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Yang Y, Wang Z, Hu Q, Liu L, Ma G, Yang C. Enhancing the clinical value of single-phase computed tomography angiography in the assessment of collateral circulation in acute ischemic stroke: A narrative review. Brain Circ 2024; 10:35-41. [PMID: 38655435 PMCID: PMC11034444 DOI: 10.4103/bc.bc_54_23] [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: 07/11/2023] [Revised: 10/31/2023] [Accepted: 11/13/2023] [Indexed: 04/26/2024] Open
Abstract
Acute ischemic stroke (AIS) condition assessment and clinical prognosis are significantly influenced by the compensatory state of cerebral collateral circulation. A standard clinical test known as single-phase computed tomography angiography (sCTA) is useful for quickly and accurately assessing the creation or opening of cerebral collateral circulation, which is crucial for the diagnosis and treatment of AIS. To improve the clinical application of sCTA in the clinical assessment of collateral circulation, we examine the present use of sCTA in AIS in this work.
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Affiliation(s)
- Yunqiu Yang
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
- Intelligent Equipment Research Center, Zhuhai Institutes of Advanced Technology,Chinese Academy of Sciences, Zhuhai,Guangdong Province, China
| | - Zhen Wang
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
- Intelligent Equipment Research Center, Zhuhai Institutes of Advanced Technology,Chinese Academy of Sciences, Zhuhai,Guangdong Province, China
| | - Qingmao Hu
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Libo Liu
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Guorui Ma
- Intelligent Equipment Research Center, Zhuhai Institutes of Advanced Technology,Chinese Academy of Sciences, Zhuhai,Guangdong Province, China
| | - Chen Yang
- Obstetric Ward Center, Shenzhen Futian District Maternity & Child Healthcare Hospital,Shenzhen, China
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2
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Liu Q, Shi K, Wang Y, Shi FD. Neurovascular Inflammation and Complications of Thrombolysis Therapy in Stroke. Stroke 2023; 54:2688-2697. [PMID: 37675612 DOI: 10.1161/strokeaha.123.044123] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Intravenous thrombolysis via tPA (tissue-type plasminogen activator) is the only approved pharmacological treatment for acute ischemic stroke, but its benefits are limited by hemorrhagic transformation. Emerging evidence reveals that tPA swiftly mobilizes immune cells which extravasate into the brain parenchyma via the cerebral vasculature, augmenting neurovascular inflammation, and tissue injury. In this review, we summarize the pronounced alterations of immune cells induced by tPA in patients with stroke and experimental stroke models. We argue that neuroinflammation, triggered by ischemia-induced cell death and exacerbated by tPA, compromises neurovascular integrity and the microcirculation, leading to hemorrhagic transformation. Finally, we discuss current and future approaches to attenuate thrombolysis-associated hemorrhagic transformation via uncoupling immune cells from the neurovascular unit.
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Affiliation(s)
- Qiang Liu
- Department of Neurology, Tianjin Medical University General Hospital, China (Q.L., F.-D.S.)
| | - Kaibin Shi
- Department of Neurology, National Clinical Research Center for Neurological Diseases of China, Beijing Tiantan Hospital, Capital Medical University (K.S., Y.W., F.-D.S.)
| | - Yongjun Wang
- Department of Neurology, National Clinical Research Center for Neurological Diseases of China, Beijing Tiantan Hospital, Capital Medical University (K.S., Y.W., F.-D.S.)
| | - Fu-Dong Shi
- Department of Neurology, Tianjin Medical University General Hospital, China (Q.L., F.-D.S.)
- Department of Neurology, National Clinical Research Center for Neurological Diseases of China, Beijing Tiantan Hospital, Capital Medical University (K.S., Y.W., F.-D.S.)
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3
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Sinha A, Stanwell P, Killingsworth MC, Bhaskar SMM. Prognostic accuracy and impact of cerebral collateral status on clinical and safety outcomes in acute ischemic stroke patients receiving reperfusion therapy: a systematic meta-analysis. Acta Radiol 2023; 64:698-718. [PMID: 35311387 DOI: 10.1177/02841851221080517] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cerebral collateral status has a potential role in mediating postreperfusion clinical and safety outcomes in acute ischemic stroke (AIS). PURPOSE To investigate the prognostic accuracy and impact of collateral status on clinical and safety outcomes in patients with AIS receiving reperfusion therapy. MATERIAL AND METHODS Studies with AIS patients treated with reperfusion therapy, collateral status assessed using Tan, ASITN/SIR, or similar collateral grading methods and data stratified according to collateral status were included. Relevant data on clinical outcomes, such as functional outcome at 90 days, mortality at 90 days, angiographic reperfusion, symptomatic intracerebral hemorrhage (sICH) and hemorrhagic transformation (HT), were collated and analyzed. RESULTS A meta-analysis of 18 studies involving 4132 patients with AIS was conducted. Good collateral status was significantly associated with angiographic reperfusion (odds ratio [OR]=1.97, 95% confidence interval [CI]=1.38-2.80; P < 0.0001), sICH (OR=0.67, 95% CI=0.46-0.99; P = 0.042), and 90-day functional outcome (OR=3.05, 95% CI=1.78-5.24; P < 0.0001). However, its association with HT (OR=0.76, 95% CI=0.38-1.51; P = 0.425) and three-month mortality (OR=0.53, 95% CI=0.17-1.69; P = 0.280) did not reach statistical significance. The prognostic accuracy of collaterals for predicting angiographic reperfusion, HT, functional outcome (at 90 days), and mortality (at 90 days) were 63%, 49%, 66%, and 48%, respectively. CONCLUSION Cerebral collaterals are significantly associated with clinical and safety outcomes, albeit with a prognostic accuracy range of 48%-66%; thus, evaluation of their patency is a useful prognostic tool in patients with AIS receiving reperfusion therapy.
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Affiliation(s)
- Akansha Sinha
- Global Health Neurology and Translational Neuroscience Laboratory, 550242Sydney and Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,7800University of New South Wales (UNSW), 1511South Western Sydney Clinical School, Liverpool, NSW, Australia
| | - Peter Stanwell
- School of Health Sciences, 5982University of Newcastle, Callaghan, Newcastle, NSW, Australia
| | - Murray C Killingsworth
- Global Health Neurology and Translational Neuroscience Laboratory, 550242Sydney and Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,7800University of New South Wales (UNSW), 1511South Western Sydney Clinical School, Liverpool, NSW, Australia.,NSW Brain Clot Bank, 441551NSW Health Pathology, Sydney, NSW, Australia.,Correlative Microscopy Facility, Department of Anatomical Pathology, 34378NSW Health Pathology, and Liverpool Hospital, Liverpool, NSW, Australia
| | - Sonu M M Bhaskar
- Global Health Neurology and Translational Neuroscience Laboratory, 550242Sydney and Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,7800University of New South Wales (UNSW), 1511South Western Sydney Clinical School, Liverpool, NSW, Australia.,NSW Brain Clot Bank, 441551NSW Health Pathology, Sydney, NSW, Australia.,Department of Neurology and Neurophysiology, 34378Liverpool Hospital and South Western Sydney Local Health District, Sydney, NSW, Australia
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4
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Darwish ES, Othman MH, Youssef AH, Tawfik AM, Tohamy AM. Predictive value of cerebral collaterals on CT angiography on the outcome of patients with acute anterior ischemic stroke receiving thrombolysis treatment. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2022. [DOI: 10.1186/s41983-022-00599-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract
Background
Functional outcomes of patient with acute ischemic stroke are influenced by the status of the cerebral collaterals. The study aims at evaluating the influence of cerebral collaterals on clinical and radiological outcome in patients with acute anterior ischemic stroke (AAIS) treated with IV recombinant tissue plasminogen activator (IV-rtPA).
Results
Independent predictors of good functional outcomes were in the form of low NIHSS (odds ratio = 1.23, 95%CI = 1.01–2.34, p = 0.01), ASPECT ≥ 8 (odds ratio = 4.56, 95%CI = 3.40–7.89, p < 0.001), and good collateral status by Miteff grading system (odds ratio = 1.23, 95%CI = 2.22–6.79, p < 0.001).
Conclusion
Good collateral status is associated with milder stroke volume and good functional outcome. Also, low NIHSS, ASPECT score ≥ 8 and good collateral status by Miteff grading system were reliable independent predictors of favorable outcome in IV-rtPA treated patients with AAIS.
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5
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Laflamme M, Carrondo-Cottin S, Valdès MM, Simonyan D, Audet MÈ, Gariépy JL, Camden MC, Gariépy C, Verreault S, Lavoie P. Association between Early Ischemic Changes and Collaterals in Acute Stroke: A Retrospective Study. AJNR Am J Neuroradiol 2022; 43:1424-1430. [PMID: 36137656 PMCID: PMC9575540 DOI: 10.3174/ajnr.a7632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 07/13/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE The quality of leptomeningeal collaterals may influence the speed of infarct progression in acute stroke. Our main objective was to evaluate the association of leptomeningeal collateral score and its interaction with time with ischemic changes on CT in patients with acute stroke. MATERIALS AND METHODS Adult patients with acute stroke symptoms and anterior circulation large-vessel occlusion on CTA from 2015 to 2019 were included. Routinely performed NCCT and multiphase CTA were reviewed to assess ASPECTS and the leptomeningeal collateral score. We built multivariate regression models to assess the association between leptomeningeal collateral score and its interaction with time and ASPECTS. Performance measures to predict poor ASPECTS at different time thresholds (identified with receiver operating characteristic curve analysis) were estimated in a subgroup of patients with poor leptomeningeal collateral scores. RESULTS Leptomeningeal collateral scores 0-1 were associated with lower ASPECTS, and the model with dichotomized and trichotomized leptomeningeal collateral score showed a significant multiplicative interaction between time and the leptomeningeal collateral score. The negative predictive value for poor ASPECTS was >0.9 for at least the first 3 hours from stroke onset to imaging, and the positive predictive value was <0.5 for every time threshold tested in the subgroup of patients with leptomeningeal collateral scores 0-3. CONCLUSIONS Poor (0-1) leptomeningeal collateral scores were associated with lower ASPECTS, and an increase in time has a multiplicative interaction with the leptomeningeal collateral score on ASPECTS.
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Affiliation(s)
- M Laflamme
- Form the Division of Neurosurgery, Department of Surgery (M.L., C.G., P.L.)
| | - S Carrondo-Cottin
- Department of Neurosciences, Centre Hospitalier Universitaire de Québec -Université Laval Research Center (S.C.C.), Quebec, Canada
| | - M-M Valdès
- Department of Radiology (M.-M.V., M.-È.A, J.-L.G.)
| | - D Simonyan
- Clinical and Evaluative Research Platform (D.S.)
| | - M-È Audet
- Department of Radiology (M.-M.V., M.-È.A, J.-L.G.)
| | - J-L Gariépy
- Department of Radiology (M.-M.V., M.-È.A, J.-L.G.)
| | - M-C Camden
- Division of Neurology, Department of Medicine (M.-C.C., S.V.), Centre Hospitalier Universitaire de Québec -Université Laval, Quebec, Canada
| | - C Gariépy
- Form the Division of Neurosurgery, Department of Surgery (M.L., C.G., P.L.)
| | - S Verreault
- Division of Neurology, Department of Medicine (M.-C.C., S.V.), Centre Hospitalier Universitaire de Québec -Université Laval, Quebec, Canada
| | - P Lavoie
- Form the Division of Neurosurgery, Department of Surgery (M.L., C.G., P.L.)
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6
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Application of Three-Dimensional Arterial Spin Labeling Technique in the Assessment of Cerebral Blood Perfusion in Patients with Middle Cerebral Artery Occlusion: Analysis of Clinical Implications and Prognostic Factors. DISEASE MARKERS 2022; 2022:6990590. [PMID: 35990249 PMCID: PMC9385308 DOI: 10.1155/2022/6990590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/04/2022] [Accepted: 07/19/2022] [Indexed: 11/17/2022]
Abstract
Objective. To explore the value of three-dimensional- (3D-) arterial spin labeling (ASL) technique in evaluating cerebral perfusion in patients with unilateral middle cerebral artery occlusion (MCAO) and to observe the influencing factors of poor prognosis via long-term follow-up of patients who survived the disease. Methods. The clinical data of 60 patients with unilateral middle cerebral artery (MCA) M1 segment occlusion diagnosed by magnetic resonance angiography (MRA) from January 2018 to January 2022 were retrospectively analyzed. All patients were examined by routine MRI, MRA, and 3D-ASL, in which two postlabeling delays (PLDs; 1525 ms and 2525 ms) were used in 3D-ASL. Cerebral blood flow (CBF) in the regions of interest (ROIs) of MCA on the affected side and the mirror side was measured. The clinical data and laboratory indexes of patients were collected and evaluated by clinical scales. With the modified Rankin Score (mRS) as the outcome indicator, patients were assigned to either the poor or the good prognosis group to analyze the factors influencing patient prognosis via univariate and multivariate analyses. Results. Among unilateral MCAO patients, there was a significant difference in the CBF of the affected side between the PLD 1525 ms and 2525 ms groups (
), but there was no significant difference in the CBF of the mirror side (
). Compared with the mirror side, 43 cases (71.7%) of the affected CBF presented with hypoperfusion, 9 cases (15.0%) with normal perfusion, and 8 cases (13.3%) with hyperperfusion. Age, NIHSS score, collateral circulation, and homocysteine (Hcy) were identified by multivariate Logistic regression analysis as independent risk factors for adverse outcomes. Conclusion. MCAO can lead to cerebral blood perfusion decline, and 3D-ASL technique can evaluate the post-MCAO cerebral blood perfusion level. Old age, high NIHSS scores, poor collateral circulation, and high Hcy levels are associated with poor clinical outcomes.
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7
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Hong Y, Fang J, Ma M, Su W, Zhou M, Tang L, Tang H, He L. The Hyperdense middle cerebral artery sign is associated with poor leptomeningeal collaterals in acute ischemic stroke: a retrospective study. BMC Neurol 2022; 22:51. [PMID: 35148711 PMCID: PMC8832774 DOI: 10.1186/s12883-022-02566-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 01/19/2022] [Indexed: 02/08/2023] Open
Abstract
Background The hyperdense middle cerebral artery sign (HMCAS) is an early radiological marker to provide an early diagnosis and to identify ischemia. As reported, HMCAS is associated with heavy clot burden. Moreover, a heavy clot burden may cause obstruction of the orifices of arteries for leptomeningeal collateral flows and can lead to severe clinical conditions. However, the direct relationship between HMCAS and collateral flows remains unclear. Therefore, we explored the association between HMCAS and leptomeningeal collaterals in patients with acute ischemic stroke. Methods Consecutive ischemic stroke patients were enrolled from January 2015 to April 2021. HMCAS appearance and collateral status were detected by multimodal computed tomography at admission. Logistic regression analyses helped to identify the association between HMCAS, collateral flows and stroke severity. Results In 494 included patients, 180 (36.4%) presented with HMCAS. Ipsilateral collaterals were not seen or less prominent in patients with HMCAS (P < 0.001). The HMCAS appearance was significantly associated with less collaterals (odds ratio 5.17, 95% confidence interval 3.27-8.18, P < 0.001), internal carotid artery + M1/M1 occlusion, the initial stroke severity and follow-up outcomes. Subgroup analyses further confirmed HMCAS as an indicator of poor collaterals in ischemic stroke (all P values < 0.05). Conclusions HMCAS is associated with poor leptomeningeal collaterals, the stroke severity and a poor neurological outcome. Therefore, the HMCAS appearance can act as an early warning sign for healthcare professionals to be alert for poor collateral flows and poor neurological outcomes in ischemic stroke patients with middle cerebral artery occlusion.
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Affiliation(s)
- Ye Hong
- Department of Neurology, West China Hospital of Sichuan University, Wainan Guoxue Xiang #37, Chengdu, 610041, Sichuan, China.,Institute of Brain Science and Brain-Inspired Technology of West China Hospital, Sichuan University, Chengdu, China
| | - Jinghuan Fang
- Department of Neurology, West China Hospital of Sichuan University, Wainan Guoxue Xiang #37, Chengdu, 610041, Sichuan, China.,Institute of Brain Science and Brain-Inspired Technology of West China Hospital, Sichuan University, Chengdu, China
| | - Mengmeng Ma
- Department of Neurology, West China Hospital of Sichuan University, Wainan Guoxue Xiang #37, Chengdu, 610041, Sichuan, China.,Institute of Brain Science and Brain-Inspired Technology of West China Hospital, Sichuan University, Chengdu, China
| | - Wei Su
- Department of Neurology, West China Hospital of Sichuan University, Wainan Guoxue Xiang #37, Chengdu, 610041, Sichuan, China.,Institute of Brain Science and Brain-Inspired Technology of West China Hospital, Sichuan University, Chengdu, China
| | - Muke Zhou
- Department of Neurology, West China Hospital of Sichuan University, Wainan Guoxue Xiang #37, Chengdu, 610041, Sichuan, China.,Institute of Brain Science and Brain-Inspired Technology of West China Hospital, Sichuan University, Chengdu, China
| | - Li Tang
- Department of Neurology, West China Hospital of Sichuan University, Wainan Guoxue Xiang #37, Chengdu, 610041, Sichuan, China.,Institute of Brain Science and Brain-Inspired Technology of West China Hospital, Sichuan University, Chengdu, China
| | - Huairong Tang
- Department of Health Management Center, West China Hospital of Sichuan University, Wainan Guoxue Xiang #37, Chengdu, 610041, Sichuan, China.
| | - Li He
- Department of Neurology, West China Hospital of Sichuan University, Wainan Guoxue Xiang #37, Chengdu, 610041, Sichuan, China. .,Institute of Brain Science and Brain-Inspired Technology of West China Hospital, Sichuan University, Chengdu, China.
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8
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Collateral Status and Clinical Outcomes after Mechanical Thrombectomy in Patients with Anterior Circulation Occlusion. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:7796700. [PMID: 35126946 PMCID: PMC8808144 DOI: 10.1155/2022/7796700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/06/2021] [Accepted: 12/07/2021] [Indexed: 11/18/2022]
Abstract
Background. Successful mechanical thrombectomy (MT) requires reliable, noninvasive selection criteria. We aimed to investigate the association of collateral status and clinical outcomes after MT in patients with ischemic stroke due to anterior circulation occlusion. Methods. 109 patients with poor collaterals and 110 aged, sex-matched patients with good collaterals were enrolled in the study. Collateral circulation was estimated by the CT angiography with a 0–3 scale. The collateral status was categorized as poor collaterals (scores 0–1) and good collaterals (scores 2-3). The reperfusion was assessed by the modified Treatment in Cerebral Infarction scale (mTICI, score 0/1/2a/2b/3). The clinical outcomes included the scores on the modified Rankin scale (mRS, ranging from 0 to 6) and death 90 days after mechanical thrombectomy. Results. Patients with greater scores of collateral status were more likely to achieve successful reperfusion (mTICI 2b/3). Patients with good collaterals were significantly associated with a higher chance of achieving mRS of 0–1 at 90 days (adjusted ORs: 4.55; 95% CI: 3.17–7.24; and
< 0.001) and a lower risk of death at 90 days (adjusted ORs: 0.87; 95% CI: 4.0%–28.0%; and
= 0.012) compared to patients with poor collaterals. In subgroup analyses, patients with statin use seem to benefit more from the effect of collateral status on good mRS (≤2). Conclusion. Among patients with acute ischemic stroke caused by anterior circulation occlusion, better collateral status is associated with higher scores on mRS and lower mortality after mechanical thrombectomy. Statin use might have an interaction with the effect of collateral status.
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9
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Huang ZX, Li YK, Li SZ, Huang XJ, Chen Y, Hong QL, Cai QK, Han YF. A Dynamic Nomogram for 3-Month Prognosis for Acute Ischemic Stroke Patients After Endovascular Therapy: A Pooled Analysis in Southern China. Front Aging Neurosci 2021; 13:796434. [PMID: 34966271 PMCID: PMC8710662 DOI: 10.3389/fnagi.2021.796434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Cerebral edema (CDE) is a common complication in patients with acute ischemic stroke (AIS) and can reduce the benefit of endovascular therapy (EVT). To determine whether certain risk factors are associated with a poor prognosis mediated by CDE after EVT. The 759 patients with anterior circulation stroke treated by EVT at three comprehensive stroke centers in China from January 2014 to October 2020 were analyzed. Patients underwent follow-up for 3 months after inclusion. The primary endpoint was a measure of a poor prognosis (modified Rankin Scale score ≥ 3) at 3 months assessed in all patients receiving EVT. Least absolute shrinkage and selection operator and multivariate logistic regression were used to select variables for the prognostic nomogram. Based on these variables, the nomogram was established and validated. In addition, structural equation modeling was used to explore the pathways linking CDE and a poor prognosis. Seven predictors were identified, namely, diabetes, age, baseline Alberta Stroke Program Early CT score, modified Thrombolysis in Cerebral Infarction score, early angiogenic CDE, National Institutes of Health Stroke Scale score, and collateral circulation. The nomogram consisting of these variables showed the best performance, with a large area under the curve in both the internal validation set (0.850; sensitivity, 0.737; specificity, 0.887) and external validation set (0.875; sensitivity, 0.752; specificity, 0.878). In addition, CDE (total path coefficient = 0.24, P < 0.001) served as a significant moderator. A nomogram for predicting a poor prognosis after EVT in AIS patients was established and validated with CDE as a moderator.
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Affiliation(s)
- Zhi-Xin Huang
- Department of Neurology, Guangdong Second Provincial General Hospital, Guangzhou, China.,Department of Neurology, The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.,The School of Medicine, Jinan University, Guangzhou, China
| | - Yong-Kun Li
- Department of Neurology, Fujian Provincial Hospital, Shengli Clinical College of Fujian Medical University, Fuzhou, China.,Department of Neurology, Xiamen Key Laboratory of Brain Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Shi-Zhan Li
- Department of Neurology, The No. 1 People's Hospital of Yulin, Yulin, China
| | - Xian-Jun Huang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Ying Chen
- Department of Neurology, Xiamen Key Laboratory of Brain Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Quan-Long Hong
- Department of Neurology, The First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou, China
| | - Qian-Kun Cai
- Department of Neurology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Yun-Fei Han
- Department of Neurology, Medical School of Nanjing University, Jinling Hospital, Nanjing, China
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10
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Park PSW, Dewey HM, Choi PMC. Caught in Action - Evolving Emergent Large Vessel Occlusion and Collateral Failure During Alteplase Infusion for Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2021; 31:106176. [PMID: 34715521 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/28/2021] [Accepted: 10/08/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Published reports of acute deterioration during alteplase infusion for acute ischemic stroke due to development of partial to complete large vessel occlusion and collateral failure are sparce. MATERIALS AND METHODS We describe an 84-year-old patient with a fluctuating clinical course due to evolving emergent large vessel occlusion of right M1 segment of the middle cerebral artery and collateral failure during alteplase infusion. Potential mechanisms of acute deterioration within 24 h after thrombolysis are discussed. RESULTS Urgent mechanical thrombectomy was performed with resultant partial recanalization and small volume residual infarcts at 72 h magnetic resonance imaging of brain. CONCLUSIONS Progression from partial to complete occlusion may occur within minutes, even during administration of intravenous thrombolytics in hyper-acute stroke. In patients who deteriorate within 24 h of stroke onset, non-contrast CT of brain, followed by CT perfusion and angiography, is the imaging protocol of choice in the mechanical thrombectomy era.
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Affiliation(s)
- Peter S W Park
- Department of Neurosciences, Box Hill Hospital, Eastern Health, Level 2, 5 Arnold St, Box Hill, Victoria 3128, Australia; Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia.
| | - Helen M Dewey
- Department of Neurosciences, Box Hill Hospital, Eastern Health, Level 2, 5 Arnold St, Box Hill, Victoria 3128, Australia; Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia.
| | - Philip M C Choi
- Department of Neurosciences, Box Hill Hospital, Eastern Health, Level 2, 5 Arnold St, Box Hill, Victoria 3128, Australia; Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia.
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11
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Camara R, Matei N, Zhang JH. Evolution of the stroke paradigm: A review of delayed recanalization. J Cereb Blood Flow Metab 2021; 41:945-957. [PMID: 33325765 PMCID: PMC8054720 DOI: 10.1177/0271678x20978861] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
While the time window for reperfusion after ischemic stroke continues to increase, many patients are not candidates for reperfusion under current guidelines that allow for reperfusion within 24 h after last known well time; however, many case studies report favorable outcomes beyond 24 h after symptom onset for both spontaneous and medically induced recanalization. Furthermore, modern imaging allows for identification of penumbra at extended time points, and reperfusion risk factors and complications are becoming better understood. Taken together, continued urgency exists to better understand the pathophysiologic mechanisms and ideal setting of delayed recanalization beyond 24 h after onset of ischemia.
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Affiliation(s)
- Richard Camara
- Departments of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, USA
| | - Nathanael Matei
- Departments of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, USA
| | - John H Zhang
- Departments of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, USA.,Department of Anesthesiology, Loma Linda University, Loma Linda, CA, USA.,Department of Neurosurgery, Loma Linda University, Loma Linda, CA, USA
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12
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Matei N, Camara J, Zhang JH. The Next Step in the Treatment of Stroke. Front Neurol 2021; 11:582605. [PMID: 33551950 PMCID: PMC7862333 DOI: 10.3389/fneur.2020.582605] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 12/23/2020] [Indexed: 12/12/2022] Open
Abstract
Although many patients do not receive reperfusion therapy because of delayed presentation and/or severity and location of infarct, new reperfusion approaches are expanding the window of intervention. Novel application of neuroprotective agents in combination with the latest methods of reperfusion provide a path to improved stroke intervention outcomes. We examine why neuroprotective agents have failed to translate to the clinic and provide suggestions for new approaches. New developments in recanalization therapy in combination with therapeutics evaluated in parallel animal models of disease will allow for novel, intra-arterial deployment of therapeutic agents over a vastly expanded therapeutic time window and with greater likelihood success. Although the field of neuronal, endothelial, and glial protective therapies has seen numerous large trials, the application of therapies in the context of newly developed reperfusion strategies is still in its infancy. Given modern imaging developments, evaluation of the penumbra will likely play a larger role in the evolving management of stroke. Increasingly more patients will be screened with neuroimaging to identify patients with adequate collateral blood supply allowing for delayed rescue of the penumbra. These patients will be ideal candidates for therapies such as reperfusion dependent therapeutic agents that pair optimally with cutting-edge reperfusion techniques.
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Affiliation(s)
- Nathanael Matei
- Department of Ophthalmology, University of Southern California, Los Angeles, CA, United States
| | - Justin Camara
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, United States
| | - John H Zhang
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, United States.,Department of Anesthesiology, Loma Linda University, Loma Linda, CA, United States.,Department of Neurosurgery, Loma Linda University, Loma Linda, CA, United States
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13
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Li X, Liu H, Zeng W, Liu X, Wen Y, Xiong Q, Yang R. The Value of Whole-Brain Perfusion Parameters Combined with Multiphase Computed Tomography Angiography in Predicting Hemorrhagic Transformation in Ischemic Stroke. J Stroke Cerebrovasc Dis 2020; 29:104690. [PMID: 32067854 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104690] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/18/2020] [Accepted: 01/22/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To explore the value of whole-brain perfusion parameters combined with multiphase computed tomography angiography (MP-CTA) in predicting the hemorrhagic transformation (HT) of ischemic stroke. METHODS A total of 64 patients with ischemic stroke who underwent noncontrast computed tomography, computed tomography perfusion imaging, and computed tomography angiography before treatment from August 2017 to June 2019 were included retrospectively. The perfusion parameters cerebral blood volume (CBV), cerebral blood flow (CBF), time to peak (TTP), mean transit time (MTT), time to maximum (Tmax), and permeability surface (PS) were measured by postprocessing software (Advantage Workstation 4.7 (Revolution, GE Healthcare, USA)), and their ratios between the healthy and affect side relative CBV, relative CBF, relative time to peak (rTTP), relative mean transit time (rMTT), relative Tmax, and relative permeability surface (rPS) were calculated. The differences in perfusion parameters between the HT group and the non-HT group were evaluated. The collateral circulation scores and HT rates were assessed by MP-CTA. Receiver operating characteristic curves were drawn to analyze the diagnostic efficiency of valuable parameters and their correlations with HT. The rate of HT in different treatments were compared. RESULTS The CBV values in the HT group were lower than those in the non-HT group (P < .05), while the TTP, MTT, Tmax, PS, rTTP, rMTT, and rPS values in the HT group were higher than those in the non-HT group (P < .05). PS (r = .63, area under curve = .881) and rPS (r = .52, area under curve = .814) were significantly correlated with HT. The combination of perfusion parameters and the MP-CTA scores can improve the diagnostic efficiency (area under curve = .891). The HT rate in the group with poor collateral (64.29%) was higher than that in the group with good collateral (11.11%). CONCLUSIONS Whole-brain perfusion parameters and MP-CTA scores have important application value in assessing the HT risk of ischemic stroke patients before treatment.
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Affiliation(s)
- Xiang Li
- Chongqing Three Gorges Central Hospital, Chongqing, China
| | | | - Wenbing Zeng
- Chongqing Three Gorges Central Hospital, Chongqing, China.
| | - Xinghua Liu
- Chongqing Three Gorges Central Hospital, Chongqing, China
| | - Yun Wen
- Chongqing Three Gorges Central Hospital, Chongqing, China
| | - Qiuxia Xiong
- Chongqing Three Gorges Central Hospital, Chongqing, China
| | - Ran Yang
- Chongqing Three Gorges Central Hospital, Chongqing, China
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14
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Villringer K, Zimny S, Galinovic I, Nolte CH, Fiebach JB, Khalil AA. The Association Between Recanalization, Collateral Flow, and Reperfusion in Acute Stroke Patients: A Dynamic Susceptibility Contrast MRI Study. Front Neurol 2019; 10:1147. [PMID: 31708866 PMCID: PMC6823193 DOI: 10.3389/fneur.2019.01147] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/14/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Collateral circulation in ischemic stroke patients plays an important role in infarct evolution und assessing patients' eligibility for endovascular treatment. By means of dynamic susceptibility contrast MRI, we aimed to investigate the effects of reperfusion, recanalization, and collateral flow on clinical and imaging outcomes after stroke. Methods: Retrospective analysis of 184 patients enrolled into the prospective observational 1000Plus study (clinicaltrials.org NCT00715533). Inclusion criteria were vessel occlusion on baseline MR-angiography, imaging within 24 h after stroke onset and follow-up perfusion imaging. Baseline Higashida score using subtracted dynamic MR perfusion source images was used to quantify collateral flow. The influence of these variables, and their interaction with vessel recanalization, on clinical and imaging outcomes was assessed using robust linear regression. Results: Ninety-eight patients (53.3%) showed vessel recanalization. Higashida score (p = 0.002), and recanalization (p = 0.0004) were independently associated with reperfusion. However, we found no evidence that the association between Higashida score and reperfusion relied on recanalization status (p = 0.2). NIHSS on admission (p < 0.0001) and recanalization (p = 0.001) were independently associated with long-term outcome at 3 months, however, Higashida score (p = 0.228) was not. Conclusion: Higashida score and recanalization were independently associated with reperfusion, but the association between recanalization and reperfusion was similar regardless of collateral flow quality. Recanalization was associated with long-term outcome. DSC-based measures of collateral flow were not associated with long-term outcome, possibly due to the complex dynamic nature of collateral recruitment, timing of imaging and the employed post-processing.
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Affiliation(s)
- Kersten Villringer
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sascha Zimny
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Ev.-Luth. Diakonissenanstalt zu Flensburg, Flensburg, Germany
| | - Ivana Galinovic
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ahmed A Khalil
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.,Mind, Brain, Body Institute, Berlin School of Mind and Brain, Humboldt-Universität Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
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15
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Annus Á, Nagy A, Vécsei L, Klivényi P. 24-Hour Near-Infrared Spectroscopy Monitoring of Acute Ischaemic Stroke Patients Undergoing Thrombolysis or Thrombectomy: A Pilot Study. J Stroke Cerebrovasc Dis 2019; 28:2337-2342. [PMID: 31182266 DOI: 10.1016/j.jstrokecerebrovasdis.2019.05.026] [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: 03/23/2019] [Revised: 04/29/2019] [Accepted: 05/24/2019] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Monitoring of acute ischaemic stroke patients during thrombolysis or thrombectomy is based mostly on frequent physical examinations, since no objective measurement of cerebrovascular haemodynamics is available in routine clinical practice. Near-infrared spectroscopy (NIRS) is a bed-side, noninvasive assessment tool that could help monitor these patients and potentially guide therapeutic interventions. Our goal in this pilot study was to investigate whether NIRS is a suitable method to monitor leptomeningeal collateral circulation via changes in cortical oxygen saturation in the first 24 hours of acute ischaemic stroke. PATIENTS AND METHODS Our study included 5 patients with acute anterior circulation infarcts. All patients received thrombolytic therapy and 1 had thrombectomy. 24-hour continuous NIRS monitoring was performed on all participants. RESULTS We aimed to give a detailed description of each NIRS recording and explain how the observed findings could correlate with changes in anterior watershed territory collateral circulation and clinical outcome. CONCLUSION Our pilot study supports the use of NIRS monitoring in acute ischaemic stroke. We believe that this technique could provide real-time information on the dynamic changes of leptomeningeal collateral circulation and help monitor the effects of thrombolysis and thrombectomy.
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Affiliation(s)
- Ádám Annus
- Department of Neurology, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - András Nagy
- Department of Radiology, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - László Vécsei
- Department of Neurology, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary; MTA-SZTE Neuroscience Research Group, Szeged, Hungary
| | - Péter Klivényi
- Department of Neurology, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary.
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16
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Jiang B, Ball RL, Michel P, Li Y, Zhu G, Ding V, Su B, Naqvi Z, Eskandari A, Desai M, Wintermark M. Factors influencing infarct growth including collateral status assessed using computed tomography in acute stroke patients with large artery occlusion. Int J Stroke 2019; 14:603-612. [PMID: 31096871 DOI: 10.1177/1747493019851278] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In major ischemic stroke caused by a large artery occlusion, neuronal loss varies considerably across individuals without revascularization. This study aims to identify which patient characteristics are most highly associated with this variability. Demographic and clinical information were retrospectively collected on a registry of 878 patients. Imaging biomarkers including Alberta Stroke Program Early CT score, noncontrast head computed tomography infarct volume, perfusion computed tomography infarct core and penumbra, occlusion site, collateral score, and recanalization status were evaluated on the baseline and early follow-up computed tomography images. Infarct growth rates were calculated by dividing infarct volumes by the time elapsed between the computed tomography scan and the symptom onset. Collateral score was graded into four levels (0, 1, 2, and 3) in comparison with the normal side. Correlation of perfusion computed tomography and noncontrast head computed tomography infarct volumes and infarct growth rates were estimated with the nonparametric Spearman's rank correlation. Conditional inference trees were used to identify the clinical and imaging biomarkers that were most highly associated with the infarct growth rate and modified Rankin Scale at 90 days. Two hundred and thirty-two patients met the inclusion criteria for this study. The median infarct growth rates for perfusion computed tomography and noncontrast head computed tomography were 11.2 and 6.2 ml/log(min) in logarithmic model, and 18.9 and 10.4 ml/h in linear model, respectively. Noncontrast head computed tomography and perfusion computed tomography infarct volumes and infarct growth rates were significantly correlated (rho=0.53; P < 0.001). Collateral status was the strongest predictor for infarct growth rates. For collateral=0, the perfusion computed tomography and noncontrast head computed tomography infarct growth rate were 31.56 and 16.86 ml/log(min), respectively. Patients who had collateral >0 and penumbra volumes>92 ml had the lowest predicted perfusion computed tomography infarct growth rates (6.61 ml/log(min)). Collateral status was closely related to the diversity of infarct growth rates, poor collaterals were associated with a faster infarct growth rates and vice versa.
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Affiliation(s)
- Bin Jiang
- 1 Department of Radiology, Neuroradiology Section, Stanford University School of Medicine, Stanford, USA
| | - Robyn L Ball
- 2 Department of Medicine, Quantitative Sciences Unit, Stanford University, Stanford, USA
| | - Patrik Michel
- 3 Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Ying Li
- 1 Department of Radiology, Neuroradiology Section, Stanford University School of Medicine, Stanford, USA
| | - Guangming Zhu
- 1 Department of Radiology, Neuroradiology Section, Stanford University School of Medicine, Stanford, USA
| | - Victoria Ding
- 2 Department of Medicine, Quantitative Sciences Unit, Stanford University, Stanford, USA
| | - Bochao Su
- 1 Department of Radiology, Neuroradiology Section, Stanford University School of Medicine, Stanford, USA
| | - Zack Naqvi
- 1 Department of Radiology, Neuroradiology Section, Stanford University School of Medicine, Stanford, USA
| | - Ashraf Eskandari
- 3 Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Manisha Desai
- 2 Department of Medicine, Quantitative Sciences Unit, Stanford University, Stanford, USA
| | - Max Wintermark
- 1 Department of Radiology, Neuroradiology Section, Stanford University School of Medicine, Stanford, USA
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17
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Jiang S, Peng Y, Jing CH, Fei AH, Wang HR, Gao CJ, Chen M, Li Y, Pan S. Endovascular thrombectomy can be beneficial to acute ischemic stroke patients with large infarcts. J Neurosurg 2019; 130:1383-1390. [PMID: 29749914 DOI: 10.3171/2017.11.jns171297] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 11/04/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study aimed to assess whether patients with acute ischemic stroke (AIS) and large infarct lesions benefit from reperfusion management. To determine the efficacy of different recanalization managements on AIS patients with Alberta Stroke Program Early CT Score (ASPECTS) < 6, the authors retrospectively analyzed hospitalized patients with AIS. METHODS Eighty-nine patients with AIS and ASPECTS < 6 were screened from 13,285 hospitalized patients treated by thrombolysis, thrombectomy, or conventional care in two stroke medical centers. Logistic regression or Fisher's exact test was performed for comparison of the outcome and risk events between patients treated by thrombectomy (or thrombolysis) and conventional care. The modified Rankin Scale (mRS) score was used to assess the major clinical outcome of patients 3 months after disease onset. Disease outcome was also examined by analyzing symptom improvement at discharge. In particular, mortality and symptomatic intracranial hemorrhage (sICH) were evaluated as risk factors. RESULTS This study included 21 patients who received thrombolysis, 36 patients receiving thrombectomy, and 32 patients receiving conventional treatment. Among these 3 treatments, only the thrombectomy group clearly showed the most encouraging clinical outcome (mRS score 0-2; p < 0.05, Fisher's exact test) and marked improvement (OR 25.84, 95% CI 2.44-273.59) compared with conventional treatment. It is noteworthy that the mortality rate of the thrombectomy and thrombolysis group was similar to that of the conventional group, and thrombectomy and thrombolysis increased the risk of sICH in comparison with conventional care (p < 0.05, Fisher's exact test). CONCLUSIONS Patients with AIS and ASPECTS < 6 definitely benefited from thrombectomy with higher sICH risk, whereas thrombolysis management showed similar efficacy to the control group.
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Affiliation(s)
- Shaowei Jiang
- 1Department of Emergency, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Ya Peng
- 3Cerebral Vascular Disease Center, The First People's Hospital of Changzhou, Soochow University, Changzhou, China
| | - Chao-Hui Jing
- 2Department of Neurosurgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai; and
| | - Ai-Hua Fei
- 1Department of Emergency, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Hai-Rong Wang
- 1Department of Emergency, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Cheng-Jin Gao
- 1Department of Emergency, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Miao Chen
- 1Department of Emergency, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Yi Li
- 2Department of Neurosurgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai; and
| | - Shuming Pan
- 1Department of Emergency, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
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18
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Gregori-Pla C, Blanco I, Camps-Renom P, Zirak P, Serra I, Cotta G, Maruccia F, Prats-Sánchez L, Martínez-Domeño A, Busch DR, Giacalone G, Martí-Fàbregas J, Durduran T, Delgado-Mederos R. Early microvascular cerebral blood flow response to head-of-bed elevation is related to outcome in acute ischemic stroke. J Neurol 2019; 266:990-997. [PMID: 30739181 DOI: 10.1007/s00415-019-09226-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 01/31/2019] [Accepted: 02/01/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIMS Previously, microvascular cerebral blood flow (CBF) response to a mild head-of-bed (HOB) elevation has been shown to be altered in acute ischemic stroke (AIS) by diffuse correlation spectroscopy (DCS). We have hypothesized that early CBF response is related to the functional outcome. METHODS Patients with a non-lacunar AIS in the anterior circulation were monitored by DCS to measure relative CBF (ΔrCBF) on the frontal lobes bilaterally during a 0°-30° HOB elevation at early (≤ 12) or late (> 12) hours from symptom onset. National Institutes of Health Stroke Scale (NIHSS) scores were recorded at baseline at 24 and at 48 h. Functional outcome was measured by the modified Rankin Scale (mRS) at 3 months. RESULTS Thirty-eight (n = 38) AIS patients [baseline NIHSS = 19 (interquartile range: 16, 21)] were studied. ΔrCBF decreased similarly in both hemispheres (p = 0.4) when HOB was elevated and was not associated with baseline and follow-up NIHSS scores or patient demographics. At the early phase (n = 17), a lower or paradoxical ΔrCBF response to HOB elevation was associated with an unfavorable functional outcome (mRS > 2) in the ipsilesional (but not in the contralesional) hemisphere (p = 0.010). ΔrCBF response in the late acute phase was not related to mRS. CONCLUSIONS Early CBF response to mild HOB elevation in the ipsilesional hemisphere is related to functional outcome. Further studies may enable optical monitoring at the bedside to individualize management strategies in the early phase of AIS.
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Affiliation(s)
- Clara Gregori-Pla
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Av. Carl Friedrich Gauss, 3, Castelldefels, Barcelona, 08860, Spain.
| | - Igor Blanco
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Av. Carl Friedrich Gauss, 3, Castelldefels, Barcelona, 08860, Spain
| | - Pol Camps-Renom
- Department of Neurology, Sant Pau Biomedical Research Institute, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Peyman Zirak
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Av. Carl Friedrich Gauss, 3, Castelldefels, Barcelona, 08860, Spain
| | - Isabel Serra
- Centre de Recerca Matemàtica (CRM), Bellaterra, Spain
| | - Gianluca Cotta
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Av. Carl Friedrich Gauss, 3, Castelldefels, Barcelona, 08860, Spain
| | - Federica Maruccia
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Av. Carl Friedrich Gauss, 3, Castelldefels, Barcelona, 08860, Spain.,Neurotraumatology and Neurosurgery Research Unit, Vall d'Hebron University Research Institute, Barcelona, Spain
| | - Luís Prats-Sánchez
- Department of Neurology, Sant Pau Biomedical Research Institute, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Alejandro Martínez-Domeño
- Department of Neurology, Sant Pau Biomedical Research Institute, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - David R Busch
- Departments of Anesthesiology and Pain Management; Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Giacomo Giacalone
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Av. Carl Friedrich Gauss, 3, Castelldefels, Barcelona, 08860, Spain.,San Raffaele Scientific Institute, Milan, Italy
| | - Joan Martí-Fàbregas
- Department of Neurology, Sant Pau Biomedical Research Institute, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Turgut Durduran
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Av. Carl Friedrich Gauss, 3, Castelldefels, Barcelona, 08860, Spain.,Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | - Raquel Delgado-Mederos
- Department of Neurology, Sant Pau Biomedical Research Institute, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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19
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Makris N, Chamard L, Mikkelsen IK, Hermier M, Derex L, Pedraza S, Thomalla G, Østergaard L, Baron JC, Nighoghossian N, Berthezène Y, Cho TH. Acute reperfusion without recanalization: Serial assessment of collaterals within 6 h of using perfusion-weighted magnetic resonance imaging. J Cereb Blood Flow Metab 2019; 39:251-259. [PMID: 29291673 PMCID: PMC6365601 DOI: 10.1177/0271678x17744716] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Acute reperfusion despite persistent arterial occlusion may occur in up to 30% of ischemic stroke patients. Recruitment of leptomeningeal collaterals may explain this phenomenon. Using dynamic susceptibility-contrast perfusion imaging (DSC-PI), we assessed acute changes in collateral flow among patients without recanalization. From a multicenter prospective database (I-KNOW), 46 patients with magnetic resonance angiography visible occlusion in whom both reperfusion and recanalization were assessed within 6 h of onset were identified. Maps of collateral flow at arterial, capillary and late venous phases were generated from DSC-PI through inter-frame registration, baseline signal subtraction and temporal summation, and graded blind to all other relevant clinical and radiological data using the Higashida scale. Flow direction and the acute evolution of collaterals were evaluated against the reperfusion status. Among patients without recanalization ( n = 33), flow direction remained retrograde. Collateral grades significantly improved between admission and acute follow-up in patients who reperfused (OR: 4.57; 95% CI: 1.1-22.7; p = 0.048), but not in those without reperfusion (OR: 1.34; 95% CI: 0.4-4.5; p = 0.623). Our study confirmed that acute reperfusion without recanalization is associated with a significant improvement of retrograde collateral flow. DSC-PI can detect acute changes in collateral flow, and may help evaluate novel treatments targeting leptomeningeal collaterals.
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Affiliation(s)
- Nikolaos Makris
- 1 Department of Stroke Medicine and Department of Neuroradiology, Université Lyon 1, CREATIS, CNRS UMR 5220-INSERM U1206, INSA-Lyon; Hospices Civils de Lyon, Lyon, France
| | - Leila Chamard
- 1 Department of Stroke Medicine and Department of Neuroradiology, Université Lyon 1, CREATIS, CNRS UMR 5220-INSERM U1206, INSA-Lyon; Hospices Civils de Lyon, Lyon, France
| | - Irene K Mikkelsen
- 2 Center of Functionally Integrative Neuroscience, Aarhus University, Aarhus, Denmark
| | - Marc Hermier
- 1 Department of Stroke Medicine and Department of Neuroradiology, Université Lyon 1, CREATIS, CNRS UMR 5220-INSERM U1206, INSA-Lyon; Hospices Civils de Lyon, Lyon, France
| | - Laurent Derex
- 1 Department of Stroke Medicine and Department of Neuroradiology, Université Lyon 1, CREATIS, CNRS UMR 5220-INSERM U1206, INSA-Lyon; Hospices Civils de Lyon, Lyon, France
| | - Salvador Pedraza
- 3 Department of Radiology (IDI), Girona Biomedical Research Institute (IDIBGI), Hospital Universitari de Girona Dr Josep Trueta, Girona, Spain
| | - Götz Thomalla
- 4 Department of Neurology, Head and Neuro Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Leif Østergaard
- 2 Center of Functionally Integrative Neuroscience, Aarhus University, Aarhus, Denmark
| | - Jean-Claude Baron
- 5 University of Cambridge, Department of Clinical Neurosciences, Cambridge, UK; INSERM U894, Hôpital Sainte-Anne, Université Paris Descartes, Paris, France
| | - Norbert Nighoghossian
- 1 Department of Stroke Medicine and Department of Neuroradiology, Université Lyon 1, CREATIS, CNRS UMR 5220-INSERM U1206, INSA-Lyon; Hospices Civils de Lyon, Lyon, France
| | - Yves Berthezène
- 1 Department of Stroke Medicine and Department of Neuroradiology, Université Lyon 1, CREATIS, CNRS UMR 5220-INSERM U1206, INSA-Lyon; Hospices Civils de Lyon, Lyon, France
| | - Tae-Hee Cho
- 1 Department of Stroke Medicine and Department of Neuroradiology, Université Lyon 1, CREATIS, CNRS UMR 5220-INSERM U1206, INSA-Lyon; Hospices Civils de Lyon, Lyon, France
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20
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Tian DC, Shi K, Zhu Z, Yao J, Yang X, Su L, Zhang S, Zhang M, Gonzales RJ, Liu Q, Huang D, Waters MF, Sheth KN, Ducruet AF, Fu Y, Lou M, Shi FD. Fingolimod enhances the efficacy of delayed alteplase administration in acute ischemic stroke by promoting anterograde reperfusion and retrograde collateral flow. Ann Neurol 2018; 84:717-728. [PMID: 30295338 PMCID: PMC6282815 DOI: 10.1002/ana.25352] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 09/18/2018] [Accepted: 09/23/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The present study was undertaken to determine the efficacy of coadministration of fingolimod with alteplase in acute ischemic stroke patients in a delayed time window. METHODS This was a prospective, randomized, open-label, blinded endpoint clinical trial, enrolling patients with internal carotid artery or middle cerebral artery proximal occlusion within 4.5 to 6 hours from symptom onset. Patients were randomly assigned to receive alteplase alone or alteplase with fingolimod. All patients underwent pretreatment and 24-hour noncontrast computed tomography (CT)/perfusion CT/CT angiography. The coprimary endpoints were the decrease of National Institutes of Health Stroke Scale scores over 24 hours and the favorable shift of modified Rankin Scale score (mRS) distribution at day 90. Exploratory outcomes included vessel recanalization, anterograde reperfusion, and retrograde reperfusion of collateral flow. RESULTS Each treatment group included 23 patients. Compared with alteplase alone, patients receiving fingolimod plus alteplase exhibited better early clinical improvement at 24 hours and a favorable shift of mRS distribution at day 90. In addition, patients who received fingolimod and alteplase exhibited a greater reduction in the perfusion lesion accompanied by suppressed infarct growth by 24 hours. Fingolimod in conjunction with alteplase significantly improved anterograde reperfusion of downstream territory and prevented the failure of retrograde reperfusion from collateral circulation. INTERPRETATION Fingolimod may enhance the efficacy of alteplase administration in the 4.5- to 6-hour time window in patients with a proximal cerebral arterial occlusion and salvageable penumbral tissue by promoting both anterograde reperfusion and retrograde collateral flow. These findings are instructive for the design of future trials of recanalization therapies in extended time windows. Ann Neurol 2018;84:725-736.
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Affiliation(s)
- De-Cai Tian
- Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Kaibin Shi
- Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China.,Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Zilong Zhu
- Department of Neurology, Tianjin HuanHu Hospital, Tianjin, China
| | - Jia Yao
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaoxia Yang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Lei Su
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Sheng Zhang
- Department of Neurology, School of Medicine, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Meixia Zhang
- Department of Neurology, School of Medicine, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Rayna J Gonzales
- Department of Basic Medical Sciences, University of Arizona College of Medicine, Phoenix, AZ
| | - Qiang Liu
- Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ
| | - DeRen Huang
- Neuroscience Center, Mount Carmel Health System, Westerville, OH
| | - Michael F Waters
- Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Kevin N Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Andrew F Ducruet
- Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Ying Fu
- Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Min Lou
- Department of Neurology, School of Medicine, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Fu-Dong Shi
- Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China.,Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ
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21
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Ginsberg MD. The cerebral collateral circulation: Relevance to pathophysiology and treatment of stroke. Neuropharmacology 2017; 134:280-292. [PMID: 28801174 DOI: 10.1016/j.neuropharm.2017.08.003] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 07/28/2017] [Accepted: 08/06/2017] [Indexed: 12/29/2022]
Abstract
The brain's collateral circulation consists of arterial anastomotic channels capable of providing nutrient perfusion to brain regions whose normal sources of flow have become compromised, as occurs in acute ischemic stroke. Modern CT-based neuroimaging is capable of providing detailed information as to collateral extent and sufficiency and is complemented by magnetic resonance-based methods. In the present era of standard-of-care IV thrombolysis for acute ischemic stroke, and following the recent therapeutic successes of randomized clinical trials of acute endovascular intervention, the sufficiency of the collateral circulation has been convincingly established as a key factor influencing the likelihood of successful reperfusion and favorable clinical outcome. This article reviews the features of the brain's collateral circulation; methods for its evaluation in the acute clinical setting; the relevance of collateral circulation to prognosis in acute ischemic stroke; the specific insights into the collateral circulation learned from recent trials of endovascular intervention; and the major influence of genetic factors. Finally, we emphasize the need to develop therapeutic approaches to augment collateral perfusion as an adjunctive strategy to be employed along with, or prior to, thrombolysis and endovascular interventions, and we highlight the possible potential of inhaled nitric oxide, albumin, and other approaches. This article is part of the Special Issue entitled 'Cerebral Ischemia'.
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Affiliation(s)
- Myron D Ginsberg
- Department of Neurology, University of Miami Miller School of Medicine, Clinical Research Center, Room 1331, 1120 NW 14th Street, Miami, FL 33136, USA.
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22
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Mundiyanapurath S, Diatschuk S, Loebel S, Pfaff J, Pham M, Möhlenbruch MA, Wick W, Bendszus M, Ringleb PA, Radbruch A. Outcome of patients with proximal vessel occlusion of the anterior circulation and DWI-PWI mismatch is time-dependent. Eur J Radiol 2017. [PMID: 28629575 DOI: 10.1016/j.ejrad.2017.03.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE Patients with ischemic stroke and large vessel occlusion are assumed to benefit from endovascular therapy (ET) independent of the symptom onset-to-treatment time (OTT) if they present with a mismatch of diffusion- and perfusion-weighted imaging (DWI-PWI mismatch). We aimed at studying the influence of OTT on clinical outcome in these patients. METHODS Retrospective database review in a tertiary care university hospital. All patients presented with proximal vessel occlusion of the anterior circulation and DWI-PWI mismatch. Primary outcome was the influence of OTT on modified Rankin scale (mRS) score three months after treatment, dichotomized in favourable (0-2) and unfavourable outcome (3-6). Secondary outcome was the effect of OTT on the shift of the mRS score. Patients treated within an early time window (<340min) and a late time window (≥340min) were compared. RESULTS 139 patients were included. The rate of favourable outcome was significantly higher in patients who were treated in an early compared to those treated in a late time window (31 [49%] vs. 20 patients [27%], p=0.005). Adjusted multivariate logistic regression revealed that late treatment was an independent negative predictor of favourable outcome (odds ratio 0.39, confidence interval [0.18-0.84]; p=0.016). A shift towards higher mRS scores for late treatment was evident (p=0.015). In sensitivity analysis, OTT remained an independent predictor when evaluated as continuous variable. These findings were confirmed in patients with a comparable DWI-PWI mismatch according to the definitions from large trials (DEFUSE 2, DEFUSE 3, SWIFT-PRIME, EXTEND-IA). CONCLUSION Outcome of patients with comparable DWI-PWI mismatch is time-dependent.
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Affiliation(s)
| | - Sascha Diatschuk
- German Cancer Research Centre, Department of Radiology, Heidelberg, Germany
| | - Sarah Loebel
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Johannes Pfaff
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Mirko Pham
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany; Institute for Diagnostic and Interventional Neuroradiology, University Hospital Würzburg, Germany
| | | | - Wolfgang Wick
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany; CCU Neurooncology, German Cancer Consortium (DKTK) & German Cancer Research Centre (DKFZ), Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter A Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Alexander Radbruch
- German Cancer Research Centre, Department of Radiology, Heidelberg, Germany; Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
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23
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Yeo LLL, Tan BYQ, Andersson T. Review of Post Ischemic Stroke Imaging and Its Clinical Relevance. Eur J Radiol 2017; 96:145-152. [PMID: 28237773 DOI: 10.1016/j.ejrad.2017.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 02/09/2017] [Accepted: 02/11/2017] [Indexed: 10/20/2022]
Abstract
In this day and age, multiple imaging modalities are available to the stroke physician in the post-treatment phase.The practical challenge for physicians who treat stroke is to evaluate the pros and cons of each technique and select the best choice for the situation. The choice of imaging modality remains contentious at best and varies among different institutions and centres. This is no simple task an there are many factors to consider, including the differential diagnosis which need to be evaluated, the availability and reliability of the imaging technique and time and expertise required to perform and interpret the scanning. Other ancillary competing interest also come into play such as the financial cost of the modality, the requirement for patient monitoring during the imaging procedure and patient comfort. In an effort to clear some of the ambiguity surrounding this topic we present some of the current techniques in use and others, which are still in the realm of research and have not yet transitioned into clinical practice.
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Affiliation(s)
- Leonard L L Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore; Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Benjamin Y Q Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Tommy Andersson
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
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24
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Ginsberg MD. Expanding the concept of neuroprotection for acute ischemic stroke: The pivotal roles of reperfusion and the collateral circulation. Prog Neurobiol 2016; 145-146:46-77. [PMID: 27637159 DOI: 10.1016/j.pneurobio.2016.09.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/22/2016] [Accepted: 09/10/2016] [Indexed: 12/27/2022]
Abstract
This review surveys the efforts taken to achieve clinically efficacious protection of the ischemic brain and underscores the necessity of expanding our purview to include the essential role of cerebral perfusion and the collateral circulation. We consider the development of quantitative strategies to measure cerebral perfusion at the regional and local levels and the application of these methods to elucidate flow-related thresholds of ischemic viability and to characterize the ischemic penumbra. We stress that the modern concept of neuroprotection must consider perfusion, the necessary substrate upon which ischemic brain survival depends. We survey the major mechanistic approaches to neuroprotection and review clinical neuroprotection trials, focusing on those phase 3 multicenter clinical trials for acute ischemic stroke that have been completed or terminated. We review the evolution of thrombolytic therapies; consider the lessons learned from the initial, negative multicenter trials of endovascular therapy; and emphasize the highly successful positive trials that have finally established a clinical role for endovascular clot removal. As these studies point to the brain's collateral circulation as key to successful reperfusion, we next review the anatomy and pathophysiology of collateral perfusion as it relates to ischemic infarction, as well as the molecular and genetic influences on collateral development. We discuss the current MR and CT-based diagnostic methods for assessing the collateral circulation and the prognostic significance of collaterals in ischemic stroke, and we consider past and possible future therapeutic directions.
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Affiliation(s)
- Myron D Ginsberg
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, United States.
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