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Ferrone NG, Sanmartin MX, O'Hara J, Jimenez J, Ferrone SR, Lodato Z, Lacher G, Bandi S, Convey A, Bastani M, Lee UJ, Morales Vialet J, White T, Wang JJ, Katz JM, Sanelli PC. Diagnostic Accuracy of Cone-Beam CT for Acute Intracranial Hemorrhage: A Systematic Review and Meta-Analysis. J Am Coll Radiol 2024:S1546-1440(24)00692-6. [PMID: 39147252 DOI: 10.1016/j.jacr.2024.07.026] [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: 06/13/2024] [Revised: 07/19/2024] [Accepted: 07/24/2024] [Indexed: 08/17/2024]
Abstract
OBJECTIVE Our purpose was to synthesize evidence in the literature to determine the diagnostic accuracy of cone-beam CT (CBCT) for the detection of intracranial hemorrhage (ICH) and hemorrhage types, including intraparenchymal hemorrhage (IPH), subarachnoid hemorrhage (SAH), and intraventricular hemorrhage (IVH). METHODS We performed a meta-analysis following the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Our protocol was registered with International Prospective Register of Systematic Reviews (PROSPERO-CRD42021261915). Systematic searches were last performed on April 30, 2024, in EMBASE, PubMed, Web-of-Science, Scopus, and Cumulative Index to Nursing and Allied Health Literature databases. Inclusion criteria were (1) studies reporting diagnostic metrics of CBCT for ICH and (2) studies using a reference standard to determine ICH. Exclusion criteria were (1) case reports, abstracts, reviews and (2) studies without patient-level data. Pooled estimates and 95% confidence intervals (CIs) were calculated for diagnostic odds ratios (DORs), sensitivity, and specificity using random-effects and common-effects models. Mixed methods appraisal tool was used to evaluate risk of bias. RESULTS Seven studies were included in the meta-analysis yielding 466 patients. Mean or median age ranged from 54 to 75 years. Female patients represented 51.4% (222 of 432) in reported studies. Multidetector CT was the reference standard in all studies. DOR, pooled sensitivity, and pooled specificity for ICH were 5.28 (95% CI: 4.11-6.46), 0.88 (95% CI: 0.79-0.97), and 0.99 (95% CI: 0.98-1.0). Pooled sensitivity for IPH, SAH, and IVH was 0.98 (95% CI: 0.95-1.0), 0.82 (95% CI: 0.57-1.0), and 0.78 (95% CI: 0.55-1.0). Pooled specificity for IPH, SAH, and IVH was 0.99 (95% CI: 0.98-1.0), 0.99 (95% CI: 0.97-1.0), and 1.0 (95% CI: 0.98-1.0). DISCUSSION CBCT had moderate DOR and high pooled specificity for ICH and hemorrhage types. However, pooled sensitivity varied by hemorrhage type, with the highest sensitivity for IPH, followed by SAH and IVH.
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Affiliation(s)
- Nicholas G Ferrone
- Northwell, New Hyde Park, New York, New York; Institute of Health System Science, The Feinstein Institutes for Medical Research, Manhasset, New York, New York
| | - Maria X Sanmartin
- Northwell, New Hyde Park, New York, New York; Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, New York
| | | | | | - Sophia R Ferrone
- Northwell, New Hyde Park, New York, New York; Institute of Health System Science, The Feinstein Institutes for Medical Research, Manhasset, New York, New York
| | - Zachary Lodato
- Northwell, New Hyde Park, New York, New York; Institute of Health System Science, The Feinstein Institutes for Medical Research, Manhasset, New York, New York
| | - Gregory Lacher
- Northwell, New Hyde Park, New York, New York; Institute of Health System Science, The Feinstein Institutes for Medical Research, Manhasset, New York, New York
| | - Sanjana Bandi
- Northwell, New Hyde Park, New York, New York; Institute of Health System Science, The Feinstein Institutes for Medical Research, Manhasset, New York, New York
| | - Alicia Convey
- Northwell, New Hyde Park, New York, New York; Institute of Health System Science, The Feinstein Institutes for Medical Research, Manhasset, New York, New York
| | - Mehrad Bastani
- Northwell, New Hyde Park, New York, New York; Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, New York
| | - Un Jung Lee
- Department of Biostatistics, The Feinstein Institutes for Medical Research, Manhasset, New York, New York
| | | | - Timothy White
- Northwell, New Hyde Park, New York, New York; Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, New York
| | - Jason J Wang
- Northwell, New Hyde Park, New York, New York; Director of Data Analytics, Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, New York
| | - Jeffrey M Katz
- Northwell, New Hyde Park, New York, New York; Chief of Neurovascular Services, Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, New York
| | - Pina C Sanelli
- Northwell, New Hyde Park, New York, New York; Institute of Health System Science, The Feinstein Institutes for Medical Research, Manhasset, New York, New York; Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, New York; Vice Chair of Research, Department of Radiology and Co-Director of PRIME (Policy Research and Imaging Effectiveness) Center, Neiman Health Policy Institute.
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Da Ros V, Duggento A, Cavallo AU, Bellini L, Pitocchi F, Toschi N, Mascolo AP, Sallustio F, Di Giuliano F, Diomedi M, Floris R, Garaci F, Zeleňák K, Maestrini I. Can machine learning of post-procedural cone-beam CT images in acute ischemic stroke improve the detection of 24-h hemorrhagic transformation? A preliminary study. Neuroradiology 2023; 65:599-608. [PMID: 36280607 DOI: 10.1007/s00234-022-03070-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 10/12/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Hemorrhagic transformation (HT) is an independent predictor of unfavorable outcome in acute ischemic stroke (AIS) patients undergoing endovascular thrombectomy (EVT). Its early identification could help tailor AIS management. We hypothesize that machine learning (ML) applied to cone-beam computed tomography (CB-CT), immediately after EVT, improves performance in 24-h HT prediction. METHODS We prospectively enrolled AIS patients undergoing EVT, post-procedural CB-CT, and 24-h non-contrast CT (NCCT). Three raters independently analyzed imaging at four anatomic levels qualitatively and quantitatively selecting a region of interest (ROI) < 5 mm2. Each ROI was labeled as "hemorrhagic" or "non-hemorrhagic" depending on 24-h NCCT. For each level of CB-CT, Mean Hounsfield Unit (HU), minimum HU, maximum HU, and signal- and contrast-to-noise ratios were calculated, and the differential HU-ROI value was compared between both hemispheres. The number of anatomic levels affected was computed for lesion volume estimation. ML with the best validation performance for 24-h HT prediction was selected. RESULTS One hundred seventy-two ROIs from affected hemispheres of 43 patients were extracted. Ninety-two ROIs were classified as unremarkable, whereas 5 as parenchymal contrast staining, 29 as ischemia, 7 as subarachnoid hemorrhages, and 39 as HT. The Bernoulli Naïve Bayes was the best ML classifier with a good performance for 24-h HT prediction (sensitivity = 1.00; specificity = 0.75; accuracy = 0.82), though precision was 0.60. CONCLUSION ML demonstrates high-sensitivity but low-accuracy 24-h HT prediction in AIS. The automated CB-CT imaging evaluation resizes sensitivity, specificity, and accuracy rates of visual interpretation reported in the literature so far. A standardized quantitative interpretation of CB-CT may be warranted to overcome the inter-operator variability.
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Affiliation(s)
- Valerio Da Ros
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Andrea Duggento
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Armando Ugo Cavallo
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Luigi Bellini
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Francesca Pitocchi
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Nicola Toschi
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Alfredo Paolo Mascolo
- Stroke Center, Department of Systems Medicine, University Hospital of Rome "Tor Vergata", Viale Oxford 81, 00133, Rome, Italy
| | - Fabrizio Sallustio
- Stroke Center, Department of Systems Medicine, University Hospital of Rome "Tor Vergata", Viale Oxford 81, 00133, Rome, Italy
| | - Francesca Di Giuliano
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Marina Diomedi
- Stroke Center, Department of Systems Medicine, University Hospital of Rome "Tor Vergata", Viale Oxford 81, 00133, Rome, Italy
| | - Roberto Floris
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Francesco Garaci
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Kamil Zeleňák
- Clinic of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 03659, Martin, Slovakia
| | - Ilaria Maestrini
- Stroke Center, Department of Systems Medicine, University Hospital of Rome "Tor Vergata", Viale Oxford 81, 00133, Rome, Italy.
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Kato N, Otani K, Abe Y, Sano T, Nagayama G, Sasaki Y, Ikemura A, Kan I, Kodama T, Ishibashi T, Murayama Y. Diagnostic performance of intraoperative cone beam computed tomography compared with postoperative magnetic resonance imaging for detecting hemorrhagic transformation after endovascular treatment following large vessel occlusion. J Stroke Cerebrovasc Dis 2022; 31:106790. [PMID: 36156445 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106790] [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: 03/25/2022] [Revised: 09/07/2022] [Accepted: 09/13/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES Early detection of hemorrhagic transformation (HT) in patients with large vessel occlusion (LVO) after endovascular treatment is important for postoperative patient management. We investigated the diagnostic performance of intraoperative cone beam computed tomography (CBCT) with reference standard magnetic resonance imaging (MRI) for detecting HT. MATERIALS AND METHODS Consecutive patients with LVO treated by endovascular treatment who underwent intraoperative CBCT and postoperative MRI were included. Two observers evaluated all images for the presence of HT. Sensitivity and specificity for detecting HT were calculated with MRI as reference standard. The observers classified HT according to the European Cooperative Acute Stroke Study (ECASS). Inter-method and inter-rater agreement for the detection of HT and for the ECASS classification were assessed using kappa or weighted Brennan-Prediger (wBP) statistics. RESULTS Images of 106 procedures (94 for anterior circulation) were analyzed. The sensitivity and specificity for detecting HT on CBCT were 0.77 and 0.83, respectively, for all procedures and 0.83 and 0.8, respectively, for anterior circulation. The inter-method agreement for HT detection (κ = 0.63 overall, κ = 0.69 anterior circulation) and ECASS classification (wBP = 0.67 overall, wBP = 0.77 anterior circulation) were substantial. The inter-rater agreement for HT detection (κ = 0.87 overall, κ = 0.85 anterior circulation) and for ECASS classification (wBP = 0.95 overall, wBP = 0.92 anterior circulation) were almost perfect. CONCLUSIONS The diagnostic performance of CBCT for the detection of HT in stroke patients treated for LVO was acceptable with excellent inter-rater agreement. Intraoperative CBCT may be useful to trigger early interventions if HT is detected, although detailed classifications of HT may be difficult.
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Affiliation(s)
- Naoki Kato
- Department of Neurosurgery, The Jikei University School of Medicine Tokyo, Tokyo, Japan.
| | | | - Yukiko Abe
- Department of Radiology, The Jikei University Hospital, Tokyo, Japan
| | - Tohru Sano
- Department of Neurosurgery, The Jikei University School of Medicine Tokyo, Tokyo, Japan
| | - Gota Nagayama
- Department of Neurosurgery, The Jikei University School of Medicine Tokyo, Tokyo, Japan
| | - Yuichi Sasaki
- Department of Neurosurgery, The Jikei University School of Medicine Tokyo, Tokyo, Japan
| | - Ayako Ikemura
- Department of Neurosurgery, The Jikei University School of Medicine Tokyo, Tokyo, Japan
| | - Issei Kan
- Department of Neurosurgery, The Jikei University School of Medicine Tokyo, Tokyo, Japan
| | - Tomonobu Kodama
- Department of Neurosurgery, The Jikei University School of Medicine Tokyo, Tokyo, Japan
| | - Toshihiro Ishibashi
- Department of Neurosurgery, The Jikei University School of Medicine Tokyo, Tokyo, Japan
| | - Yuichi Murayama
- Department of Neurosurgery, The Jikei University School of Medicine Tokyo, Tokyo, Japan
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Flat Panel CT Scanning Is Helpful in Predicting Hemorrhagic Transformation in Acute Ischemic Stroke Patients Undergoing Endovascular Thrombectomy. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5527101. [PMID: 33954174 PMCID: PMC8060075 DOI: 10.1155/2021/5527101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/28/2021] [Accepted: 03/23/2021] [Indexed: 11/18/2022]
Abstract
Purpose Hyperdense lesions are frequently revealed on flat panel CT (FP-CT) immediately after endovascular thrombectomy in patients with acute ischemic stroke. This study is aimed at discriminating hyperdense lesions caused by extravasation plus hemorrhage from those caused by contrast extravasation alone. Methods We retrospectively analyzed clinical and radiological data of patients who underwent an immediate postprocedure FP-CT scan and a follow-up noncontrast CT 24 hours after thrombectomy. We especially focused on the Maximum Hounsfield Units (HUmax) of each hyperdense lesion. A hyperdense lesion was judged to be hemorrhagic when it persisted on noncontrast CT and/or developed a mass effect. Results Of 81 patients included in this study, 32 (39.5%) patients presented 41 hyperdense lesions on FP-CT. The chance of hemorrhagic transformation is higher in patients with hyperdense lesions on FP-CT than that in patients without hyperdense lesions (23/32 vs. 1/49, p < 0.001). The HUmax of hyperdensity on FP-CT can predict hemorrhagic transformation with an area under the curve of 0.805 (95% CI: 0.67-0.94, p = 0.02). The sensitivity, specificity, positive, and negative predictive values of hyperdensity on FP-CT for hemorrhagic transformation were 96%, 84%, 72%, and 98%, respectively. A HUmax of >600 predicted hemorrhagic transformation with a sensitivity of 50% and a specificity of 100%. Conclusions The presence of hyperdensity on FP-CT can predict hemorrhagic transformation with a high sensitivity and negative predictive value. The measurement of HUmax of hyperdense lesion on FP-CT can be applied to the management of patients undergoing endovascular recanalization.
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Shi ZS, Duckwiler GR, Jahan R, Tateshima S, Szeder V, Saver JL, Kim D, Sharma LK, Vespa PM, Salamon N, Villablanca JP, Viñuela F, Feng L, Loh Y, Liebeskind DS. Early Blood-Brain Barrier Disruption after Mechanical Thrombectomy in Acute Ischemic Stroke. J Neuroimaging 2018; 28:283-288. [PMID: 29484769 DOI: 10.1111/jon.12504] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 01/31/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND AND PURPOSE The impact of blood-brain barrier (BBB) disruption can be detected by intraparenchymal hyperdense lesion on the computed tomography (CT) scan after endovascular stroke therapy. The purpose of this study was to determine whether early BBB disruption predicts intracranial hemorrhage and poor outcome in patients with acute ischemic stroke treated with mechanical thrombectomy. METHODS We analyzed patients with anterior circulation stroke treated with mechanical thrombectomy and identified BBB disruption on the noncontrast CT images immediately after endovascular treatment. Follow-up CT or magnetic resonance imaging scan was performed at 24 hours to assess intracranial hemorrhage. We dichotomized patients into those with moderate BBB disruption versus those with minor BBB disruption and no BBB disruption. We evaluated the association of moderate BBB disruption after mechanical thrombectomy with intracranial hemorrhage and clinical outcomes. RESULTS Moderate BBB disruption after mechanical thrombectomy was found in 56 of 210 patients (26.7%). Moderate BBB disruption was independently associated with higher rates of hemorrhagic transformation (OR 25.33; 95% CI 9.93-64.65; P < .001), parenchymal hematoma (OR 20.57; 95% CI 5.64-74.99; P < .001), and poor outcome at discharge (OR 2.35; 95% CI 1.09-5.07; P = .03). The association of BBB disruption with intracranial hemorrhage remained in patients with successful reperfusion after mechanical thrombectomy. The location of BBB disruption was not associated with intracranial hemorrhage and poor outcome. CONCLUSIONS Moderate BBB disruption is common after mechanical thrombectomy in a quarter of patients with acute ischemic stroke and increases the risk of intracranial hemorrhage and poor outcome.
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Affiliation(s)
- Zhong-Song Shi
- Department of Neurosurgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Province Key Laboratory of Brain Function and Disease, Sun Yat-sen University, Guangzhou, China.,RNA Biomedical Institute, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Gary R Duckwiler
- Division of Interventional Neuroradiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Reza Jahan
- Division of Interventional Neuroradiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Satoshi Tateshima
- Division of Interventional Neuroradiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Viktor Szeder
- Division of Interventional Neuroradiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Jeffrey L Saver
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Doojin Kim
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Latisha K Sharma
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Paul M Vespa
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Noriko Salamon
- Division of Diagnostic Neuroradiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - J Pablo Villablanca
- Division of Diagnostic Neuroradiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Fernando Viñuela
- Division of Interventional Neuroradiology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Lei Feng
- Department of Neuroradiology, Kaiser Permanente Medical Center, Los Angeles, CA
| | - Yince Loh
- Interventional Neuroradiology and Neurocritical Care Services, Madigan Army Medical Center, Tacoma, WA
| | - David S Liebeskind
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA.,Neurovascular Imaging Research Core, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Ava L, Berkefeld J, Lauer A, Seiler A, Pfeilschifter W, Müller-Eschner M, You SJ, Weidauer S, Pilatus U, Wagner M. Predictive Value of Pooled Cerebral Blood Volume Mapping for Final Infarct Volume in Patients with Major Artery Occlusions. A Retrospective Analysis. Clin Neuroradiol 2017; 27:435-442. [DOI: 10.1007/s00062-017-0569-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 02/13/2017] [Indexed: 11/27/2022]
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Frölich AM, Buhk JH, Fiehler J, Kemmling A. Voxel-Based Sensitivity of Flat-Panel CT for the Detection of Intracranial Hemorrhage: Comparison to Multi-Detector CT. PLoS One 2016; 11:e0165794. [PMID: 27806106 PMCID: PMC5091958 DOI: 10.1371/journal.pone.0165794] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 10/18/2016] [Indexed: 11/18/2022] Open
Abstract
Objectives Flat-panel CT (FPCT) allows cross-sectional parenchymal, vascular and perfusion imaging within the angiography suite, which could greatly facilitate acute stroke management. We hypothesized that FPCT offers equal diagnostic accuracy compared to multi-detector CT (MDCT) as a primary tool to exclude intracranial hemorrhage. Methods 22 patients with intracranial hematomas who had both MDCT and FPCT performed within 24 hours were retrospectively identified. Patients with visible change in hematoma size or configuration were excluded. Two raters independently segmented hemorrhagic lesions. Data sets and corresponding binary lesion maps were co-registered to compare hematoma volume. Diagnostic accuracy of FPCT to detect hemorrhage was calculated from voxel-wise analysis of lesion overlap compared to reference MDCT. Results Mean hematoma size was similar between MDCT (16.2±8.9 ml) and FPCT (16.1±8.6 ml), with near perfect correlation of hematoma sizes between modalities (ρ = 0.95, p<0.001). Sensitivity and specificity of FPCT to detect hemorrhagic voxels was 61.6% and 99.8% for intraventricular hematomas and 67.7% and 99.5% for all other intracranial hematomas. Conclusions In this small sample containing predominantly cases with subarachnoid hemorrhage, FPCT based assessment of hemorrhagic volume in brain yields acceptable accuracy compared to reference MDCT, albeit with a limited sensitivity on a voxel level. Further assessment and improvement of FPCT is necessary before it can be applied as a primary imaging modality to exclude intracranial hemorrhage in acute stroke patients.
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Affiliation(s)
- Andreas M Frölich
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Jan-Hendrik Buhk
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Andre Kemmling
- Department of Neuroradiology, Campus Lübeck, University Medical Center Schleswig-Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany
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Eckert M, Gölitz P, Lücking H, Struffert T, Knossalla F, Doerfler A. Optimized Flat-Detector CT in Stroke Imaging: Ready for First-Line Use? Cerebrovasc Dis 2016; 43:9-16. [DOI: 10.1159/000450727] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 09/07/2016] [Indexed: 11/19/2022] Open
Abstract
Background: Using flat-detector CT (FD-CT) for stroke imaging has the advantage that both diagnostic imaging and endovascular therapy can be performed directly within the Angio Suite without any patient transfer and time delay. Thus, stroke management could be speeded up significantly, and patient outcome might be improved. But as precondition for using FD-CT as primary imaging modality, a reliable exclusion of intracranial hemorrhage (ICH) has to be possible. This study aimed to investigate whether optimized native FD-CT, using a newly implemented reconstruction algorithm, may reliably detect ICH in stroke patients. Additionally, the potential to identify ischemic changes was evaluated. Methods: Cranial FD-CT scans were obtained in 102 patients presenting with acute ischemic stroke (n = 32), ICH (n = 45) or transient ischemic attack (n = 25). All scans were reconstructed with a newly implemented half-scan cone-beam algorithm. Two experienced neuroradiologists, unaware of clinical findings, evaluated independently the FD-CTs screening for hemorrhage or ischemic signs. The findings were correlated to CT, and rater and inter-rater agreement was assessed. Results: FD-CT demonstrated high sensitivity (95-100%) and specificity (100%) in detecting intracerebral and intraventricular hemorrhage (IVH). Overall, interobserver agreement (κ = 0.92) was almost perfect and rater agreement to CT highly significant (r = 0.81). One infratentorial ICH and 10 or 11 of 22 subarachnoid hemorrhages (SAHs) were missed of whom 7 were perimesencephalic. The sensitivity for detecting acute ischemic signs was poor in blinded readings (0 or 25%, respectively). Conclusions: Optimized FD-CT, using a newly implemented reconstruction algorithm, turned out as a reliable tool for detecting supratentorial ICH and IVH. However, detection of infratentorial ICH and perimesencephalic SAH is limited. The potential of FD-CT in detecting ischemic changes is poor in blinded readings. Thus, plain FD-CT seems insufficient as a standalone modality in acute stroke, but within a multimodal imaging approach primarily using the FD technology, native FD-CT seems capable to exclude reliably supratentorial hemorrhage. Currently, FD-CT imaging seems not yet ready for wide adoption, replacing regular CT, and should be reserved for selected patients. Furthermore, prospective evaluations are necessary to validate this approach in the clinical setting.
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Schneider T, Mahraun T, Schroeder J, Frölich A, Hoelter P, Wagner M, Darcourt J, Cognard C, Bonafé A, Fiehler J, Siemonsen S, Buhk JH. Intraparenchymal Hyperattenuations on Flat-Panel CT Directly After Mechanical Thrombectomy are Restricted to the Initial Infarct Core on Diffusion-Weighted Imaging. Clin Neuroradiol 2016; 28:91-97. [PMID: 27637922 DOI: 10.1007/s00062-016-0543-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 08/23/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE The presence of intraparenchymal hyperattenuations (IPH) on flat-panel computed tomography (FP-CT) after endovascular recanalization in stroke patients is a common phenomenon. They are thought to occur in ischemic areas with breakdown of the blood-brain barrier but previous studies that investigated a mutual interaction are scarce. We aimed to assess the relationship of IPH localization with prethrombectomy diffusion-weighted imaging (DWI) lesions. METHODS This retrospective multicenter study included 27 acute stroke patients who underwent DWI prior to FP-CT following mechanical thrombectomy. After software-based coregistration of DWI and FP-CT, lesion volumetry was conducted and overlapping was analyzed. RESULTS Two different patterns were observed: IPH corresponding to the DWI lesion and IPH exceeding the DWI lesion. The latter showed demarcated infarction of DWI exceeding IPH at 24 h. No major hemorrhage following IPH was observed. Most IPH were manifested within the basal ganglia and insular cortex. CONCLUSION The IPH primarily appeared within the initial ischemic core and secondarily within the penumbral tissue that progressed to infarction. The IPH represent the minimum final infarct volume, which may help in periinterventional decision making.
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Affiliation(s)
- Tanja Schneider
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Haus O22, 20246, Hamburg, Germany.
| | - Tobias Mahraun
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Haus O22, 20246, Hamburg, Germany
| | - Julian Schroeder
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Frölich
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Haus O22, 20246, Hamburg, Germany
| | - Philip Hoelter
- Department of Neuroradiology, University Clinic Erlangen, Erlangen, Germany
| | - Marlies Wagner
- Institute of Neuroradiology, Goethe University Hospital, Frankfurt, Germany
| | - Jean Darcourt
- Départment de Neuroradiologie diagnostique et thérapeutique, University Hospital of Purpan, Toulouse, France
| | - Christophe Cognard
- Départment de Neuroradiologie diagnostique et thérapeutique, University Hospital of Purpan, Toulouse, France
| | - Alain Bonafé
- Départment de Neuroradiologie, Hospitalier Universitaire Gui de Chauliac, Montpellier, France
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Haus O22, 20246, Hamburg, Germany
| | - Susanne Siemonsen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Haus O22, 20246, Hamburg, Germany
| | - Jan-Hendrik Buhk
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Haus O22, 20246, Hamburg, Germany
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Pjontek R, Önenköprülü B, Scholz B, Kyriakou Y, Schubert GA, Nikoubashman O, Othman A, Wiesmann M, Brockmann MA. Metal artifact reduction for flat panel detector intravenous CT angiography in patients with intracranial metallic implants after endovascular and surgical treatment. J Neurointerv Surg 2015; 8:824-9. [PMID: 26346458 PMCID: PMC4975832 DOI: 10.1136/neurintsurg-2015-011787] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 07/13/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND Flat panel detector CT angiography with intravenous contrast agent injection (IV CTA) allows high-resolution imaging of cerebrovascular structures. Artifacts caused by metallic implants like platinum coils or clips lead to degradation of image quality and are a significant problem. OBJECTIVE To evaluate the influence of a prototype metal artifact reduction (MAR) algorithm on image quality in patients with intracranial metallic implants. METHODS Flat panel detector CT after intravenous application of 80 mL contrast agent was performed with an angiography system (Artis zee; Siemens, Forchheim, Germany) using a 20 s rotation protocol (200° rotation angle, 20 s acquisition time, 496 projections). The data before and after MAR of 26 patients with a total of 34 implants (coils, clips, stents) were independently evaluated by two blinded neuroradiologists. RESULTS MAR improved the assessability of the brain parenchyma and small vessels (diameter <1 mm) in the neighborhood of metallic implants and at a distance of 6 cm (p<0.001 each, Wilcoxon test). Furthermore, MAR significantly improved the assessability of parent vessel patency and potential aneurysm remnants (p<0.005 each, McNemar test). MAR, however, did not improve assessability of stented vessels. CONCLUSIONS When an intravenous contrast protocol is used, MAR significantly ameliorates the assessability of brain parenchyma, vessels, and treated aneurysms in patients with intracranial coils or clips.
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Affiliation(s)
- Rastislav Pjontek
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Belgin Önenköprülü
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Bernhard Scholz
- Healthcare, Imaging & Therapy Division, Siemens AG, Forchheim, Germany
| | - Yiannis Kyriakou
- Healthcare, Imaging & Therapy Division, Siemens AG, Forchheim, Germany
| | - Gerrit A Schubert
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany Institute of Neuroscience and Medicine 4, Medical Imaging Physics, Forschungszentrum Jülich, Jülich, Germany
| | - Ahmed Othman
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Marc A Brockmann
- Department of Diagnostic and Interventional Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
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Payabvash S, Khan AA, Qureshi MH, Saeed O, Suri MFK, Qureshi AI. Detection of Intraparenchymal Hemorrhage After Endovascular Therapy in Patients with Acute Ischemic Stroke Using Immediate Postprocedural Flat-Panel Computed Tomography Scan. J Neuroimaging 2015; 26:213-8. [PMID: 26282065 DOI: 10.1111/jon.12277] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 05/14/2015] [Accepted: 05/28/2015] [Indexed: 12/01/2022] Open
Abstract
PURPOSE To assess the diagnostic value of parenchymal hyperdense lesions visualized on the flat-panel CT scan in detecting/excluding intraparenchymal hemorrhage (IPH) after the endovascular treatment of acute stroke patients. METHODS Two separate cohorts of acute ischemic stroke patients who underwent endovascular treatment were evaluated. In the first group, patients were evaluated for hyperdense parenchymal lesions immediately after the treatment with flat-panel CT scan; whereas, in the second group, patients underwent multidetector CT scan post procedure. IPH was defined as hyperdensity that persisted for >24 hours on follow up CT scan. RESULTS A total of 30 patients were evaluated with flat panel, and 135 with multidetector CT scan immediately after the endovascular treatment. Hyperdense lesions were visualized on 7/30 (23%) of those evaluated with flat-panel CT versus 74/135 (55%) of those evaluated with multidetector CT scan. Based on 24-hour follow up imaging, hyperdense parenchymal lesions on immediate postprocedural flat-panel or multidetector CT studies had 100% sensitivity and negative predictive value for IPH; whereas, the specificity, and positive predictive value of such lesions were 88% and, 57% on the flat panel; and 53% and, 27% on the multidetector CT study, respectively. CONCLUSION The absence of hyperdense lesions on immediate postprocedural flat-panel CT scan of ischemic stroke patients can exclude IPH with a high sensitivity and negative predictive value. The hyperdense parenchymal lesions visualized on flat-panel versus multidetector CT studies may have comparable sensitivity and negative predictive value for the detection of IPH.
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Affiliation(s)
- Seyedmehdi Payabvash
- Zeenat Qureshi Stroke Institute, Centracare Health System, St. Cloud, MN.,Department of Radiology, University of Minnesota, Minneapolis, MN
| | - Asif A Khan
- Zeenat Qureshi Stroke Institute, Centracare Health System, St. Cloud, MN
| | - Mushtaq H Qureshi
- Zeenat Qureshi Stroke Institute, Centracare Health System, St. Cloud, MN
| | - Omar Saeed
- Zeenat Qureshi Stroke Institute, Centracare Health System, St. Cloud, MN
| | - M Fareed K Suri
- Zeenat Qureshi Stroke Institute, Centracare Health System, St. Cloud, MN
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute, Centracare Health System, St. Cloud, MN
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Visualization of novel microstents in patients with unruptured intracranial aneurysms with contrast-enhanced flat panel detector CT. Eur J Radiol 2015; 84:1313-7. [PMID: 25952185 DOI: 10.1016/j.ejrad.2015.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Revised: 04/05/2015] [Accepted: 04/11/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVES The aim of our study was to evaluate the feasibility of contrast-enhanced flat panel detector CT (FPDCT) for visualizing the novel microstents implanted in patients with unruptured wide-necked intracranial aneurysms. METHODS Forty-four cases of patients who underwent stent assisted coiling at our department were retrospectively analyzed. In each case, FPDCT images were performed after stent and coils deployment and then assessed in the terms of stent struts and all radiopaque markers and tantalum strands visibility separately using a 3-grade scale (1 - inadequate, 2 - good, 3 - excellent). RESULTS Stent struts visibility was assessed to be inadequate for evaluation in all cases. All radiopaque markers and tantalum strands visibility was excellent in 61.4% and good in 38.6% of cases. We observed 4 (9.09%) cases of incomplete stent opening. Treated aneurysm size <10mm was an independent predictor of excellent stent all radiopaque markers and tantalum strands visibility (ρ=0.014). CONCLUSIONS Contrast-enhanced FPDCT is feasible for visualizing stents implanted in patients with intracranial aneurysms as it gives precise visualization of the relationships between the stent tantalum strands and the vessel wall. Stents used in the treatment of aneurysms ≥10 mm in size are worse visualized because of the coil streaking artifacts.
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13
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Pfaff J, Herweh C, Pham M, Schönenberger S, Bösel J, Ringleb PA, Heiland S, Bendszus M, Möhlenbruch M. Mechanical thrombectomy using a combined CT/C-arm X-ray system. J Neurointerv Surg 2015; 8:621-5. [PMID: 25935925 PMCID: PMC4893107 DOI: 10.1136/neurintsurg-2015-011744] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 04/17/2015] [Indexed: 11/06/2022]
Abstract
Background Mechanical thrombectomy (MT) using stent-retrievers has been proven to be a safe and effective treatment in acute ischemic stroke (AIS), particularly in large vessel occlusion. Other than patient characteristics, time to recanalization is the most important factor linked to outcome. MT is usually performed in a dedicated angiography suite using a floor- and/or ceiling-mounted biplane angiographic system. Here we report our first experience of MT with a new combined CT and mobile C-arm X-ray device setup. Methods Patients with AIS underwent stroke imaging (non-contrast enhanced CT, CT perfusion, and CT angiography) using a commercially available 64-slice CT scanner which was modified for combined use with a C-arm system. In patients with large vessel occlusion, MT was conducted without further patient transfer within the CT imaging suite using a mobile C-arm X-ray device equipped with a 30×30 cm (12×12 inch), 1.5×1.5 k full-view flat detector which was positioned between the gantry and patient table. The safety and feasibility of this new system was assessed in preliminary patients. Results Angiographic imaging quality of the mobile C-arm was feasible and satisfactory for diagnostic angiography and MT. Using this setup, time between stroke imaging and groin puncture (picture-to-puncture time) was reduced by up to 35 min (including time for preparation of the patient such as intubation). Conclusions MT using a combined CT/C-arm system is safe and feasible. The potential advantages, particularly time saving and ensuing improvement in patient outcome, need to be assessed in a larger study.
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Affiliation(s)
- Johannes Pfaff
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Christian Herweh
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Mirko Pham
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | | | - Julian Bösel
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Peter A Ringleb
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Sabine Heiland
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
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