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Panni P, Lapergue B, Maïer B, Finitsis S, Clarençon F, Richard S, Marnat G, Bourcier R, Sibon I, Dargazanli C, Blanc R, Consoli A, Eugène F, Vannier S, Spelle L, Denier C, Boulanger M, Gauberti M, Saleme S, Macian F, Rosso C, Naggara O, Turc G, Ozkul-Wermester O, Papagiannaki C, Albucher JF, Darcourt J, Le Bras A, Evain S, Wolff V, Pop R, Timsit S, Gentric JC, Bourdain F, Veunac L, Arquizan C, Gory B. Clinical Impact and Predictors of Diffusion Weighted Imaging (DWI) Reversal in Stroke Patients with Diffusion Weighted Imaging Alberta Stroke Program Early CT Score 0-5 Treated by Thrombectomy : Diffusion Weighted Imaging Reversal in Large Volume Stroke. Clin Neuroradiol 2022; 32:939-950. [PMID: 35412044 DOI: 10.1007/s00062-022-01156-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/02/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE To determine whether reversal of DWI lesions (DWIr) on the DWI-ASPECTS (diffusion weighted imaging Alberta Stroke Program CT Score) template should serve as a predictor of 90-day clinical outcome in acute ischemic stroke (AIS) patients with pretreatment diffusion-weighted imaging (DWI)-ASPECTS 0-5 treated with thrombectomy, and to determine its predictors in current practice. METHODS We analyzed data of all consecutive patients included in the prospective multicenter national Endovascular Treatment in Ischemic Stroke Registry between 1 January 2015 and 31 December 2020 with a premorbid mRS ≤ 2, who presented with a pretreatment DWI-ASPECTS 0-5 score, underwent thrombectomy and had an available 24 h post-interventional MRI follow-up. Multivariable analyses were performed to evaluate the clinical impact of DWIr on early neurological improvement (ENI), 3‑month modified Rankin scale (mRS) score distribution (shift analysis) and to define independent predictors of DWIr. RESULTS Early neurological improvement was detected in 82/211 (41.7%) of patients while 3‑month functional independence was achieved by 75 (35.5%) patients. The DWI reversal (39/211, 18.9%) resulted an independent predictor of both ENI (aOR 3.6, 95% CI 1.2-7.7; p 0.018) and 3‑month clinical outcome (aOR for mRS shift: 2.2, 95% CI 1-4.6; p 0.030). Only successful recanalization (mTICI 2c-3) independently predicted DWIr in the studied population (aOR 3.3, 95% CI 1.3-7.9; p 0.009). CONCLUSION The DWI reversal occurs in a non-negligible proportion of DWI-ASPECTS 0-5 patients subjected to thrombectomy and significantly influences clinical outcome. The mTICI 2c-3 recanalization emerged as an independent DWIr predictor.
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Affiliation(s)
- Pietro Panni
- Department of Neuroradiology, Division of Interventional Neuroradiology, Department of Neurosurgery, San Raffaele University Hospital, Milan, Italy.
| | - Bertrand Lapergue
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - Benjamin Maïer
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Stephanos Finitsis
- AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Sébastien Richard
- CHRU-Nancy, Department of Neurology, Stroke Unit, Université de Lorraine, 54000, Nancy, France.,CIC-P 1433, INSERM U1116, CHRU-Nancy, 54000, Nancy, France
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Romain Bourcier
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Igor Sibon
- Neurology, University Hospital of Bordeaux, Bordeaux, France
| | - Cyril Dargazanli
- Department of Interventional Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | - Raphaël Blanc
- Department of Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Arturo Consoli
- Diagnostic and Interventional Neuroradiology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - François Eugène
- Department of Neuroradiology, University Hospital of Rennes, Rennes, France
| | | | | | | | | | | | | | | | - Charlotte Rosso
- Department of Neurology, CHU Pitié-Salpétrière, Paris, France
| | | | - Guillaume Turc
- Department of Neurology, Hôpital Saint-Anne, Paris, France
| | | | | | | | | | - Anthony Le Bras
- Department of Neuroradiology, CHBA Bretagne Atlantique, Vannes, France
| | - Sarah Evain
- Neurology, CHBA Bretagne Atlantique, Vannes, France
| | - Valérie Wolff
- Department of Neurology, CHU Strasbourg, Strasbourg, France
| | - Raoul Pop
- Neuroradiology, CHU Strasbourg, Strasbourg, France
| | - Serge Timsit
- Department of Neurology, CHU Brest, Brest, France
| | | | | | | | | | - Benjamin Gory
- CHRU-Nancy, Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, 54000, Nancy, France.,IADI, INSERM U1254, Université de Lorraine, 54000, Nancy, France
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Safouris A, Palaiodimou L, Szikora I, Kargiotis O, Magoufis G, Psychogios K, Paraskevas G, Spiliopoulos S, Brountzos E, Nardai S, Goyal N, De Sousa DA, Strbian D, Caso V, Alexandrov A, Tsivgoulis G. Endovascular treatment for anterior circulation large-vessel occlusion ischemic stroke with low ASPECTS: a systematic review and meta-analysis. Ther Adv Neurol Disord 2022; 15:17562864221139632. [PMID: 36467113 PMCID: PMC9716457 DOI: 10.1177/17562864221139632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 10/31/2022] [Indexed: 08/30/2023] Open
Abstract
BACKGROUND Endovascular treatment (EVT) for acute ischemic stroke (AIS) patients presenting with Alberta Stroke Program Early CT Score (ASPECTS) 0-5 has not yet proven safe and effective by clinical trials. OBJECTIVES The aim of the study was to assess whether EVT in AIS patients presenting with low ASPECTS is beneficial. DESIGN Systematic review and meta-analysis of available studies in accordance with the PRISMA statement. DATA SOURCES AND METHODS We have searched MEDLINE, the Cochrane Central Register of Controlled Trials, and reference lists of articles published until 28 May 2022 with the aim to calculate (1) modified Rankin scale (mRS) score 0-3 at 3 months, (2) mRS score 0-2 at 3 months, (3) symptomatic intracranial hemorrhage (sICH), and (3) mortality at 3 months. RESULTS Overall, 24 eligible studies were included in the meta-analysis, comprising a total of 2539 AIS patients with ASPECTS 0-5 treated with EVT. The pooled proportion of EVT-treated patients achieving mRS 0-3 at 3 months was calculated at 38.4%. The pooled proportion of EVT-treated patients achieving mRS 0-2 at 3 months was 25.7%. Regarding safety outcomes, sICH occurred in 12.8% of patients. The 3-month pooled mortality was 30%. In pairwise meta-analysis, patients treated with EVT had a higher likelihood of achieving mRS 0-3 at 3 months compared with patients treated with best medical therapy (BMT, OR: 2.41). sICH occurred more frequently in EVT-treated patients compared with the BMT-treated patients (OR: 2.30). Mortality at 3 months was not different between the two treatment groups (OR: 0.71). CONCLUSION EVT may be beneficial for AIS patients with low baseline ASPECTS despite an increased risk for sICH. Further data from randomized-controlled clinical trials are needed to elucidate the role of EVT in this subgroup of AIS patients. REGISTRATION The protocol has been registered in the International Prospective Register of Ongoing Systematic Reviews PROSPERO; Registration Number: CRD42022334417.
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Affiliation(s)
- Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus,
Greece
- Second Department of Neurology, Attikon
University Hospital, Athens, Greece
- School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Aktios Rehabilitation Center, Athens,
Greece
- Department of Neurointerventions, National
Institute of Mental Health, Neurology and Neurosurgery, Section of
Neurointervention, Department of Neurosurgery, Semmelweis University,
Budapest, Hungary
| | - Lina Palaiodimou
- Second Department of Neurology, Attikon
University Hospital, Athens, Greece
- School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | - István Szikora
- Department of Neurointerventions, National
Institute of Mental Health, Neurology and Neurosurgery, Section of
Neurointervention, Department of Neurosurgery, Semmelweis University,
Budapest, Hungary
| | | | - George Magoufis
- Neuroradiology Department, Metropolitan
Hospital, Piraeus, Greece
| | | | - Georgios Paraskevas
- Second Department of Neurology, Attikon
University Hospital, Athens, Greece
- School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | - Stavros Spiliopoulos
- Interventional Radiology Department, Attikon
University Hospital, Athens, Greece
| | - Elias Brountzos
- Interventional Radiology Department, Attikon
University Hospital, Athens, Greece
| | - Sándor Nardai
- Department of Neurointerventions, National
Institute of Mental Health, Neurology and Neurosurgery, Section of
Neurointervention, Department of Neurosurgery, Semmelweis University,
Budapest, Hungary
| | - Nitin Goyal
- Department of Neurology, The University of
Tennessee Health Science Center, Memphis, TN, USA
- Department of Neurosurgery, The University of
Tennessee Health Science Center and Semmes Murphey Neurologic and Spine
Clinic. Memphis, TN, USA
| | - Diana Aguiar De Sousa
- Stroke Center, Lisbon Central University
Hospital and Faculty of Medicine, University of Lisbon, Lisbon,
Portugal
| | - Daniel Strbian
- Neurological Research Unit, University Medical
Center Hamburg-Eppendorf, Hamburg, Germany
| | - Valeria Caso
- Neurology Unit, ‘M. Bufalini’ Hospital-AUSL
Romagna, Cesena, Italy
| | - Andrei Alexandrov
- Department of Neurology, The University of
Tennessee Health Science Center, Memphis, TN, USA
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon
University Hospital, Rimini 1, Chaidari, 124 62 Athens, Greece
- School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Department of Neurology, The University of
Tennessee Health Science Center, Memphis, TN, USA
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Xie S, Han N, Chen X, Yin K, Xu G, Dong Y, Lv P. Posterior cerebral artery embolism resulting in bilateral paramedian thalamic infarction: A case report. Medicine (Baltimore) 2022; 101:e32071. [PMID: 36451504 PMCID: PMC9704929 DOI: 10.1097/md.0000000000032071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
RATIONALE Bilateral thalamic infarcts are not easily recognized, it have diverse clinical manifestations and relatively severe symptoms. It may leave long-term drowsiness, cognitive impairment, and speech impairment. We report a case of bilateral paramedian thalamic infarction with impaired consciousness as the main symptom. The digital subtraction angiography suggested that the left superior cerebellar artery and posterior cerebral artery (PCA) were occluded. PATIENTS CONCERN A previously 67-year-old man was taken to our hospital after 9.5 hours of acute dizziness and loss of consciousness. DIAGNOSIS The cranial DWI + MRA suggested acute cerebral infarction in bilateral thalamus and bilateral midbrain, and the left posterior cerebral artery was not clearly visualized. The patient was diagnosed with posterior cerebral artery embolism. INTERVENTIONS A mechanical thrombectomy was performed. OUTCOME The patient's symptoms did not completely improve after revascularization, followed by fluctuating consciousness. LESSONS Recurrent lethargy in patients after endovascular treatment may be a clinical manifestation of damage to thalamic structures or due to the presence of ineffective recanalization.
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Affiliation(s)
- Shaowei Xie
- Department of Neurology, Hebei General Hospital, Shijiazhuang, Hebei, China
- Hebei Provincial Key Laboratory of Cerebral Networks and Cognitive Disorders, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Ning Han
- Department of Neurology, Hebei General Hospital, Shijiazhuang, Hebei, China
- Hebei Provincial Key Laboratory of Cerebral Networks and Cognitive Disorders, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Xingyu Chen
- Department of Neurology, Hebei General Hospital, Shijiazhuang, Hebei, China
- Hebei Provincial Key Laboratory of Cerebral Networks and Cognitive Disorders, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Kuochang Yin
- Department of Neurology, Hebei General Hospital, Shijiazhuang, Hebei, China
- Hebei Provincial Key Laboratory of Cerebral Networks and Cognitive Disorders, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Guodong Xu
- Department of Neurology, Hebei General Hospital, Shijiazhuang, Hebei, China
- Hebei Provincial Key Laboratory of Cerebral Networks and Cognitive Disorders, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Yanhong Dong
- Department of Neurology, Hebei General Hospital, Shijiazhuang, Hebei, China
- Hebei Provincial Key Laboratory of Cerebral Networks and Cognitive Disorders, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Peiyuan Lv
- Department of Neurology, Hebei General Hospital, Shijiazhuang, Hebei, China
- Hebei Provincial Key Laboratory of Cerebral Networks and Cognitive Disorders, Hebei General Hospital, Shijiazhuang, Hebei, China
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Yuan Z, Yang Y, Luo Y, Chen X, Luo H, Li J, Meng R, Xie Y, Jiang L, Lv Z, Rong B, Li Z. Alberta Stroke Program Early CT Score applied to hyperdense lesion on noncontrast CT immediately post-thrombectomy is a predictor of poor outcome in acute ischemic stroke: A case-control study. Medicine (Baltimore) 2022; 101:e30514. [PMID: 36086765 PMCID: PMC10980400 DOI: 10.1097/md.0000000000030514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 08/05/2022] [Indexed: 11/26/2022] Open
Abstract
We aimed to evaluate whether Alberta Stroke Program Early CT Score (ASPECTS) applied to hyperdense lesion on noncontrast CT obtained immediately post-thrombectomy (post-ASPECTS) is useful for predicting poor outcome. We retrospectively reviewed patients who underwent noncontrast CT (NCCT) immediately after mechanical thrombectomy between January 2017 and July 2020 in our comprehensive stroke center. We collected baseline NCCT and post-ASPECTS score. The sensitivity, specificity, and positive and negative predictive values of the post-ASPECTS in predicting clinical outcome were calculated. A total of 223 patients were included. The hyperdense lesion on NCCT immediately after endovascular thrombectomy presented in 85.7% (191/223) patients, poor clinical outcome was in 56.1% (112/191) of hyperdense lesion patients. Low post-ASPECTS was associated with poor outcome (OR 0.390; 95% CI 0.258-0.589; P = .001), with an AUCROC curve of 0.753 (95% CI 0.684-0.822), while baseline NCCT-ASPECTS was not (OR 0. 754; 95% CI 0. 497-1.144; P = .185). A score ≤ 7 in post-ASPECTS was the best cut-off to poor clinical outcome (sensitivity 84.8%; specificity 52.7%; positive predictive value 68.4%; negative predictive value 73.8%). Our results point to the proportion of patients who present hyperdense lesion on NCCT is very high, post-ASPECTS could predict poor clinical outcomes in patients with stroke treated with endovascular mechanical thrombectomy, and post-ASPECTS may achieved better predictive value than baseline ASPECTS.
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Affiliation(s)
- Zhengzhou Yuan
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, ChengDu, China
- Department of Neurology, Affiliated Hospital of Southwest Medical University, LuZhou, China
| | - Yuan Yang
- Department of Neurology, Affiliated Hospital of Southwest Medical University, LuZhou, China
| | - Ying Luo
- Department of Neurology, Affiliated Hospital of Southwest Medical University, LuZhou, China
| | - Xiu Chen
- Department of Neurology, Affiliated Hospital of Southwest Medical University, LuZhou, China
| | - Hua Luo
- Department of Neurology, Affiliated Hospital of Southwest Medical University, LuZhou, China
| | - Jinglun Li
- Department of Neurology, Affiliated Hospital of Southwest Medical University, LuZhou, China
| | - Renliang Meng
- Department of Neurology, Affiliated Hospital of Southwest Medical University, LuZhou, China
| | - Yang Xie
- Department of Neurology, Affiliated Hospital of Southwest Medical University, LuZhou, China
| | - Li Jiang
- Department of Neurology, Affiliated Hospital of Southwest Medical University, LuZhou, China
| | - Zhiyu Lv
- Department of Neurology, Affiliated Hospital of Southwest Medical University, LuZhou, China
| | - Benbing Rong
- Department of Neurology, Affiliated Hospital of Southwest Medical University, LuZhou, China
| | - Zuoxiao Li
- Department of Neurology, Affiliated Hospital of Southwest Medical University, LuZhou, China
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Pillai Perianen P, Yan B. Are We Ready to Offer Endovascular Thrombectomy to All Patients With Large Ischemic Core? Front Neurol 2022; 13:893975. [PMID: 35493819 PMCID: PMC9043548 DOI: 10.3389/fneur.2022.893975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 03/18/2022] [Indexed: 11/13/2022] Open
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Bing F, Berger I, Fabry A, Moroni AL, Casile C, Morel N, M'Biene S, Guellerin J, Pignal-Jacquard C, Vadot W, Rodier G, Delory T, Jund J. Intra- and inter-rater consistency of dual assessment by radiologist and neurologist for evaluating DWI-ASPECTS in ischemic stroke. Rev Neurol (Paris) 2021; 178:219-225. [PMID: 34785042 DOI: 10.1016/j.neurol.2021.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 08/04/2021] [Accepted: 08/11/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To estimate the intra -and inter-rater consistency of radiologist and neurologist working in pairs attributing DWI-ASPECTS (Diffusion Alberta Stroke Program Early CT Score) in patients with acute middle cerebral artery ischemic stroke referred for mechanical thrombectomy, intravenous thrombolysis or bridging therapy. METHODS Five neurologists and 5 radiologists working in pairs and in hour period scored independently and in two reading sessions anonymized DWI-ASPECTS of 80 patients presenting with acute anterior ischaemic stroke in our center. We measured agreement between pairs using intraclass correlation coefficients (ICCs). A Fleiss kappa was used for dichotomized (0-6;7-10) and trichotomized (0-3;4-6;7-10) ASPECTS. The interrater distribution of the score in the trichotomized (0-3;4-6;7-10) ASPECTS was calculated. We determined the interrater (Cohen kappa) and intrarater (Fleiss kappa) agreement on the ASPECTS regions. RESULTS The average DWI-ASPECTS was 6.35 (SD±2.44) for the first reading, and 6.47 (SD±2.44) for the second one. The ICC was 0.853 (95%CI, 0.798-0.896) for the interrater, and 0.862 (95%CI, 0.834-0.885) for the intrarater evaluation. Kappa coefficients were high for dichotomized (k=0.75) and trichotomized (k=0.64) ASPECTS. Evaluators agreement on the ASPECTS category (0-3), (4-6) and (7-10) was 88, 76 and 93% respectively. The anatomic region infarcted was well identified (k=0.70-0.77), except for the internal capsula (k=0.57). Interrater agreement was fair for M5 (k=0.37), moderate for internal capsula (0.52) and substantial for the other regions (0.60-0.79). CONCLUSIONS Reliability of DWI-ASPECTS is good when determined by radiologist and neurologist working in pairs, which corresponds to our current clinical practice. However, discrepancies are possible for cut-off determination, which may impact the indication of thrombectomy, and for the determination of the exact infarcted region. Agreement to propose category (4-6) is lower than for (0-3) and (8-10) ASPECTS categories.
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Affiliation(s)
- F Bing
- Radiology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France.
| | - I Berger
- Neurology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - A Fabry
- Radiology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - A-L Moroni
- Radiology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - C Casile
- Radiology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - N Morel
- Neurology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - S M'Biene
- Radiology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - J Guellerin
- Neurology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - C Pignal-Jacquard
- Radiology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - W Vadot
- Neurology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - G Rodier
- Neurology Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - T Delory
- Clinical Research Unit, CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - J Jund
- Medical Information and Evaluation Unit (SIEM), CHANGE, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
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He G, Wei L, Lu H, Li Y, Zhao Y, Zhu Y. Advances in imaging acute ischemic stroke: evaluation before thrombectomy. Rev Neurosci 2021; 32:495-512. [PMID: 33600678 DOI: 10.1515/revneuro-2020-0061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/05/2020] [Indexed: 11/15/2022]
Abstract
Recent advances in neuroimaging have demonstrated significant assessment benefits and appropriate triage of patients based on specific clinical and radiological features in the acute stroke setting. Endovascular thrombectomy is arguably the most important aspect of acute stroke management with an extended time window. Imaging-based physiological information may potentially shift the treatment paradigm from a rigid time-based model to a more flexible and individualized, tissue-based approach, increasing the proportion of patients amenable to treatment. Various imaging modalities are routinely used in the diagnosis and management of acute ischemic stroke, including multimodal computed tomography (CT) and magnetic resonance imaging (MRI). Therefore, these imaging methods should provide information beyond the presence or absence of intracranial hemorrhage as well as the presence and extent of the ischemic core, collateral circulation and penumbra in patients with neurological symptoms. Target mismatch may optimize selection of patients with late or unknown symptom onset who would potentially be eligible for revascularization therapy. The purpose of this study was to provide a comprehensive review of the current evidence about efficacy and theoretical basis of present imaging modalities, and explores future directions for imaging in the management of acute ischemic stroke.
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Affiliation(s)
- Guangchen He
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai200233, China
| | - Liming Wei
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai200233, China
| | - Haitao Lu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai200233, China
| | - Yuehua Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai200233, China
| | - Yuwu Zhao
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai200233, China
| | - Yueqi Zhu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai200233, China
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Jiang X, Zhao Z, Zhang Y, Lai L. The Safety and Efficacy of Endovascular Treatment for Patients With ASPECTS<6 in Anterior Circulation Stroke: A Meta-Analysis and Subgroup Analysis by Imaging Techniques. J Stroke Cerebrovasc Dis 2020; 29:105122. [PMID: 32912548 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105122] [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: 03/17/2020] [Revised: 06/07/2020] [Accepted: 06/29/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Endovascular treatment (EVT) is merely recommended as class of recommendation IIb for patients with ASPECTS <6 according to the American Heart Association guideline 2019. In addition, the best determined imaging technique for EVT in patient with ASPECTS<6 remains unknown. The objective of this study was to define the safety and efficacy of EVT for patients with ASPECTS<6 and investigate the superiority between MRI and CT for patient selection. METHODS A systematic search of PubMed, EMBASE, The Cochrane Library and other additional sources was performed for studies published with no publication period. Our study was conducted corresponding to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRIMA) guidelines. The analysis was performed using the Comprehensive Meta-Analysis (CMA) 2.0. RESULTS Five studies reporting data from 844 participants were included in our analysis according to the inclusion criteria. Consequently, EVT was associated with statistically significant higher functional independence compared with MT (OR 5.401, 95% CI 3.227-9.041). Whereas EVT was found to be related to lower mortality compared with MT based on eligible data (OR 0.461, 95% CI 0.329-0.647). No significant difference was identified in sICH between EVT and MT (OR 1.075, 95% CI 0.452-2.558). CONCLUSION According to the results of our study, we suggested that EVT is a preferred therapy in ACS patients with ASPECTS<6 in consideration of efficacy and safety. Furthermore, MRI did not show superiority over CT as no statistical difference was detected in all subgroups.
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Affiliation(s)
- Xin Jiang
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, East Lake District, 330006 Nanchang, Jiangxi, PR China; The First Clinical Medical School, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, PR China
| | - Zixu Zhao
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, East Lake District, 330006 Nanchang, Jiangxi, PR China; Queen Mary School, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, PR China
| | - Ying Zhang
- The First Clinical Medical School, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, PR China
| | - Lingfeng Lai
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, East Lake District, 330006 Nanchang, Jiangxi, PR China.
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Nishi H, Oishi N, Ishii A, Ono I, Ogura T, Sunohara T, Chihara H, Fukumitsu R, Okawa M, Yamana N, Imamura H, Sadamasa N, Hatano T, Nakahara I, Sakai N, Miyamoto S. Deep Learning–Derived High-Level Neuroimaging Features Predict Clinical Outcomes for Large Vessel Occlusion. Stroke 2020; 51:1484-1492. [DOI: 10.1161/strokeaha.119.028101] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
For patients with large vessel occlusion, neuroimaging biomarkers that evaluate the changes in brain tissue are important for determining the indications for mechanical thrombectomy. In this study, we applied deep learning to derive imaging features from pretreatment diffusion-weighted image data and evaluated the ability of these features in predicting clinical outcomes for patients with large vessel occlusion.
Methods—
This multicenter retrospective study included patients with anterior circulation large vessel occlusion treated with mechanical thrombectomy between 2013 and 2018. We designed a 2-output deep learning model based on convolutional neural networks (the convolutional neural network model). This model employed encoder-decoder architecture for the ischemic lesion segmentation, which automatically extracted high-level feature maps in its middle layers, and used its information to predict the clinical outcome. Its performance was internally validated with 5-fold cross-validation, externally validated, and the results compared with those from the standard neuroimaging biomarkers Alberta Stroke Program Early CT Score and ischemic core volume. The prediction target was a good clinical outcome, defined as a modified Rankin Scale score at 90-day follow-up of 0 to 2.
Results—
The derivation cohort included 250 patients, and the validation cohort included 74 patients. The convolutional neural network model showed the highest area under the receiver operating characteristic curve: 0.81±0.06 compared with 0.63±0.05 and 0.64±0.05 for the Alberta Stroke Program Early CT Score and ischemic core volume models, respectively. In the external validation, the area under the curve for the convolutional neural network model was significantly superior to those for the other 2 models.
Conclusions—
Compared with the standard neuroimaging biomarkers, our deep learning model derived a greater amount of prognostic information from pretreatment neuroimaging data. Although a confirmatory prospective evaluation is needed, the high-level imaging features derived by deep learning may offer an effective prognostic imaging biomarker.
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Affiliation(s)
- Hidehisa Nishi
- From the Department of Neurosurgery (H.N., A.I., I.O., M.O., S.M.), Kyoto University Graduate School of Medicine, Japan
| | - Naoya Oishi
- Medical Innovation Center (N.O.), Kyoto University Graduate School of Medicine, Japan
| | - Akira Ishii
- From the Department of Neurosurgery (H.N., A.I., I.O., M.O., S.M.), Kyoto University Graduate School of Medicine, Japan
| | - Isao Ono
- From the Department of Neurosurgery (H.N., A.I., I.O., M.O., S.M.), Kyoto University Graduate School of Medicine, Japan
| | - Takenori Ogura
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Japan (T.O., H.C.)
| | - Tadashi Sunohara
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Japan (T.S., R.F., H.I., N.S.)
| | - Hideo Chihara
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Japan (T.O., H.C.)
| | - Ryu Fukumitsu
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Japan (T.S., R.F., H.I., N.S.)
| | - Masakazu Okawa
- From the Department of Neurosurgery (H.N., A.I., I.O., M.O., S.M.), Kyoto University Graduate School of Medicine, Japan
| | | | - Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Japan (T.S., R.F., H.I., N.S.)
| | - Nobutake Sadamasa
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Japan (T.S., R.F., H.I., N.S.)
| | | | - Ichiro Nakahara
- Department of Comprehensive Strokology, Fujita Health University School of Medicine, Toyoake, Japan (I.N.)
| | - Nobuyuki Sakai
- Department of Neurosurgery, Koseikai Takeda Hospital, Kyoto, Japan (N.S.)
| | - Susumu Miyamoto
- From the Department of Neurosurgery (H.N., A.I., I.O., M.O., S.M.), Kyoto University Graduate School of Medicine, Japan
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Endovascular Thrombectomy for Low ASPECTS Large Vessel Occlusion Ischemic Stroke: A Systematic Review and Meta-Analysis. Can J Neurol Sci 2020; 47:612-619. [DOI: 10.1017/cjn.2020.71] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
ABSTRACT:Background:The current American Heart Association guidelines for acute ischemic stroke reserve Grade 1A recommendation for the use of endovascular thrombectomy (EVT) for patients with an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of ≥6.Objective:We aim to determine the safety and efficacy of EVT for large vessel occlusion ischemic stroke patients with low ASPECTS (5 or less).Methods:Medline, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched for studies appraising the outcomes of EVT for low ASPECTS ischemic stroke. A meta-analysis of proportions compared the clinical outcomes of patients undergoing EVT and those receiving best medical therapy only.Results:Nine studies (1,196 patients) were included. There was a trend (p = 0.11) toward a higher rate of symptomatic intracranial hemorrhage (sICH) in the EVT group (9.2%; 95% CI 6.1–13.6; I2 53.37%) compared to the medical group (5.5%; 95% CI 3.7–8.1; I2 0%). There was no difference (p = 0.41) in the pooled 90-day mortality of EVT patients (30.7%; 95% CI 21.7–41.5; I2 84.23%) and medical patients (36.6%; 95% CI 26.4–48.1; I2 76.2%). EVT patients had better (p = 0.001) 90-day outcomes, with 27.7% (95% CI 21.8–34.5; I2 62.08%) of patients attaining a modified Rankin Scale of 0–2 compared to only 3.7% (95% CI 2.3–5.9; I2 87.21%) in the medical group.Conclusions:This meta-analysis demonstrates a trend in higher sICH among low ASPECTS patients undergoing EVT. Despite this, a significant proportion of this subset of patients still achieved good functional outcomes at 90 days. Randomized trials are necessary to substantiate this result as significant bias is inherent in the observational studies included in this review.
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11
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Cagnazzo F, Derraz I, Dargazanli C, Lefevre PH, Gascou G, Riquelme C, Bonafe A, Costalat V. Mechanical thrombectomy in patients with acute ischemic stroke and ASPECTS ≤6: a meta-analysis. J Neurointerv Surg 2019; 12:350-355. [DOI: 10.1136/neurintsurg-2019-015237] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 07/18/2019] [Accepted: 07/18/2019] [Indexed: 11/03/2022]
Abstract
BackgroundIt is uncertain whether mechanical thrombectomy (MT) increases the probability of a good outcome (modified Rankin Scale (mRS) 0–2) in patients with Alberta Stroke Program Early CT Score (ASPECTS) 0–6.ObjectiveTo assess the impact of MT in patients with pretreatment ASPECTS 0–6.MethodsAccording to PRISMA guidelines, we performed a systematic search of three databases for series of patients with ASPECTS 0–6 treated by MT. Random-effects meta-analysis was used to pool the following: rate of mRS 0–2 at 3 months follow-up, symptomatic intracranial hemorrhage (sICH), and mortality rates.ResultsWe included 17 studies and 1378 patients with ASPECTS 0–6 (1194 MT, 184 medical management). The rate of mRS 0–2 was 30.1% and 3.2% after MT and medical management, respectively. MT gave higher odds of mRS 0–2 (OR 4.76, p=0.01). Patients with ASPECTS 6 and 5 had comparable rates of good outcome (37.7% and 33.3%, respectively). Overall, the rate of mRS 0–2 was 17.1% in patients with ASPECTS 0–4: 22.1% and 13.9% of patients with ASPECTS 4 and 0–3 were functionally independent, respectively. Successful recanalization (Thrombolysis in Cerebral Infarction grade 2b–3) gave higher odds of mRS 0–2 than unsuccessful reperfusion (OR 5.2, p=0.001). The MT group tended to have lower odds of sICH compared with the controls (OR 0.48, p=0.06). Patients aged <70 years had higher rates of mRS 0–2 than those aged >70 years (40.3% vs 16.2%).ConclusionsPatients with ASPECTS 0–6may benefit from MT. Successful reperfusion increases the probability of 3-month functional independence without increasing the risk of sICH. Patients with ASPECTS 5 and 6 have comparable outcomes. MT can still enable approximately one in four patients with ASPECTS 4 to be independent, whereas only 14% of subjects with ASPECTS 0–3 regain a good functional outcome.
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Acute ischemic stroke patients with diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomography Score ≤ 5 can benefit from endovascular treatment: a single-center experience and literature review. Neuroradiology 2019; 61:451-459. [PMID: 30725121 PMCID: PMC6431332 DOI: 10.1007/s00234-019-02177-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 01/22/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE The recommendation strength of the guidelines for mechanical thrombectomy among patients with large pre-treatment core infarct is weak. We evaluated the safety and outcome of endovascular treatment for acute ischemic stroke with diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) ≤ 5. METHODS Data on acute ischemic stroke patients with DWI-ASPECTS ≤ 5 who underwent endovascular treatment within 6 h, or presented an arterial spin labeling-DWI (ASL-DWI) mismatch within 12 h, at our center were retrospectively collected. We report the clinical characteristics and outcome of every patient, and review the relevant literature. RESULTS Among the 19 patients who were enrolled, all experienced successful reperfusion, and 10 achieved a favorable outcome (modified Rankin scale (mRS) ≤ 2). Two patients presented with symptomatic intracranial hemorrhage (sICH); both of them had a poor outcome (mRS > 2). CONCLUSION Acute ischemic stroke patients with large DWI lesions caused by large vessel occlusion can achieve a favorable clinical outcome with endovascular treatment if recanalization is performed within 6 h, or after 6 h in case of an ASL-DWI mismatch.
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Phan K, Saleh S, Dmytriw AA, Maingard J, Barras C, Hirsch JA, Kok HK, Brooks M, Chandra RV, Asadi H. Influence of ASPECTS and endovascular thrombectomy in acute ischemic stroke: a meta-analysis. J Neurointerv Surg 2018; 11:664-669. [PMID: 30415223 DOI: 10.1136/neurintsurg-2018-014250] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 10/16/2018] [Accepted: 10/18/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND Prompt revascularization of the ischemic penumbra following an acute ischemic event (AIS) has established benefit within the literature. However, use of the semi-quantitative Alberta Stroke Program Early CT Score (ASPECTS) to evaluate patient suitability for revascularization has been inconsistent in patient risk stratification and selection. OBJECTIVE To conduct a meta-analysis to evaluate the available evidence for a clinically valid ASPECTS threshold in assessment of suitability for revascularization following AIS. METHODS Two independent reviewers searched Medline (Ovid) and Cochrane Central Register of Systematic Reviews databases for studies appraising outcomes of endovascular thrombectomy (EVT) in relation to a variably-defined preoperative ASPECTS. RESULTS A total of 13 articles were included. The pooled good outcome proportion after EVT was 41.4% (95% CI 36.4% to 46.6%; p<0.001), with subjective study-specific definitions of favorable and unfavorable subgroup outcomes of 49.7% (95% CI 44.2% to 55.3%; I2=76.5%; p<0.001) and 33.2% (95% CI 28.5% to 38.3%; I2=33.16%), respectively. Objective trichotomization into low (0-4), intermediate (5-7), and high (8-10) subgroups yielded pooled good outcome proportions of 17.1% (95% CI 6.8% to 36.8%; I2=64.24%; p=0.039), 35.7% (95% CI 30.5% to 41.3%; I2=23.11%; p=0.245), and 49.7% (95% CI 44.2% to 55.3%; I2=76.5%; p<0.001) for low, intermediate, and high ASPECTS, respectively. CONCLUSIONS A subjectively favorable ASPECTS is associated with significantly better outcomes after EVT than an unfavorable ASPECTS, regardless of the cut-off used. EVT is unlikely to be useful in patients with an objectively low ASPECTS and is likely to be useful for those with high ASPECTS; findings in patients with intermediate ASPECTS were equivocal.
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Affiliation(s)
- Kevin Phan
- NeuroSpine Surgery Research Group (NSURG), Sydney, New South Wales, Australia
| | - Serag Saleh
- NeuroSpine Surgery Research Group (NSURG), Sydney, New South Wales, Australia
| | - Adam A Dmytriw
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
- Department of Medical Imaging, St Michael's Hospital, Toronto, Ontario, Canada
| | - Julian Maingard
- Interventional Neuroradiology, Austin Health, Heidelberg, Victoria, Australia
| | - Christen Barras
- University of Adelaide, Adelaide, South Australia, Australia
| | - Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hong Kuan Kok
- Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - Mark Brooks
- Interventional Neuroradiology, Austin Health, Heidelberg, Victoria, Australia
| | - Ronil V Chandra
- Interventional Neuroradiology Unit, Monash Health, Clayton, Victoria, Australia
- Department of Imaging, Monash University, Clayton, Victoria, Australia
| | - Hamed Asadi
- Department of Radiology, Beaumont Hospital, Dublin, Ireland
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Ohta T, Morimoto M, Okada K, Fukuda M, Onishi H, Masahira N, Matsuoka T, Tsuno T, Takemura M. Mechanical Thrombectomy in Anterior Circulation Occlusion Could Be More Effective than Medical Management Even in Low DWI-ASPECTS Patients. Neurol Med Chir (Tokyo) 2018; 58:156-163. [PMID: 29479041 PMCID: PMC5929913 DOI: 10.2176/nmc.oa.2017-0203] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The purpose of this study was to investigate whether patients with low preoperative Diffusion-weighted Imaging Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) could benefit from mechanical thrombectomy for acute anterior circulation occlusion. This was a retrospective, non-blinded, cohort study. From September 2012 to August 2016, 83 consecutive patients of acute anterior circulation occlusion were treated with thrombectomy using second-generation devices or medical management. The DWI-ASPECTS was scored after the first MRI. Patient characteristics and clinical outcomes were compared between the treatment groups. Significant dependence was defined as a modified Rankin scale score ≥3 at 90 days. As a result, 33 patients underwent mechanical thrombectomy and 50 received medical management. In the mechanical thrombectomy group, the variable of lower DWI-ASPECTS (5, 4–6 vs. 8, 7–8, P < 0.001), especially ≤6, was significantly associated with poor prognosis. However, compared with patients of DWI-ASPECTS ≤ 6 who received medical management, there were significantly fewer patients with poor outcomes in thrombectomy (dependent in 11 of 15 vs. 23 of 23, respectively; P = 0.019). Although patients with lower pretreatment DWI-ASPECTS could benefit less from thrombectomy, their outcomes were still better than medical management. Therefore, mechanical thrombectomy could be considered in some patients with low pretreatment DWI-ASPECTS.
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Affiliation(s)
- Tsuyoshi Ohta
- Department of Neurosurgery, Kochi Health Sciences Center
| | | | - Kenji Okada
- Department of Neurosurgery, Kochi Health Sciences Center
| | - Maki Fukuda
- Department of Neurosurgery, Kochi Health Sciences Center
| | - Hirokazu Onishi
- Department of Emergency Medicine, Kochi Health Sciences Center
| | | | | | - Takaya Tsuno
- Department of Neurosurgery, Kochi Health Sciences Center
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15
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Koizumi S, Kimura T, Shojima M, Inoue T. Initial Attempt to Select Patients for Mechanical Thrombectomy Using Noncontrast Computed Tomography and Symptom-Based Criteria: Single-Center Experience. World Neurosurg 2018; 112:e581-e587. [PMID: 29410336 DOI: 10.1016/j.wneu.2018.01.091] [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: 10/25/2017] [Revised: 01/11/2018] [Accepted: 01/12/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND In the treatment of acute ischemic stroke (AIS), patients need to be selected for mechanical thrombectomy (MT) in the acute phase. Selection criteria vary, however, depending on the patient's situation. This study investigated the effectiveness of a noncontrast computed tomography and symptom-based protocol for selecting patients for MT. METHODS This retrospective study included 20 patients with AIS. The first 8 patients (earlier group) were screened by magnetic resonance imaging (MRI). Among the later 12 patients, MRI was deliberately skipped in 9, and major vessel occlusion was confirmed by digital subtraction angiography after meeting 4 criteria: 1) hospital arrival within 90 minutes from onset; 2) National Institutes of Health Stroke Scale score 9-25; 3) history or presence of atrial fibrillation; and 4) Alberta Stroke Program Early CT Score of 9-10. The clinical outcomes and time course were compared. RESULTS Among the later period group, 9 of 12 patients skipped MRI-based confirmation of large vessel occlusion. They underwent the direct angiography protocol, which had a 78% (7/9) positive predictive value for identifying large-vessel occlusion. In this group, National Institutes of Health Stroke Scale scores on the next day had significantly improved (median -8 points) compared with those at admission. Good functional outcome did not differ between the groups at 3 months. CONCLUSIONS Noncontrast computed tomography and symptom-based selection of MT to treat AIS can be useful for achieving better neurologic recovery in a subgroup of patients. This approach could broaden the use of MT.
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Affiliation(s)
- Satoshi Koizumi
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan; Department of Neurosurgery, The University of Tokyo, Tokyo, Japan.
| | - Toshikazu Kimura
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan
| | - Masaaki Shojima
- Department of Neurosurgery, The University of Tokyo, Tokyo, Japan
| | - Tomohiro Inoue
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan
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Dekker L, Geraedts VJ, Hund H, Cannegieter SC, Nogueira RG, Goyal M, van den Wijngaard IR. Importance of Reperfusion Status after Intra-Arterial Thrombectomy for Prediction of Outcome in Anterior Circulation Large Vessel Stroke. INTERVENTIONAL NEUROLOGY 2018; 7:137-147. [PMID: 29719551 DOI: 10.1159/000486246] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 11/30/2017] [Indexed: 01/19/2023]
Abstract
Background Reperfusion status after intra-arterial thrombectomy (IAT) is a critical predictor of functional outcome after acute ischemic stroke. However, most prognostic models have not included a detailed assessment of reperfusion status after IAT. Objective The aim of this work was to assess the association between successful reperfusion and clinical outcome. Methods Clinical, radiological, and procedural variables of patients treated with IAT were extracted from our prospective stroke registry. The association with functional outcome using the modified Rankin Scale (mRS) after 3 months was assessed using multivariable logistic regression. An extension of the modified TICI score, eTICI, was used to classify reperfusion status. The prognostic value of reperfusion status after IAT in addition to age, stroke severity, imaging characteristics, treatment with intravenous thrombolysis, and time from symptom onset to the end of IAT was assessed with logistic regression and summarized with receiver operating characteristic curves. Results In total, 119 patients were included (mean age 66 years). In multivariable analysis, age >80 years (OR 6.8, 95% CI 1.2-39.8), NIHSS at presentation >15 (OR 7.3, 95% CI 2.3-23.5), and incomplete reperfusion status (eTICI score <2C; OR 10.3, 95% CI 3.5-30.6) were the strongest predictors of a poor outcome (mRS 3-6). Adding reperfusion status to the model improved the prognostic accuracy (AUC 0.88, 95% CI 0.91-0.94). Our results indicate a large difference between using an eTICI cutoff of ≥2C versus ≥2B: a cutoff ≥2C improved the predictive value for a good clinical outcome (2C: positive predictive value, PPV, 0.78; 2B: PPV 0.32). Conclusion Our results promote using reperfusion status for assessing prognosis in ischemic stroke patients treated with IAT. A model using eTICI ≥2C had greater PPV than eTICI ≥2B and could improve prognostic accuracy.
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Affiliation(s)
- Luuk Dekker
- Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands.,Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Victor J Geraedts
- Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands.,Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hajo Hund
- Department of Radiology, Haaglanden Medical Center, The Hague, the Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mayank Goyal
- Department of Neurosciences, Radiology and Community Health Services, University of Calgary, Calgary, Alberta, Canada
| | - Ido R van den Wijngaard
- Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands.,Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
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Abstract
The Alberta Stroke Program Early CT score (ASPECTS) is a 10-point semiquantitative topographic scoring system developed for the assessment of early ischemic changes (EICs) on noncontrast-enhanced computed tomography (NCCT) in patients with acute ischemic stroke involving the middle cerebral artery (MCA) territory. One point is subtracted from a total score of 10, if an EIC is present in any part of each of the ASPECTS regions. Higher ASPECTS has been associated with better outcomes and a lower risk of symptomatic intracerebral hemorrhage. To date, there are still controversies regarding the utility of ASPECTS for selecting patients for intravenous and intra-arterial therapies. This article provides a comprehensive review regarding methodology, limitations, and interobserver reproducibility of ASPECTS, as well as application of ASPECTS in clinical care. The focus of this review is ASPECTS evaluation on NCCT. The application of ASPECTS on multimodal computed tomography and magnetic resonance imaging (MRI) is briefly described.
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Affiliation(s)
- Supada Prakkamakul
- *Department of Radiology, King Chulalongkorn Memorial Hospital the Thai Red Cross Society, Bangkok, Thailand †Division of Neurointervention, Texas Stroke Institute, Plano, TX
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18
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Ryu CW, Shin HS, Park S, Suh SH, Koh JS, Choi HY. Alberta Stroke Program Early CT Score in the Prognostication after Endovascular Treatment for Ischemic Stroke: A Meta-analysis. Neurointervention 2017; 12:20-30. [PMID: 28316866 PMCID: PMC5355457 DOI: 10.5469/neuroint.2017.12.1.20] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 02/20/2017] [Indexed: 01/19/2023] Open
Abstract
Purpose The Alberta Stroke Program Early CT Score (ASPECTS) was devised to quantify the extent of early ischemic changes in the middle cerebral artery territory on brain CT. We performed a systematic review and meta-analysis of studies that presented clinical outcomes and baseline ASPECTS in ischemic stroke patients managed with endovascular methods to validate the use of ASPECTS for risk prognostication. Materials and Methods We searched the MEDLINE, EMBASE, and Cochran databases for observational or interventional studies that reported clinical outcomes and baseline ASPECTS in ischemic stroke patients treated with endovascular methods. Data were pooled to perform a meta-analysis for comparisons of clinical outcomes between high and low ASPECTS patients. Results A meta-analysis of 13 studies (six observational and seven interventional) revealed favorable outcomes (mRS sore 0-2 at 90 days) for high baseline ASPECTS (odds ratio=2.22; 95% CI: 1.74-2.86). Conclusion High ASPECTS is a predictor of favorable outcome after endovascular therapy for ischemic stroke.
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Affiliation(s)
- Chang-Woo Ryu
- Department of Radiology, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, South Korea
| | - Hee Shup Shin
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, South Korea
| | - Soonchan Park
- Department of Radiology, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, South Korea
| | - Sang Hyun Suh
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jun Seok Koh
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, South Korea
| | - Hye-Yeon Choi
- Department of Neurology, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, South Korea
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Yoon W, Kim SK, Park MS, Baek BH, Lee YY. Predictive Factors for Good Outcome and Mortality After Stent-Retriever Thrombectomy in Patients With Acute Anterior Circulation Stroke. J Stroke 2017; 19:97-103. [PMID: 28178407 PMCID: PMC5307937 DOI: 10.5853/jos.2016.00675] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/22/2016] [Accepted: 12/29/2016] [Indexed: 01/19/2023] Open
Abstract
Background and Purpose Predictive factors associated with stent-retriever thrombectomy for patients with acute anterior circulation stroke remain to be elucidated. This study aimed to investigate clinical and procedural factors predictive of good outcome and mortality after stent-retriever thrombectomy in a large cohort of patients with acute anterior circulation stroke. Methods We analyzed clinical and procedural data in 335 patients with acute anterior circulation stroke treated with stent-retriever thrombectomy. A good outcome was defined as a modified Rankin Scale score of 0 to 2 at 3 months. The associations between clinical, imaging, and procedural factors and good outcome and mortality, respectively, were evaluated using logistic regression analysis. Results Using multivariate analysis, age (odds ratio [OR], 0.965; 95% confidence interval [CI], 0.944-0.986; P=0.001), successful revascularization (OR, 4.658; 95% CI, 2.240-9.689; P<0.001), parenchymal hemorrhage (OR, 0.150; 95% CI, 0.049-0.460; P=0.001), and baseline NIHSS score (OR, 0.908; 95% CI, 0.855-0.965; P=0.002) were independent predictors of good outcome. Independent predictors of mortality were age (OR, 1.043; 95% CI, 1.002-1.086; P=0.041), successful revascularization (OR, 0.171; 95% CI, 0.079-0.370; P<0.001), parenchymal hemorrhage (OR, 2.961; 95% CI, 1.059-8.276; P=0.038), and a history of previous stroke/TIA (OR, 3.124; 95% CI, 1.340-7.281; P=0.008). Conclusions Age, revascularization status, and parenchymal hemorrhage are independent predictors of both good outcome and mortality after stent retriever thrombectomy for acute anterior circulation stroke. In addition, NIHSS score on admission is independently associated with good outcome, whereas a history of previous stroke is independently associated with mortality.
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Affiliation(s)
- Woong Yoon
- Department of Radiology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Seul Kee Kim
- Department of Radiology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Man Seok Park
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Byung Hyun Baek
- Department of Radiology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Yun Young Lee
- Department of Radiology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
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