homeostasis but was associated with reduced edema-corrected tissue infarct volume, which might be directly linked to improved functional outcome.
Collapse
Affiliation(s)
- G Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - H Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany.,Faculty of Medicine Mannheim, University of Heidelberg, Heidelberg, Germany
| | - F Flottmann
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J Nawabi
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - S Elsayed
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - G Schön
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - G Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - U Hanning
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
23
|
Mair G, von Kummer R, Morris Z, von Heijne A, Bradey N, Cala L, Peeters A, Farrall AJ, Adami A, Potter G, Sandercock PAG, Lindley RI, Wardlaw JM. Effect of IV alteplase on the ischemic brain lesion at 24-48 hours after ischemic stroke. Neurology 2018; 91:e2067-e2077. [PMID: 30366975 PMCID: PMC6282236 DOI: 10.1212/wnl.0000000000006575] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 08/14/2018] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE To determine whether alteplase alters the development of ischemic lesions on brain imaging after stroke. METHODS The Third International Stroke Trial (IST-3) was a randomized controlled trial of IV alteplase for ischemic stroke. We assessed CT or brain MRI at baseline (pretreatment) and 24 to 48 hours posttreatment for acute lesion visibility, extent, and swelling, masked to all other data. We analyzed associations between treatment allocation, change in brain tissue appearances between baseline and follow-up imaging, and 6-month functional outcome in IST-3. We performed a meta-analysis of randomized trials of alteplase vs control with pre- and postrandomization imaging. RESULTS Of 3,035 patients recruited in IST-3, 2,916 had baseline and follow-up brain imaging. Progression in either lesion extent or swelling independently predicted poorer 6-month outcome (adjusted odds ratio [OR] = 0.92, 95% confidence interval [CI] 0.88-0.96, p < 0.001; OR = 0.73, 95% CI 0.66-0.79, p < 0.001, respectively). Patients allocated alteplase were less likely than controls to develop increased lesion visibility at follow-up (OR = 0.77, 95% CI 0.67-0.89, p < 0.001), but there was no evidence that alteplase reduced progression of lesion extent or swelling. In meta-analysis of 6 trials including IST-3 (n = 4,757), allocation to alteplase was associated with a reduction in ischemic lesion extent on follow-up imaging (OR = 0.85, 95% CI 0.76-0.95, p = 0.004). CONCLUSION Alteplase was associated with reduced short-term progression in lesion visibility. In meta-analysis, alteplase reduced lesion extent. These findings may indicate that alteplase improves functional outcome by reducing tissue damage. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that IV alteplase impedes the progression of ischemic brain lesions on imaging after stroke.
Collapse
Affiliation(s)
- Grant Mair
- From Edinburgh Imaging, and UK Dementia Research Institute at the University of Edinburgh and Centre for Clinical Brain Sciences (G.M., Z.M., A.J.F., J.M.W.), and Division of Clinical Neurosciences (P.A.G.S.), University of Edinburgh, UK; Department of Neuroradiology (R.v.K.), Dresden University Stroke Centre, Germany; Danderyd Hospital (A.v.H.), Stockholm, Sweden; Neuroradiology (N.B.), James Cook University Hospital, Middlesborough, UK; School of Medicine (L.C.), University of Western Australia; Cliniques Universitaires St Luc (A.P.), Neurologie, Belgium; Stroke Center (A.A.), Department of Neurology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy; Department of Neuroradiology (G.P.), Salford Royal NHS Foundation Trust, Manchester, UK; and Westmead Hospital Clinical School and The George Institute for Global Health (R.I.L.), University of Sydney, Australia
| | - Rüdiger von Kummer
- From Edinburgh Imaging, and UK Dementia Research Institute at the University of Edinburgh and Centre for Clinical Brain Sciences (G.M., Z.M., A.J.F., J.M.W.), and Division of Clinical Neurosciences (P.A.G.S.), University of Edinburgh, UK; Department of Neuroradiology (R.v.K.), Dresden University Stroke Centre, Germany; Danderyd Hospital (A.v.H.), Stockholm, Sweden; Neuroradiology (N.B.), James Cook University Hospital, Middlesborough, UK; School of Medicine (L.C.), University of Western Australia; Cliniques Universitaires St Luc (A.P.), Neurologie, Belgium; Stroke Center (A.A.), Department of Neurology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy; Department of Neuroradiology (G.P.), Salford Royal NHS Foundation Trust, Manchester, UK; and Westmead Hospital Clinical School and The George Institute for Global Health (R.I.L.), University of Sydney, Australia
| | - Zoe Morris
- From Edinburgh Imaging, and UK Dementia Research Institute at the University of Edinburgh and Centre for Clinical Brain Sciences (G.M., Z.M., A.J.F., J.M.W.), and Division of Clinical Neurosciences (P.A.G.S.), University of Edinburgh, UK; Department of Neuroradiology (R.v.K.), Dresden University Stroke Centre, Germany; Danderyd Hospital (A.v.H.), Stockholm, Sweden; Neuroradiology (N.B.), James Cook University Hospital, Middlesborough, UK; School of Medicine (L.C.), University of Western Australia; Cliniques Universitaires St Luc (A.P.), Neurologie, Belgium; Stroke Center (A.A.), Department of Neurology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy; Department of Neuroradiology (G.P.), Salford Royal NHS Foundation Trust, Manchester, UK; and Westmead Hospital Clinical School and The George Institute for Global Health (R.I.L.), University of Sydney, Australia
| | - Anders von Heijne
- From Edinburgh Imaging, and UK Dementia Research Institute at the University of Edinburgh and Centre for Clinical Brain Sciences (G.M., Z.M., A.J.F., J.M.W.), and Division of Clinical Neurosciences (P.A.G.S.), University of Edinburgh, UK; Department of Neuroradiology (R.v.K.), Dresden University Stroke Centre, Germany; Danderyd Hospital (A.v.H.), Stockholm, Sweden; Neuroradiology (N.B.), James Cook University Hospital, Middlesborough, UK; School of Medicine (L.C.), University of Western Australia; Cliniques Universitaires St Luc (A.P.), Neurologie, Belgium; Stroke Center (A.A.), Department of Neurology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy; Department of Neuroradiology (G.P.), Salford Royal NHS Foundation Trust, Manchester, UK; and Westmead Hospital Clinical School and The George Institute for Global Health (R.I.L.), University of Sydney, Australia
| | - Nick Bradey
- From Edinburgh Imaging, and UK Dementia Research Institute at the University of Edinburgh and Centre for Clinical Brain Sciences (G.M., Z.M., A.J.F., J.M.W.), and Division of Clinical Neurosciences (P.A.G.S.), University of Edinburgh, UK; Department of Neuroradiology (R.v.K.), Dresden University Stroke Centre, Germany; Danderyd Hospital (A.v.H.), Stockholm, Sweden; Neuroradiology (N.B.), James Cook University Hospital, Middlesborough, UK; School of Medicine (L.C.), University of Western Australia; Cliniques Universitaires St Luc (A.P.), Neurologie, Belgium; Stroke Center (A.A.), Department of Neurology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy; Department of Neuroradiology (G.P.), Salford Royal NHS Foundation Trust, Manchester, UK; and Westmead Hospital Clinical School and The George Institute for Global Health (R.I.L.), University of Sydney, Australia
| | - Lesley Cala
- From Edinburgh Imaging, and UK Dementia Research Institute at the University of Edinburgh and Centre for Clinical Brain Sciences (G.M., Z.M., A.J.F., J.M.W.), and Division of Clinical Neurosciences (P.A.G.S.), University of Edinburgh, UK; Department of Neuroradiology (R.v.K.), Dresden University Stroke Centre, Germany; Danderyd Hospital (A.v.H.), Stockholm, Sweden; Neuroradiology (N.B.), James Cook University Hospital, Middlesborough, UK; School of Medicine (L.C.), University of Western Australia; Cliniques Universitaires St Luc (A.P.), Neurologie, Belgium; Stroke Center (A.A.), Department of Neurology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy; Department of Neuroradiology (G.P.), Salford Royal NHS Foundation Trust, Manchester, UK; and Westmead Hospital Clinical School and The George Institute for Global Health (R.I.L.), University of Sydney, Australia
| | - André Peeters
- From Edinburgh Imaging, and UK Dementia Research Institute at the University of Edinburgh and Centre for Clinical Brain Sciences (G.M., Z.M., A.J.F., J.M.W.), and Division of Clinical Neurosciences (P.A.G.S.), University of Edinburgh, UK; Department of Neuroradiology (R.v.K.), Dresden University Stroke Centre, Germany; Danderyd Hospital (A.v.H.), Stockholm, Sweden; Neuroradiology (N.B.), James Cook University Hospital, Middlesborough, UK; School of Medicine (L.C.), University of Western Australia; Cliniques Universitaires St Luc (A.P.), Neurologie, Belgium; Stroke Center (A.A.), Department of Neurology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy; Department of Neuroradiology (G.P.), Salford Royal NHS Foundation Trust, Manchester, UK; and Westmead Hospital Clinical School and The George Institute for Global Health (R.I.L.), University of Sydney, Australia
| | - Andrew J Farrall
- From Edinburgh Imaging, and UK Dementia Research Institute at the University of Edinburgh and Centre for Clinical Brain Sciences (G.M., Z.M., A.J.F., J.M.W.), and Division of Clinical Neurosciences (P.A.G.S.), University of Edinburgh, UK; Department of Neuroradiology (R.v.K.), Dresden University Stroke Centre, Germany; Danderyd Hospital (A.v.H.), Stockholm, Sweden; Neuroradiology (N.B.), James Cook University Hospital, Middlesborough, UK; School of Medicine (L.C.), University of Western Australia; Cliniques Universitaires St Luc (A.P.), Neurologie, Belgium; Stroke Center (A.A.), Department of Neurology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy; Department of Neuroradiology (G.P.), Salford Royal NHS Foundation Trust, Manchester, UK; and Westmead Hospital Clinical School and The George Institute for Global Health (R.I.L.), University of Sydney, Australia
| | - Alessandro Adami
- From Edinburgh Imaging, and UK Dementia Research Institute at the University of Edinburgh and Centre for Clinical Brain Sciences (G.M., Z.M., A.J.F., J.M.W.), and Division of Clinical Neurosciences (P.A.G.S.), University of Edinburgh, UK; Department of Neuroradiology (R.v.K.), Dresden University Stroke Centre, Germany; Danderyd Hospital (A.v.H.), Stockholm, Sweden; Neuroradiology (N.B.), James Cook University Hospital, Middlesborough, UK; School of Medicine (L.C.), University of Western Australia; Cliniques Universitaires St Luc (A.P.), Neurologie, Belgium; Stroke Center (A.A.), Department of Neurology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy; Department of Neuroradiology (G.P.), Salford Royal NHS Foundation Trust, Manchester, UK; and Westmead Hospital Clinical School and The George Institute for Global Health (R.I.L.), University of Sydney, Australia
| | - Gillian Potter
- From Edinburgh Imaging, and UK Dementia Research Institute at the University of Edinburgh and Centre for Clinical Brain Sciences (G.M., Z.M., A.J.F., J.M.W.), and Division of Clinical Neurosciences (P.A.G.S.), University of Edinburgh, UK; Department of Neuroradiology (R.v.K.), Dresden University Stroke Centre, Germany; Danderyd Hospital (A.v.H.), Stockholm, Sweden; Neuroradiology (N.B.), James Cook University Hospital, Middlesborough, UK; School of Medicine (L.C.), University of Western Australia; Cliniques Universitaires St Luc (A.P.), Neurologie, Belgium; Stroke Center (A.A.), Department of Neurology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy; Department of Neuroradiology (G.P.), Salford Royal NHS Foundation Trust, Manchester, UK; and Westmead Hospital Clinical School and The George Institute for Global Health (R.I.L.), University of Sydney, Australia
| | - Peter A G Sandercock
- From Edinburgh Imaging, and UK Dementia Research Institute at the University of Edinburgh and Centre for Clinical Brain Sciences (G.M., Z.M., A.J.F., J.M.W.), and Division of Clinical Neurosciences (P.A.G.S.), University of Edinburgh, UK; Department of Neuroradiology (R.v.K.), Dresden University Stroke Centre, Germany; Danderyd Hospital (A.v.H.), Stockholm, Sweden; Neuroradiology (N.B.), James Cook University Hospital, Middlesborough, UK; School of Medicine (L.C.), University of Western Australia; Cliniques Universitaires St Luc (A.P.), Neurologie, Belgium; Stroke Center (A.A.), Department of Neurology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy; Department of Neuroradiology (G.P.), Salford Royal NHS Foundation Trust, Manchester, UK; and Westmead Hospital Clinical School and The George Institute for Global Health (R.I.L.), University of Sydney, Australia
| | - Richard I Lindley
- From Edinburgh Imaging, and UK Dementia Research Institute at the University of Edinburgh and Centre for Clinical Brain Sciences (G.M., Z.M., A.J.F., J.M.W.), and Division of Clinical Neurosciences (P.A.G.S.), University of Edinburgh, UK; Department of Neuroradiology (R.v.K.), Dresden University Stroke Centre, Germany; Danderyd Hospital (A.v.H.), Stockholm, Sweden; Neuroradiology (N.B.), James Cook University Hospital, Middlesborough, UK; School of Medicine (L.C.), University of Western Australia; Cliniques Universitaires St Luc (A.P.), Neurologie, Belgium; Stroke Center (A.A.), Department of Neurology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy; Department of Neuroradiology (G.P.), Salford Royal NHS Foundation Trust, Manchester, UK; and Westmead Hospital Clinical School and The George Institute for Global Health (R.I.L.), University of Sydney, Australia
| | - Joanna M Wardlaw
- From Edinburgh Imaging, and UK Dementia Research Institute at the University of Edinburgh and Centre for Clinical Brain Sciences (G.M., Z.M., A.J.F., J.M.W.), and Division of Clinical Neurosciences (P.A.G.S.), University of Edinburgh, UK; Department of Neuroradiology (R.v.K.), Dresden University Stroke Centre, Germany; Danderyd Hospital (A.v.H.), Stockholm, Sweden; Neuroradiology (N.B.), James Cook University Hospital, Middlesborough, UK; School of Medicine (L.C.), University of Western Australia; Cliniques Universitaires St Luc (A.P.), Neurologie, Belgium; Stroke Center (A.A.), Department of Neurology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy; Department of Neuroradiology (G.P.), Salford Royal NHS Foundation Trust, Manchester, UK; and Westmead Hospital Clinical School and The George Institute for Global Health (R.I.L.), University of Sydney, Australia.
| |
Collapse
|
24
|
Drocton GT, Luttrull MD, Ajam AA, Nguyen XV. Emerging Trends in Emergent Stroke Neuroimaging. CURRENT RADIOLOGY REPORTS 2018. [DOI: 10.1007/s40134-018-0282-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
25
|
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2018; 49:e46-e110. [PMID: 29367334 DOI: 10.1161/str.0000000000000158] [Citation(s) in RCA: 3515] [Impact Index Per Article: 585.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations for clinicians caring for adult patients with acute arterial ischemic stroke in a single document. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 guidelines and subsequent updates. METHODS Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. The members of the writing group unanimously approved all recommendations except when relations with industry precluded members voting. Prerelease review of the draft guideline was performed by 4 expert peer reviewers and by the members of the Stroke Council's Scientific Statements Oversight Committee and Stroke Council Leadership Committee. These guidelines use the American College of Cardiology/American Heart Association 2015 Class of Recommendations and Levels of Evidence and the new American Heart Association guidelines format. RESULTS These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. CONCLUSIONS These guidelines are based on the best evidence currently available. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.
Collapse
|
26
|
Dual-Energy Computed Tomography in Stroke Imaging: Technical and Clinical Considerations of Virtual Noncontrast Images for Detection of the Hyperdense Artery Sign. J Comput Assist Tomogr 2017; 41:843-848. [PMID: 28708725 DOI: 10.1097/rct.0000000000000638] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The technical feasibility of virtual noncontrast (VNC) images from dual-energy computed tomography (DECT) for the detection of the hyperdense artery sign (HAS) in ischemic stroke patients was investigated. METHODS True noncontrast (TNC) scans of 60 patients either with or without HAS (n = 30 each) were investigated. Clot presence and characteristics were assessed on VNC images from DECT angiography and compared with TNC images. Clot characterization included the level of confidence for diagnosing HAS, a qualitative clot burden score, and quantitative attenuation (Hounsfield unit [HU]) measurements. RESULTS Sensitivity, specificity, and accuracy of VNC for diagnosing HAS were 97%, 90%, and 93%, respectively. No significant differences were found regarding the diagnostic confidence (P = 0.18) and clot burden score (P = 0.071). No significant HU differences were found among vessels with HAS in VNC (56 ± 7HU) and TNC (57 ± 8HU) (P = 0.691) images. CONCLUSIONS Virtual noncontrast images derived from DECT enable an accurate detection and characterization of HAS.
Collapse
|
27
|
Clinical implications of CT hyperdense artery sign in patients with acute middle cerebral artery occlusion in the era of modern mechanical thrombectomy. J Neurol 2017; 264:2450-2456. [PMID: 29075836 DOI: 10.1007/s00415-017-8655-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 10/17/2017] [Accepted: 10/21/2017] [Indexed: 12/28/2022]
Abstract
The clinical implications of the CT hyperdense artery sign have yet to be established in the new era of modern mechanical thrombectomy. This study aimed to investigate prognostic implications of the CT hyperdense middle cerebral artery sign (HMCAS) on treatment outcomes after mechanical thrombectomy for acute MCA occlusions. A retrospective analysis of CT and clinical data from 212 patients with acute MCA occlusions who underwent mechanical thrombectomy was conducted. HMCAS was determined with visual assessment by consensus of two readers. Interobserver agreement was measured. HMCAS was classified into two groups: M1 and M2 HMCAS. Associations between HMCAS and vascular risk factors, stroke etiology, and treatment outcomes were analyzed. Of 212 patients, HMCAS was identified in 118 patients (55.7%). Overall, successful reperfusion was achieved in 82.5% (175/212) and a good outcome in 45.8% (97/212). There was no significant association between HMCAS and treatment outcomes after mechanical thrombectomy, regardless of HMCAS location. Cardioembolism was more frequent in patients with a positive HMCAS (67.8 vs 48.9%, P = 0.005). Large-artery atherosclerosis was more frequent in patients with a negative HMCAS (31.9 vs 12.7%, P = 0.001). Underlying severe MCA stenosis was more frequently observed in patients with a negative HMCAS (25.5 vs 3.4%, P < 0.001). Our study suggests that the prognostic implication of a HMCAS in predicting outcomes after endovascular therapy in patients with acute MCA occlusion may be low in the era of modern mechanical thrombectomy. Negative HMCAS is predictive of in situ thrombotic occlusion due to underlying severe atherosclerotic stenosis in such patients.
Collapse
|
28
|
Bouchez L, Altrichter S, Pellaton A, Ouared R, Kulcsar Z, Sztajzel R, Platon A, Machi P, Poletti PA, Lövblad KO. Can clot density predict recanalization in acute ischemic stroke treated with intravenous tPA? CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2017. [DOI: 10.1177/2514183x17718310] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Stroke has become an absolute emergency that is treated by additional endovascular means or by replacing pharmacological options. Modern neuroradiological techniques such as computed tomography (CT) allow us to examine multiple parameters of the diseased brain. These focused on the parenchyma and hemodynamics for pretherapeutic decisions. However, it has become evident that the clot is the current target for interventional measures. Clot length is established as a marker for recanalization. The dense artery sign is known as an acute CT sign of stroke that is readily visible on acute nonenhanced CT. The rationale behind our study was to study if clot density might represent clot vulnerability or resistance to treatment. We conducted a prospective study of all consecutive stroke patients admitted to our hospital over 1 year, who presented with signs of acute middle cerebral artery stroke within the therapeutic window, and who underwent either intravenous or combined intravenous and intra-arterial thrombolysis. All patients were evaluated with a complete stroke CT protocol, transcranial color-coded duplex sonography monitoring, and clinical evaluation with the National Institutes of Health Stroke Scale (NIHSS) score. We measured clot length using planimetry on unenhanced CT and measured Hounsfield units in the clots on the same images. A total of 31 patients were included in the study (19 men, 12 women, aged 35–90 years). We found that patients with a longer clot on the unenhanced CT had a higher NIHSS score, confirming previous literature. However, we found that patients with a lower clot density recanalized to a more marked degree and had a better clinical outcome. Patients who did not recanalize had a higher clot density (49 Hounsfield units) than those who did recanalize (23 Hounsfield units). Overall, measuring the clot seems to be an important additional parameter to be taken into account. In our study, CT clot density seems to correlate with clinical outcome and recanalization. The higher density seems to represent a higher red blood cell content. This is evidence that clot composition could play a much more important role in acute stroke than thought until now and characterizing it with imaging may help in choosing the adequate treatment modality. Higher density seems to reflect erythrocyte content. Therefore, patients with a longer and denser clot may necessitate direct thrombectomy.
Collapse
Affiliation(s)
- Laurie Bouchez
- Radiology Division, Geneva University Hospital, Geneva, Switzerland
- Neuroradiology Division, Geneva University Hospital, Geneva, Switzerland
| | - Stephen Altrichter
- Neuroradiology Division, Geneva University Hospital, Geneva, Switzerland
| | - Alain Pellaton
- Neuroradiology Division, Geneva University Hospital, Geneva, Switzerland
| | - Rafik Ouared
- Neuroradiology Division, Geneva University Hospital, Geneva, Switzerland
| | - Zsolt Kulcsar
- Neuroradiology Division, Geneva University Hospital, Geneva, Switzerland
| | - Roman Sztajzel
- Neurology Department, Geneva University Hospital, Geneva, Switzerland
| | - Alexandra Platon
- Radiology Division, Geneva University Hospital, Geneva, Switzerland
| | - Paolo Machi
- Radiology Division, Geneva University Hospital, Geneva, Switzerland
| | | | - Karl-Olof Lövblad
- Neuroradiology Division, Geneva University Hospital, Geneva, Switzerland
| |
Collapse
|
29
|
Elofuke P, Reid JM, Rana A, Macleod MJ. Disappearance of the hyperdense MCA sign after stroke thrombolysis: implications for prognosis and early patient selection for clot retrieval. J R Coll Physicians Edinb 2017; 46:81-86. [PMID: 27929569 DOI: 10.4997/jrcpe.2016.203] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Disappearance of the hyperdense middle cerebral artery sign (HMCAS) following intravenous thrombolysis for ischaemic stroke is associated with improved outcome. Debate exists over which radiological thrombus characteristics can predict disappearance of the HMCAS after thrombolysis such as vessel attenuation or extent of thrombus length. Methods Ischaemic stroke patients treated with intravenous thrombolysis from our hospital were entered into a European registry. Patient demographics, stroke severity pre- and 24 hours post-thrombolysis were recorded. Patients with HMCAS were identified from the registry using records from 2010-2013. Images from the pre and post-thrombolysis computed tomography scan were measured. Thrombus characteristics (length and attenuation), extent of ischaemic change and clinical outcome (stroke severity and 3 month survival) were compared between patients with and without HMCAS disappearance. Logistic regression analysis was performed to identify predictors of HMCAS disappearance. Results HMCAS was present in 88/315 (28%) of thrombolysed ischaemic stroke patients. 36/88 (41%) of patients had thrombus disappearance 24 hours after thrombolysis. HMCAS disappearance was associated with reduced stroke severity, less radiological ischaemic change, and higher 3 month survival (87% vs 56%). Median thrombus length was shorter in the HMCAS disappearance group (11 vs 17 mm, p = 0.0004), but no significant difference in vessel attenuation was observed (48 vs 51 Hounsfield Units, p = 0.25). HMCAS disappearance occurred in 73% of cases where HMCAS length was > 10 mm, 38% when length was 10-20 mm, and 21% if < 20 mm. Thrombus length was the only independent predictor of HMCAS disappearance (odds ratio 0.90 per mm; 95% CI 0.84-0.96, p = 0.01). Conclusion Disappearance of HMCAS is associated with better clinical and radiological outcomes. A shorter thrombus is more likely to disappear postthrombolysis. The data highlight the limitation of intravenous thrombolysis in patients with longer hyperattenuated vessels, and the potential role for clot retrieval in such patients.
Collapse
Affiliation(s)
- P Elofuke
- JM Reid, Acute Stroke Unit, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK, E-mail
| | | | | | | |
Collapse
|
30
|
Stroke etiologic subtype may influence the rate of hyperdense middle cerebral artery sign disappearance after intravenous thrombolysis. J Thromb Thrombolysis 2017; 43:86-90. [PMID: 27469539 DOI: 10.1007/s11239-016-1404-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Disappearance of hyperdense middle cerebral artery sign (HMCAS) on non-contrast brain computed tomography (CT) scan is a reliable sign of arterial recanalization after intravenous (IV) thrombolysis for ischemic stroke. We aimed to assess whether stroke etiologic subtype may influence the rate of HMCAS disappearance and the clinical outcome after IV thrombolysis. We conducted a retrospective analysis of data prospectively collected from 1031 consecutive stroke patients treated with IV thrombolysis. Outcome measures were HMCAS disappearance on follow-up CT scan within 22-36 h of IV thrombolysis, neurologic improvement (NIH Stroke Scale [NIHSS] ≤4 points from baseline or NIHSS score of 0) at 7 days, and modified rankin scale (mRS) ≤1 at 3 months. Of 256 patients with HMCAS on admission CT scan, 125 had a cardioembolic stroke, 67 a stroke due to large-artery atherosclerosis (LAA), 58 a stroke of undetermined etiology, and six a stroke secondary to carotid artery dissection. HMCAS disappearance occurred in 145 (56.6 %) patients, neurologic improvement in 122 (55.0 %) patients, and mRS ≤1 in 64 (32.8 %) patients. Compared with cardioembolic stroke patients, patients with stroke due to LAA had lower odds ratios (OR) for HMCAS disappearance (OR 0.29, 95 % CI 0.15-0.58, p < 0.001), neurologic improvement (OR 0.42, 95 % CI 0.22-0.82, p = 0.011), and mRS ≤1 (OR 0.18, 95 % CI 0.06-0.52, p = 0.002). No significant differences in outcome measures were found between cardioembolic strokes and strokes of undetermined etiology. This study suggests that stroke due to LAA is associated with lower rates of HMCAS disappearance, neurologic improvement, and mRS ≤1 after IV thrombolysis, compared with cardioembolic stroke.
Collapse
|
31
|
Bouchez L, Sztajzel R, Vargas MI, Machi P, Kulcsar Z, Poletti PA, Pereira VM, Lövblad KO. CT imaging selection in acute stroke. Eur J Radiol 2016; 96:153-161. [PMID: 28277288 DOI: 10.1016/j.ejrad.2016.10.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 10/21/2016] [Accepted: 10/23/2016] [Indexed: 11/27/2022]
Abstract
Acute stroke has become an increasingly treatable cause of acute neurological deficits. Indeed, over the last two decades, the introduction of first thrombolysis, and now thrombectomy has improved patient outcomes and extended the therapeutic window. Computed tomography has been established as the most simple and readily available technique for the diagnosis and management of patients with acute stroke. Indeed, CT allows easy confirmation or exclusion of acute hemorrhage on the one hand, and on the other hand the early signs are quite reliable in the detection of ischemia. In the early phase the clot can be seen as well as exchanges related to early changes in water concentration in ischemia and the surrounding penumbra. Additional techniques such as angio-CT show the location of the clot and perfusion techniques reveal local hemodynamics as well as potential tissue viability. Newer techniques such as double energy CT and late phase CT should provide information on collateral flow as well as on the presence of early hemorrhagic transformation. All these techniques should thus make available new information on tissue viability,that is indispensable in the choice of revascularization technique. Thus CT techniques allow a quick and reliable triage as well as a finer characterization of the ischemic process. The use of all these CT techniques in an optimal way should help improve patient triage and selection of the most adequate treatment with further improvements in clinical outcomes as a result.
Collapse
Affiliation(s)
- Laurie Bouchez
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals and Medical School, 1211, Geneva, Switzerland
| | - Roman Sztajzel
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals and Medical School, 1211, Geneva, Switzerland
| | - Maria Isabel Vargas
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals and Medical School, 1211, Geneva, Switzerland
| | - Paolo Machi
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals and Medical School, 1211, Geneva, Switzerland
| | - Zsolt Kulcsar
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals and Medical School, 1211, Geneva, Switzerland
| | - Pierre-Alexandre Poletti
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals and Medical School, 1211, Geneva, Switzerland
| | - Vitor Mendes Pereira
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals and Medical School, 1211, Geneva, Switzerland
| | - Karl-Olof Lövblad
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals and Medical School, 1211, Geneva, Switzerland.
| |
Collapse
|