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Jiang M, Li G, He Q, Zhang Y, Li W, Gao Y, Yan J. Multimodal imaging evaluation of early neurological deterioration following acute ischemic stroke. Quant Imaging Med Surg 2024; 14:4763-4778. [PMID: 39022232 PMCID: PMC11250343 DOI: 10.21037/qims-24-153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 06/05/2024] [Indexed: 07/20/2024]
Abstract
Background Early neurologic deterioration occurs in up to one-third of patients with acute ischemic stroke (IS), often leading to poor functional outcomes. At present, few studies have applied amide proton transfer (APT) imaging to the evaluation of early neurological deterioration (END). This study analyzed the value of computed tomography perfusion (CTP) combined with multimodal magnetic resonance imaging (MRI) in patients with acute IS with END. Methods This retrospective study included patients with acute IS who were admitted to the neurology inpatient department in a tertiary hospital from October 2021 to June 2023. Patients with acute IS underwent CTP within 24 hours of stroke onset and MRI [arterial spin labeling (ASL), susceptibility-weighted imaging (SWI), and APT] within 7 days. END was defined as an elevation of ≥2 points on the National Institute of Health Stroke Scale (NIHSS) within 7 days of stroke onset. Univariable and multivariable analyses were used to compare clinical and imaging biomarkers in patients with acute IS with and without END. The performance of potential biomarkers in distinguishing between the two groups was evaluated using receiver operating characteristic (ROC) curve analysis. Results Among the 70 patients with acute IS, 20 (29%) had END. After conducting univariable analysis, variables were selected for entry into a binary logistic regression analysis based on our univariable analysis results, previous research findings, clinical experience, and methodological standards. The results indicated that relative cerebral blood volume (CBV) on CTP, relative cerebral blood flow (CBF) on ASL, and relative signal intensity on amide proton transfer-weighted (APTw) imaging were independent risk factors for END. The areas under the ROC curves for these risk factors were 0.710 [95% confidence interval (CI): 0.559-0.861, P=0.006], 0.839 (95% CI: 0.744-0.933, P<0.001), and 0.804 (95% CI: 0.676-0.932, P<0.001), respectively. The combined area under the curve (AUC), sensitivity, and specificity of the four indices (0.941, 100%, and 78%, respectively) were higher than those of the four indices alone. Conclusions CTP combined with multi-modal MRI better evaluated hemodynamics, tissue metabolism, and other relevant patient information, providing an objective basis for the clinical assessment of patients with acute IS with END and facilitating the development of accurate and personalized treatment plans.
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Affiliation(s)
- Meien Jiang
- Department of Medical Imaging, The Affiliated Guangdong Second Provincial General Hospital of Jinan University, Guangzhou, China
- Department of Medical Imaging, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Guomin Li
- Department of Medical Imaging, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Qinmeng He
- Department of Medical Imaging, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Yulin Zhang
- Department of Medical Imaging, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Wuming Li
- Department of Medical Imaging, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Yunyu Gao
- Central Research Institute, United Imaging Healthcare, Shanghai, China
| | - Jianhao Yan
- Department of Medical Imaging, The Affiliated Guangdong Second Provincial General Hospital of Jinan University, Guangzhou, China
- Department of Medical Imaging, Guangdong Second Provincial General Hospital, Guangzhou, China
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Arba F, Rinaldi C, Jensen M, Endres M, Fiebach JB, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Simonsen CZ, Thijs V, Gerloff C, Wardlaw JM, Thomalla G. Validation of a simple clinical tool for screening of acute lacunar stroke-A substudy of the WAKE-UP trial. Int J Stroke 2024:17474930241253987. [PMID: 38676549 DOI: 10.1177/17474930241253987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Abstract
INTRODUCTION Lacunar stroke represents around a quarter of all ischemic strokes; however, their identification with computed tomography in the hyperacute setting is challenging. We aimed to validate a clinical score to identify lacunar stroke in the acute setting, independently, with data from the WAKE-UP trial using magnetic resonance imaging. METHODS We analyzed data from the WAKE-UP trial and extracted Oxfordshire Community Stroke Project (OCSP) classification. Lacunar score was defined by National Institutes of Health Stroke Scale (NIHSS) < 7 and OCSP lacunar syndrome. Assessment of lacunar infarct by two independent investigators was blinded to clinical data. We calculated sensitivity, specificity, negative and positive predictive value (NPV and PPV, respectively) of lacunar score. RESULTS We included 503 patients in the analysis, mean (±SD) age 65.2 (±11.6) years, 325 (65%) males, median (IQR) NIHSS = 6 (4-9); 108 (22%) lacunar infarcts were identified on magnetic resonance (MR), patients fulfilling lacunar score criteria were 120 (24%), of which 47 (44%) had a lacunar infarct. Lacunar score was negative in 322 (82%) of patients without lacunar infarct. Patients with lacunar score had lower NIHSS (4 vs 7, p < 0.001), higher systolic (157 vs 151 mmHg, p = 0.001) and diastolic (86 vs 83 mmHg, p = 0.013) blood pressure and smaller infarct volume (2.4 vs 9.5 mL, p < 0.001). Performance of lacunar score was as follows: sensitivity 0.44; specificity 0.82; PPV 0.39; NPV 0.84; and accuracy 0.73. Assuming a prevalence of lacunar stroke of 13%, PPV lowered to 0.30 but NPV was 0.90. Lacunar score performed better for supratentorial lacunar infarcts. CONCLUSION Lacunar score had a very good specificity and NPV for screening of lacunar stroke. Implementation of this simple tool into clinical practice may help hyperacute management and guide patient selection in clinical trials. DATA ACCESS STATEMENT Data supporting the results of this paper are available upon reasonable request to the corresponding author.
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Affiliation(s)
- Francesco Arba
- Stroke Unit, Careggi University Hospital, Florence, Italy
| | - Chiara Rinaldi
- NEUROFARBA Department, University of Florence, Florence, Italy
| | - Märit Jensen
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Endres
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Centrum für Schlaganfallforschung Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- German Center for Mental Health (DZPG), Partner Site Berlin, Berlin, Germany
| | - Jochen B Fiebach
- Centrum für Schlaganfallforschung Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Robin Lemmens
- VIB Center for Brain & Disease Research, Department of Neurosciences, Experimental Neurology, KU Leuven-University of Leuven, Leuven, Belgium
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Glasgow, UK
| | - Norbert Nighoghossian
- Department of Stroke Medicine, Université Claude Bernard Lyon, Lyon, France
- Hospices Civils de Lyon, Lyon, France
| | - Salvador Pedraza
- Department of Radiology, Institut de Diagnòstic per la Imatge (IDI), Hospital Universitari Dr. Josep Trueta, Institut d'Investigació Biomèdica de Girona (IDIBGI), Girona, Spain
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Vincent Thijs
- Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences and UK Dementia Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
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Ladumor H, Vilanilam GK, Ameli S, Pandey I, Vattoth S. CT perfusion in stroke: Comparing conventional and RAPID automated software. Curr Probl Diagn Radiol 2024; 53:201-207. [PMID: 37891080 DOI: 10.1067/j.cpradiol.2023.10.011] [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: 06/02/2023] [Revised: 09/12/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023]
Abstract
CT perfusion (CTP) imaging is increasingly used for routine evaluation of acute ischemic stroke. Knowledge about the different types of CTP software, imaging acquisition and post-processing, and interpretation is crucial for appropriate patient selection for reperfusion therapy. Conventional vendor-provided CTP software differentiates between ischemic penumbra and core infarct using the tiebreaker of critically reduced cerebral blood volume (CBV) values within brain regions showing abnormally elevated time parameters like mean transit time (MTT) or time to peak (TTP). On the other hand, RAPID automated software differentiates between ischemic penumbra and core infarct using the tiebreaker of critically reduced cerebral blood flow (CBF) values within brain regions showing abnormally elevated time to maximum (Tmax). Additionally, RAPID calculates certain indices that confer prognostic value, such as the hypoperfusion and CBV index. In this review, we aim to familiarize the reader with the technical principles of CTP imaging, compare CTP maps generated by conventional and RAPID software, and discuss important thresholds for reperfusion and prognostic indices. Lastly, we discuss common pitfalls to help with the accurate interpretation of CTP imaging.
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Affiliation(s)
- Heta Ladumor
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W. Markham St - Slot 556, Little Rock, AR 72205, USA.
| | - George K Vilanilam
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W. Markham St - Slot 556, Little Rock, AR 72205, USA
| | - Sanaz Ameli
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W. Markham St - Slot 556, Little Rock, AR 72205, USA
| | | | - Surjith Vattoth
- Deparment of Diagnostic Radiology & Nuclear Medicine, Division of Neuroradiology, Rush University Medical Center, Chicago, IL 60612, USA
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Gu Y, Shi D, Shen H, Wang Y, Xu D, Xiao A, Jin D, Lu K, Cai W, Xu L. Nomogram Based on Dual-Layer Spectral Detector CTA Parameter for the Prediction of Infarct Core in Patients with Acute Ischemic Stroke. Diagnostics (Basel) 2023; 13:3434. [PMID: 37998572 PMCID: PMC10670594 DOI: 10.3390/diagnostics13223434] [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: 09/13/2023] [Revised: 10/30/2023] [Accepted: 11/09/2023] [Indexed: 11/25/2023] Open
Abstract
(1) Background: Acute ischemic stroke (AIS) is time-sensitive. The accurate identification of the infarct core and penumbra areas in AIS patients is an important basis for formulating treatment plans, and is the key to dual-layer spectral detector computed tomography angiography (DLCTA), a safer and more accurate diagnostic method for AIS that will replace computed tomography perfusion (CTP) in the future. Thus, this study aimed to investigate the value of DLCTA in differentiating infarct core from penumbra in patients with AIS to establish a nomogram combined with spectral computed tomography (CT) parameters for predicting the infarct core and performing multi-angle evaluation. (2) Methods: Data for 102 patients with AIS were retrospectively collected. All patients underwent DLCTA and CTP. The patients were divided into the non-infarct core group and the infarct core group, using CTP as the reference. Multivariate logistic regression analysis was used to screen predictors related to the infarct core and establish a nomogram model. The receiver operating characteristic (ROC) curve, the calibration curve, and decision curve analysis (DCA) were used to evaluate the predictive efficacy, accuracy, and clinical practicability of the model, respectively. (3) Results: Multivariate logistic analysis identified three independent predictors: iodine density (OR: 0.022, 95% CI: 0.003-0.170, p < 0.001), hypertension (OR: 7.179, 95% CI: 1.766-29.186, p = 0.006), and triglycerides (OR: 0.255, 95% CI: 0.109-0.594, p = 0.002). The AUC-ROC of the nomogram was 0.913. Calibration was good. Decision curve analysis was clinically useful. (4) Conclusions: The spectral CT parameters, specifically iodine density values, effectively differentiate between the infarct core and penumbra areas in patients with AIS. The nomogram, based on iodine density values, showed strong predictive power, discrimination, and clinical utility to accurately predict infarct core in AIS patients.
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Affiliation(s)
- Yan Gu
- Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou 215000, China; (Y.G.); (D.S.); (Y.W.); (D.X.); (A.X.); (D.J.); (K.L.); (W.C.)
| | - Dai Shi
- Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou 215000, China; (Y.G.); (D.S.); (Y.W.); (D.X.); (A.X.); (D.J.); (K.L.); (W.C.)
| | - Hao Shen
- Department of Medical Oncology, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei 230000, China;
| | - Yeqing Wang
- Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou 215000, China; (Y.G.); (D.S.); (Y.W.); (D.X.); (A.X.); (D.J.); (K.L.); (W.C.)
| | - Dandan Xu
- Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou 215000, China; (Y.G.); (D.S.); (Y.W.); (D.X.); (A.X.); (D.J.); (K.L.); (W.C.)
| | - Aoqi Xiao
- Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou 215000, China; (Y.G.); (D.S.); (Y.W.); (D.X.); (A.X.); (D.J.); (K.L.); (W.C.)
| | - Dan Jin
- Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou 215000, China; (Y.G.); (D.S.); (Y.W.); (D.X.); (A.X.); (D.J.); (K.L.); (W.C.)
| | - Kuan Lu
- Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou 215000, China; (Y.G.); (D.S.); (Y.W.); (D.X.); (A.X.); (D.J.); (K.L.); (W.C.)
| | - Wu Cai
- Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou 215000, China; (Y.G.); (D.S.); (Y.W.); (D.X.); (A.X.); (D.J.); (K.L.); (W.C.)
| | - Liang Xu
- Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou 215000, China; (Y.G.); (D.S.); (Y.W.); (D.X.); (A.X.); (D.J.); (K.L.); (W.C.)
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Schön F, Wahl H, Grey A, Krukowski P, Müller A, Puetz V, Linn J, Kaiser DPO. Improved Visualization and Quantification of Net Water Uptake in Recent Small Subcortical Infarcts in the Thalamus Using Computed Tomography. Diagnostics (Basel) 2023; 13:3416. [PMID: 37998551 PMCID: PMC10670270 DOI: 10.3390/diagnostics13223416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/01/2023] [Accepted: 11/05/2023] [Indexed: 11/25/2023] Open
Abstract
Diagnosing recent small subcortical infarcts (RSSIs) via early computed tomography (CT) remains challenging. This study aimed to assess CT attenuation values (Hounsfield Units (HU)) and net water uptake (NWU) in RSSI and explore a postprocessing algorithm's potential to enhance thalamic RSSI detection. We examined non-contrast CT (NCCT) data from patients with confirmed thalamic RSSI on diffusion-weighted magnetic resonance imaging (DW-MRI) between January 2010 and October 2017. Co-registered DW-MRI and NCCT images enabled HU and NWU quantification in the infarct area compared to unaffected contralateral tissue. Results were categorized based on symptom onset to NCCT timing. Postprocessing using window optimization and frequency-selective non-linear blending (FSNLB) was applied, with interpretations by three blinded Neuroradiologists. The study included 34 patients (median age 70 years [IQR 63-76], 14 women). RSSI exhibited significantly reduced mean CT attenuation compared to unaffected thalamus (29.6 HU (±3.1) vs. 33.3 HU (±2.6); p < 0.01). Mean NWU in the infarct area increased from 6.4% (±7.2) at 0-6 h to 16.6% (±8.7) at 24-36 h post-symptom onset. Postprocessed NCCT using these HU values improved sensitivity for RSSI detection from 32% in unprocessed CT to 41% in FSNLB-optimized CT, with specificities ranging from 86% to 95%. In conclusion, CT attenuation values and NWU are discernible in thalamic RSSI up to 36 h post-symptom onset. Postprocessing techniques, particularly window optimization and FSNLB, moderately enhance RSSI detection.
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Affiliation(s)
- Felix Schön
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Institute and Polyclinic for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Hannes Wahl
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Arne Grey
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Pawel Krukowski
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Angela Müller
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Volker Puetz
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Department of Neurology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Jennifer Linn
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Daniel P. O. Kaiser
- Institute and Polyclinic for Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Dresdner Neurovaskuläres Centrum, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
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Chen P, Pan Y, Wang J, Hui J, Gao R, Lin G, Li B, Rao J, Xia S, Ji J. The value of computed tomography perfusion deficit volumes in acute isolated brainstem infarction. Front Neurol 2023; 14:1233784. [PMID: 37928165 PMCID: PMC10620965 DOI: 10.3389/fneur.2023.1233784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/28/2023] [Indexed: 11/07/2023] Open
Abstract
Purpose Diagnosis of acute isolated brainstem infarction is challenging owing to non-specific, variable symptoms, and the effectiveness of non-contrast computed tomography (NCCT) is poor owing to limited spatial resolution and artifacts. Computed tomography perfusion (CTP) imaging parameters are significantly associated with functional outcomes in posterior circulation acute ischemic stroke; however, the role of CTP in isolated brainstem infarction remains unclear. We aimed to determine the value of CTP imaging parameters in predicting functional outcomes for affected patients. Methods In total, 116 consecutive patients with isolated pontine/midbrain hypoperfusion who underwent CTP and follow-up by magnetic resonance imaging (MRI) between January 2018 and March 2022, were retrospectively analyzed. Perfusion deficit volumes on all maps, and the final infarction volume (FIV) on MRI were quantified. "Good" functional outcome was defined as a 90-day modified Rankin Scale score of 0 and 1. Statistical analysis included uni- and multivariate regression analyses, binary logistic regressions, and receiver operating characteristics (ROC) analyses. Results In total, 113 patients had confirmed isolated pontine/midbrain infarction on follow-up MRI. Onset-to-scan time, visibility of ischemic lesions on NCCT, the baseline National Institutes of Health Stroke Scale (NIHSS) score, and perfusion deficit volumes on all CTP maps were significantly associated with FIV (p < 0.05). In a multivariate linear regression model, adjusted for age, sex, NIHSS score, onset-to-scan time, and visibility of NCCT, perfusion deficit volumes remained significantly associated with FIV. In binary logistic regression analyses, perfusion deficit volumes on all CTP maps remained independent predictors of a good functional outcome. In ROC analyses, the cerebral blood flow deficit volume showed a slightly higher discriminatory value with the largest area under the curve being 0.683 [(95% CI, 0.587-0.780), p = 0.001]. Conclusion Perfusion deficit volumes of CTP imaging could reflect the FIV and contain prognostic information on functional outcomes in patients with acute isolated brainstem infarction.
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Affiliation(s)
- Pengjun Chen
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, China
| | - Yiying Pan
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, China
| | - Jingke Wang
- Institution of Laboratory, Lishui People’s Hospital, The Sixth Affiliated Hospital of Wenzhou Medical University, Lishui, China
| | - Junguo Hui
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, China
| | - Ruijie Gao
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, China
| | - Guihan Lin
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, China
| | - Bingrong Li
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, China
| | - Jie Rao
- Department of Neurology, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, China
| | - Shuiwei Xia
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, China
| | - Jiansong Ji
- Zhejiang Provincial Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Hospital of Zhejiang University, Lishui, China
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Zedde M, Napoli M, Grisendi I, Assenza F, Moratti C, Valzania F, Pascarella R. Perfusion Status in Lacunar Stroke: A Pathophysiological Issue. Diagnostics (Basel) 2023; 13:2003. [PMID: 37370898 DOI: 10.3390/diagnostics13122003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
The pathophysiology of lacunar infarction is an evolving and debated field, where relevant information comes from histopathology, old anatomical studies and animal models. Only in the last years, have neuroimaging techniques allowed a sufficient resolution to directly or indirectly assess the dynamic evolution of small vessel occlusion and to formulate hypotheses about the tissue status and the mechanisms of damage. The core-penumbra concept was extensively explored in large vessel occlusions (LVOs) both from the experimental and clinical point of view. Then, the perfusion thresholds on one side and the neuroimaging techniques studying the perfusion of brain tissue were focused and optimized for LVOs. The presence of a perfusion deficit in the territory of a single small perforating artery was negated for years until the recent proposal of the existence of a perfusion defect in a subgroup of lacunar infarcts by using magnetic resonance imaging (MRI). This last finding opens pathophysiological hypotheses and triggers a neurovascular multidisciplinary reasoning about how to image this perfusion deficit in the acute phase in particular. The aim of this review is to summarize the pathophysiological issues and the application of the core-penumbra hypothesis to lacunar stroke.
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Affiliation(s)
- Marialuisa Zedde
- Neurology Unit, Stroke Unit, AUSL-IRCCS di Reggio Emilia, Via Amendola 2, 42122 Reggio Emilia, Italy
| | - Manuela Napoli
- Neuroradiology Unit, AUSL-IRCCS di Reggio Emilia, Via Amendola 2, 42122 Reggio Emilia, Italy
| | - Ilaria Grisendi
- Neurology Unit, Stroke Unit, AUSL-IRCCS di Reggio Emilia, Via Amendola 2, 42122 Reggio Emilia, Italy
| | - Federica Assenza
- Neurology Unit, Stroke Unit, AUSL-IRCCS di Reggio Emilia, Via Amendola 2, 42122 Reggio Emilia, Italy
| | - Claudio Moratti
- Neuroradiology Unit, AUSL-IRCCS di Reggio Emilia, Via Amendola 2, 42122 Reggio Emilia, Italy
| | - Franco Valzania
- Neurology Unit, Stroke Unit, AUSL-IRCCS di Reggio Emilia, Via Amendola 2, 42122 Reggio Emilia, Italy
| | - Rosario Pascarella
- Neuroradiology Unit, AUSL-IRCCS di Reggio Emilia, Via Amendola 2, 42122 Reggio Emilia, Italy
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Zedde M, Napoli M, Grisendi I, Assenza F, Moratti C, Valzania F, Pascarella R. CT Perfusion in Lacunar Stroke: A Systematic Review. Diagnostics (Basel) 2023; 13:diagnostics13091564. [PMID: 37174955 PMCID: PMC10177869 DOI: 10.3390/diagnostics13091564] [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: 03/18/2023] [Revised: 04/07/2023] [Accepted: 04/25/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND The main theory underlying the use of perfusion imaging in acute ischemic stroke is the presence of a hypoperfused volume of the brain downstream of an occluded artery. Indeed, the main purpose of perfusion imaging is to select patients for endovascular treatment. Computed Tomography Perfusion (CTP) is the more used technique because of its wide availability but lacunar infarcts are theoretically outside the purpose of CTP, and limited data are available about CTP performance in acute stroke patients with lacunar stroke. METHODS We performed a systematic review searching in PubMed and EMBASE for CTP and lacunar stroke with a final selection of 14 papers, which were examined for data extraction and, in particular, CTP technical issues and sensitivity, specificity, PPV, and NPV values. RESULTS A global cohort of 583 patients with lacunar stroke was identified, with a mean age ranging from 59.8 to 72 years and a female percentage ranging from 32 to 53.1%.CTP was performed with different technologies (16 to 320 rows), different post-processing software, and different maps. Sensitivity ranges from 0 to 62.5%, and specificity from 20 to 100%. CONCLUSIONS CTP does not allow to reasonable exclude lacunar infarct if no perfusion deficit is found, but the pathophysiology of lacunar infarct is more complex than previously thought.
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Affiliation(s)
- Marialuisa Zedde
- Neurology Unit, Stroke Unit, AUSL-IRCCS di Reggio Emilia, via Amendola 2, 42122 Reggio Emilia, Italy
| | - Manuela Napoli
- Neuroradiology Unit, AUSL-IRCCS di Reggio Emilia, via Amendola 2, 42122 Reggio Emilia, Italy
| | - Ilaria Grisendi
- Neurology Unit, Stroke Unit, AUSL-IRCCS di Reggio Emilia, via Amendola 2, 42122 Reggio Emilia, Italy
| | - Federica Assenza
- Neurology Unit, Stroke Unit, AUSL-IRCCS di Reggio Emilia, via Amendola 2, 42122 Reggio Emilia, Italy
| | - Claudio Moratti
- Neuroradiology Unit, AUSL-IRCCS di Reggio Emilia, via Amendola 2, 42122 Reggio Emilia, Italy
| | - Franco Valzania
- Neurology Unit, Stroke Unit, AUSL-IRCCS di Reggio Emilia, via Amendola 2, 42122 Reggio Emilia, Italy
| | - Rosario Pascarella
- Neuroradiology Unit, AUSL-IRCCS di Reggio Emilia, via Amendola 2, 42122 Reggio Emilia, Italy
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9
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Bouslama M, Ravindran K, Rodrigues GM, Pisani L, Haussen DC, Frankel MR, Nogueira RG. Falsely normal CT perfusion ischemic core readings are common and often associated with deep infarcts. J Neurointerv Surg 2023; 15:183-187. [PMID: 35273106 DOI: 10.1136/neurintsurg-2021-018490] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 02/08/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Proper identification of infarct extent is crucial for thrombectomy and prognostication. We sought to study the frequency and topographic aspects of those cases in which CT perfusion (CTP) misses a core lesion that is present on initial non-contrast CT (NCCT). METHODS A review was carried out of a prospectively collected database of endovascular patients with anterior circulation large vessel occlusion strokes from January 2014 to November 2018. Patients with an e-ASPECTS <10 and adequate CTP maps were included. Total missed ischemic core (TMC) was defined as a CTP core lesion (relative cerebral blood flow <30%) <1 mL with a visualized hypodensity on NCCT. RESULTS In total, 629 patients were analyzed of which 161 (25.6%) had a TMC. On univariate analysis, TMC was associated with isolated deep middle cerebral artery (MCA) strokes (77.6% vs 56.6%, p<0.001), lower National Institutes of Health Stroke Scale (NIHSS) score (9 (15-20) vs 17 (13-21), p=0.007) and longer times to treatment (452 (288-652) min vs 355 (236-655) min, p=0.03). After adjusting for identifiable confounders, isolated deep MCA stroke was an independent predictor of TMC (OR 2.49 (95% CI 1.63 to 3.8), p<0.001). There were no differences between patients presenting with a TMC and those not with good outcomes (modified Rankin Scale 0-2) (50.8% vs 47.6%, p=0.53) or 90-day mortality (23% vs 17.6%, p=0.17). However, TMC was associated with lower rates of any parenchymal hematomas (5.2% vs 14.6%, p=0.02; aOR 0.11 (95% CI 0.01 to 0.91), p=0.04) and smaller final infarct volumes (20.5 (11.3-42.9) mL vs 47.5 (20.3-85) mL, p<0.001). CONCLUSIONS CTP may completely fail to detect ischemic core in as many as 25% of cases, especially in isolated deep MCA strokes. Technical refinements of the post-processing algorithms are therefore warranted. TMC infarcts may have a lower risk of reperfusion hemorrhage, potentially due to greater preservation of the neurovascular unit structure in face of delayed recovery of cerebral blood flow.
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Affiliation(s)
| | | | - Gabriel Martins Rodrigues
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA.,Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Diogo C Haussen
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA.,Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael R Frankel
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA.,Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Raul G Nogueira
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA .,Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
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10
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Ge Y, Dong W, Lu H, Zhang X, Huang S, Yang Y, Ni J. Association of concomitant headache with hypoperfusion in ischemic stroke: A multimodal CT-based study. Clin Transl Sci 2022; 15:2868-2877. [PMID: 36106588 PMCID: PMC9747117 DOI: 10.1111/cts.13405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 07/04/2022] [Accepted: 08/05/2022] [Indexed: 01/26/2023] Open
Abstract
Previous investigations indicate that vessel wall elasticity may contribute to the occurrence of an ischemic stroke-associated headache. In this prospective study, the association between radiologic parameters of intracranial hemodynamic changes and concomitant headaches during the early phase of ischemic stroke was examined. Consecutive patients with acute ischemic stroke (AIS) from the First Affiliated Hospital of Soochow University were recruited and divided into two groups according to their questionnaire results and the International Classification of Headache Disorder 3 criteria. Baseline data, including stroke sub-types and neurological function, at admission and discharge were collected. Non-contrast computed tomography (CT), CT angiography, and CT perfusion were performed to assess intracranial hemodynamic changes. Multiple adjusted logistic models were used and possible confounding factors were included in sequential models. A total of 190 patients with AIS (93 headaches and 97 non-headache) were recruited. There were significant differences between the two groups in gender, hypertension, Alberta stroke program early CT score, relative cerebral blood flow (rCBF), and relative cerebral blood volume (rCBV). Furthermore, rCBV (adjusted odds ratio [OR] 0.160; 95% confidence interval [CI], 0.055-0.461; p < 0.001) and rCBF (adjusted OR, 0.309; 95% CI, 0.113-0.844; p < 0.05) were significantly associated with concomitant headache during the early phase of AIS in fully adjusted models. After adjusting for sociodemographic characteristics and other confounding factors, p values for the ORs were robust and intensified. Patients with lower rCBV and rCBF tended to experience the concomitant headache during the early phase of AIS. Regional hypoperfusion and microcirculation might play an important role in this separate clinical entity.
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Affiliation(s)
- Yi Ge
- Department of NeurologyThe First Affiliated Hospital of Soochow UniversitySuzhouJiangsuChina
| | - Wanli Dong
- Department of NeurologyThe First Affiliated Hospital of Soochow UniversitySuzhouJiangsuChina
| | - Haifeng Lu
- Department of NeurologyThe First Affiliated Hospital of Soochow UniversitySuzhouJiangsuChina
| | - Ximeng Zhang
- Department of NeurologyThe First Affiliated Hospital of Soochow UniversitySuzhouJiangsuChina
| | - Shicun Huang
- Department of NeurologyThe First Affiliated Hospital of Soochow UniversitySuzhouJiangsuChina
| | - Yi Yang
- Department of NeurologyThe First Affiliated Hospital of Soochow UniversitySuzhouJiangsuChina
| | - Jianqiang Ni
- Department of NeurologyThe First Affiliated Hospital of Soochow UniversitySuzhouJiangsuChina
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11
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Liu F, Yang X, Hou C, Li Z, Li G, Zuo L. Diagnostic value of whole-brain computed tomographic perfusion imaging for suspected large artery occlusion stroke patients in emergency department. Acta Neurol Belg 2022; 122:1219-1227. [PMID: 35023071 DOI: 10.1007/s13760-021-01859-z] [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: 07/11/2021] [Accepted: 12/27/2021] [Indexed: 12/30/2022]
Abstract
PURPOSE To evaluate the diagnostic value of whole-brain computed tomographic perfusion (WB-CTP) in emergency department for suspected large artery occlusion stroke. METHODS Suspected large artery occlusion (LAO) stroke patients had initial WB-CTP in the neurological emergency department from August 2016 to August 2018 were retrospectively reviewed for analysis. The sensitivity and specificity of non-contrast computed tomographic scan (NCCT) or WB-CTP for diagnosis of cerebral infarction was compared between the anterior circulation and posterior circulation. The imaging characteristics of WB-CTP in patients with stroke-mimics were described. RESULTS Among the 300 included patients, 259 patients (86.3%) were finally diagnosed as cerebral infarction, 16 (5.3%) were transient ischemic attack, 10 (3.3%) were epileptic seizure and 3 (1%) were cerebral venous sinus thrombosis (CVST). For patients with final diagnosis of cerebral infarction, WB-CTP found abnormality in 206 cases (79.5%). NCCT had poor sensitivity (4.6%) but high specificity (100%) for cerebral infarction. The CTP imaging had a sensitivity of 81.2% in anterior circulation and 59.6% in posterior circulation stroke, both with good specificity (57.1% and 92.6%, respectively). 60% (6/10) of epileptic patients showed abnormal perfusion in CTP maps, which was inconsistent with cerebral arterial supply territories. Hypoperfusion manifestations were discovered in areas adjacent to occlusion sinus of all 3 CVST cases. CONCLUSION This retrospective study indicates WB-CTP can be useful in identifying acute ischemic stroke in emergency department, especially for patients with acute LAO stroke. Moreover, WB-CTP may have a value in differentiating stroke mimics such as epilepsy and CVST.
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Affiliation(s)
- Feifeng Liu
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xinyi Yang
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Changlong Hou
- Department of Radiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Zhiyu Li
- Department of Radiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Gang Li
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Lian Zuo
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China.
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12
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Arora K, Gaekwad A, Evans J, O'Brien W, Ang T, Garcia-Esperon C, Blair C, Edwards LS, Chew BLA, Delcourt C, Spratt NJ, Parsons MW, Butcher KS. Diagnostic Utility of Computed Tomography Perfusion in the Telestroke Setting. Stroke 2022; 53:2917-2925. [PMID: 35652343 DOI: 10.1161/strokeaha.122.038798] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Definitive diagnosis of acute ischemic stroke is challenging, particularly in telestroke settings. Although the prognostic utility of CT perfusion (CTP) has been questioned, its diagnostic value remains under-appreciated, especially in cases without an easily visible intracranial occlusion. We assessed the diagnostic accuracy of routine CTP in the acute telestroke setting. METHODS Acute and follow-up data collected prospectively from consecutive suspected patients with stroke assessed by a state-wide telestroke service between March 2020 and August 2021 at 12 sites in Australia were analyzed. All patients in the final analysis had been assessed with multimodal CT, including CTP, which was post-processed with automated volumetric software. Diagnostic sensitivity and specificity were calculated for multimodal CT and each individual component (noncontrast CT [NCCT], CT angiogram [CTA], and CTP). Final diagnosis determined by consensus review of follow-up imaging and clinical data was used as the reference standard. RESULTS During the study period, complete multimodal CT examination was obtained in 831 patients, 457 of whom were diagnosed with stroke. Diagnostic sensitivity for ischemic stroke increased by 19.5 percentage points when CTP was included with NCCT and CTA compared with NCCT and CTA alone (73.1% positive with NCCT+CTA+CTP [95% CI, 68.8-77.1] versus 53.6% positive with NCCT+CTA alone [95% CI, 48.9-58.3], P<0.001). No difference was observed between specificities of NCCT+CTA and NCCT+CTA+CTP (98.7% [95% CI, 98.5-100] versus 98.7% [95% CI, 96.9-99.6], P=0.13). Multimodal CT, including CTP, demonstrated the highest negative predictive value (75.0% [95% CI, 72.1-77.7]). Patients with stroke not evident on CTP had small volume infarcts on follow-up (1.2 mL, interquartile range 0.5-2.7mL). CONCLUSIONS Acquisition of CTP as part of a telestroke imaging protocol permits definitive diagnosis of cerebral ischemia in 1 in 5 patients with normal NCCT and CTA.
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Affiliation(s)
- Kshitij Arora
- Prince of Wales Clinical School, University of New South Wales, Clinical Neurosciences, Randwick, Australia (K.A., A.G., K.S.B.)
| | - Aaron Gaekwad
- Prince of Wales Clinical School, University of New South Wales, Clinical Neurosciences, Randwick, Australia (K.A., A.G., K.S.B.)
| | - James Evans
- Gosford Hospital, Department of Neurosciences, Australia (J.E., W.O.B., L.S.E.)
| | - William O'Brien
- Gosford Hospital, Department of Neurosciences, Australia (J.E., W.O.B., L.S.E.)
| | - Timothy Ang
- Departments of Neurology and Radiology, Royal Prince Alfred Hospital, Camperdown, Australia (T.A.)
| | - Carlos Garcia-Esperon
- John Hunter Hospital, Department of Neurology, and Hunter Medical Research Institute, New Lambton Heights, Australia (C.G.-E., B.L.A.C., N.J.S.).,The University of Newcastle, School of Biomedical Sciences and Pharmacy, Callaghan, Australia (C.G.-E., B.L.A.C., N.J.S.)
| | - Christopher Blair
- Sydney Brain Centre, Ingham Institute for Applied Medical Research, Liverpool, Australia (C.B., L.S.E.)
| | - Leon S Edwards
- Gosford Hospital, Department of Neurosciences, Australia (J.E., W.O.B., L.S.E.).,Sydney Brain Centre, Ingham Institute for Applied Medical Research, Liverpool, Australia (C.B., L.S.E.).,South Western Sydney Clinical School, University of New South Wales, Department of Neurology and Neurophysiology, Liverpool, Australia (L.S.E., M.W.P.)
| | - Beng L A Chew
- John Hunter Hospital, Department of Neurology, and Hunter Medical Research Institute, New Lambton Heights, Australia (C.G.-E., B.L.A.C., N.J.S.).,The University of Newcastle, School of Biomedical Sciences and Pharmacy, Callaghan, Australia (C.G.-E., B.L.A.C., N.J.S.)
| | - Candice Delcourt
- The George Institute for Global Health, University of New South Wales, Neurological and Mental Health Division, Newtown, Australia (C.D.).,Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia (C.D.)
| | - Neil J Spratt
- John Hunter Hospital, Department of Neurology, and Hunter Medical Research Institute, New Lambton Heights, Australia (C.G.-E., B.L.A.C., N.J.S.).,The University of Newcastle, School of Biomedical Sciences and Pharmacy, Callaghan, Australia (C.G.-E., B.L.A.C., N.J.S.)
| | - Mark W Parsons
- South Western Sydney Clinical School, University of New South Wales, Department of Neurology and Neurophysiology, Liverpool, Australia (L.S.E., M.W.P.)
| | - Ken S Butcher
- Prince of Wales Clinical School, University of New South Wales, Clinical Neurosciences, Randwick, Australia (K.A., A.G., K.S.B.)
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13
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Saba L, Chen H, Cau R, Rubeis G, Zhu G, Pisu F, Jang B, Lanzino G, Suri J, Qi Y, Wintermark M. Impact Analysis of Different CT Configurations of Carotid Artery Plaque Calcifications on Cerebrovascular Events. AJNR Am J Neuroradiol 2022; 43:272-279. [PMID: 35121588 PMCID: PMC8985662 DOI: 10.3174/ajnr.a7401] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 11/15/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE CT is considered the standard reference both for quantification and characterization of carotid artery calcifications. Our aim was to investigate the relationship among different types of calcium configurations detected with CT within the plaque with a novel classification and to investigate the prevalence of cerebrovascular events. MATERIALS AND METHODS Seven hundred ninety patients (men = 332; mean age, 69.7 [SD, 13] years; 508 symptomatic for cerebrovascular symptoms and 282 asymptomatic) who underwent computed tomography of the carotid arteries were retrospectively included in this institutional review board-approved study. The plaque was classified into 6 types according to the different types of calcium configurations as the following: type 1, complete absence of calcification within the plaque; type 2, intimal or superficial calcifications; type 3, deep or bulky calcifications; type 4, adventitial calcifications with internal soft plaque of <2 mm thickness; type 5, mixed patterns with intimal and bulky calcifications; and type 6, positive rim sign. RESULTS The highest prevalence of cerebrovascular events was observed for type 6, for which 89 of the 99 cases were symptomatic. Type 6 plaque had the highest degree of correlation with TIA, stroke, symptoms, and ipsilateral infarct for both sides with a higher prevalence in younger patients. The frequency of symptoms observed by configuration type significantly differed between right and left plaques, with symptoms observed more frequently in type 6 calcification on the right side (50/53; 94%) than on the left side (39/46; 85%, P < .001). CONCLUSIONS We propose a novel carotid artery plaque configuration classification that is associated with the prevalence of cerebrovascular events. If confirmed in longitudinal analysis, this classification could be used to stratify the risk of occurrence of ischemic events.
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Affiliation(s)
- L. Saba
- From the Department of Radiology (L.S., R.C., F.P.), Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy
| | - H. Chen
- Department of Radiology (H.C., G.Z., B.J., M.W.), Division of Neuroradiology, Stanford University Hospital, Stanford, California
| | - R. Cau
- From the Department of Radiology (L.S., R.C., F.P.), Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy
| | - G.D. Rubeis
- Department of Radiology, UOC of Diagnostic and Interventional Neuroradiology (G.D.R.), San Camillo-Forlanini Hospital, Rome, Italy
| | - G. Zhu
- Department of Radiology (H.C., G.Z., B.J., M.W.), Division of Neuroradiology, Stanford University Hospital, Stanford, California
| | - F. Pisu
- From the Department of Radiology (L.S., R.C., F.P.), Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy
| | - B. Jang
- Department of Radiology (H.C., G.Z., B.J., M.W.), Division of Neuroradiology, Stanford University Hospital, Stanford, California
| | - G. Lanzino
- Department of Neurologic Surgery (G.L.), Mayo Clinic, Rochester, Minnesota
| | - J.S. Suri
- Stroke Monitoring and Diagnostic Division (J.S.S.), AtheroPoint, Roseville, California
| | - Y. Qi
- Department of Xuanwu Hospital (Y.Q.), Capital Medical University, Beijing, Chin
| | - M. Wintermark
- Department of Radiology (H.C., G.Z., B.J., M.W.), Division of Neuroradiology, Stanford University Hospital, Stanford, California
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14
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Fu LJ, Zhao BB, Yang TH, Yu CS. Application Value of CT Perfusion Imaging in Patients with Posterior Circulation Hyperacute Cerebral Infarction. JOURNAL OF MEDICAL IMAGING AND HEALTH INFORMATICS 2022. [DOI: 10.1166/jmihi.2022.3707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objectives: This study aims to evaluate the application value of computed tomography perfusion (CTP) imaging in patients with posterior circulation cerebral infarction in the hyperacute phase. Methods: The changes in CTP parameters, such as time to peak (TTP), mean transfer
time (MTT), cerebral blood flow (CBF) and the cerebral blood volume (CBV) of ischemic region, as well as the ischemic penumbra, infarction core at the affected side and normal brain tissue at the uninjured side, of 168 patients with suspected posterior circulation acute ischemic stroke were
analyzed. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of each parameter map of CTP in displaying the cerebral infarction size in each part of the posterior circulation were evaluated. Results: The CTP results revealed that CBF and
CBV in the infarction area significantly decreased, and MTT and TTP in the blood supply area of cerebellum, thalamus and posterior cerebral artery (PCA) were significantly delayed. These were statistically different from those in the surrounding penumbra and normal brain tissue (P <
0.05). Furthermore, the CBF of the penumbra in each part slightly decreased, and the delay of MTT and TTP was statistically different from that in normal brains (P < 0.05). The CBV of the penumbra in the pons, midbrain and thalamus decreased, which was statistically different from
that in normal brain tissue and simple cerebral ischemia tissue (P < 0.05). The changes in CBF and MTT of the simple cerebral ischemia in each part, and TTP, except for the cerebellum, were statistically different from those of cerebral infarction and normal brain tissue (P
< 0.05). The total sensitivity, specificity and accuracy for the posterior circulation cerebral infarction was 77.2%, 98.6% and 94.9%, respectively, according to the CTP evaluation. Conclusion: The CTP parameter map can reflect the difference between an ischemic penumbra and an infraction
core in the posterior circulation. It has high sensitivity, specificity and accuracy in the CTP evaluation of posterior circulation cerebral infarctions.
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Affiliation(s)
- Le-Jun Fu
- Department of Radiology and Tianjin Key Laboratory of Functional Imaging, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Bi-Bo Zhao
- Department of Radiology, Tianjin Huanhu Hospital, Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin 300350, China
| | - Tian-Hao Yang
- Department of Radiology, Tianjin Huanhu Hospital, Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin 300350, China
| | - Chun-Shui Yu
- Department of Radiology and Tianjin Key Laboratory of Functional Imaging, Tianjin Medical University General Hospital, Tianjin 300052, China
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15
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Rudilosso S, Rodríguez-Vázquez A, Urra X, Arboix A. The Potential Impact of Neuroimaging and Translational Research on the Clinical Management of Lacunar Stroke. Int J Mol Sci 2022; 23:1497. [PMID: 35163423 PMCID: PMC8835925 DOI: 10.3390/ijms23031497] [Citation(s) in RCA: 70] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 12/21/2022] Open
Abstract
Lacunar infarcts represent one of the most frequent subtypes of ischemic strokes and may represent the first recognizable manifestation of a progressive disease of the small perforating arteries, capillaries, and venules of the brain, defined as cerebral small vessel disease. The pathophysiological mechanisms leading to a perforating artery occlusion are multiple and still not completely defined, due to spatial resolution issues in neuroimaging, sparsity of pathological studies, and lack of valid experimental models. Recent advances in the endovascular treatment of large vessel occlusion may have diverted attention from the management of patients with small vessel occlusions, often excluded from clinical trials of acute therapy and secondary prevention. However, patients with a lacunar stroke benefit from early diagnosis, reperfusion therapy, and secondary prevention measures. In addition, there are new developments in the knowledge of this entity that suggest potential benefits of thrombolysis in an extended time window in selected patients, as well as novel therapeutic approaches targeting different pathophysiological mechanisms involved in small vessel disease. This review offers a comprehensive update in lacunar stroke pathophysiology and clinical perspective for managing lacunar strokes, in light of the latest insights from imaging and translational studies.
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Affiliation(s)
- Salvatore Rudilosso
- Comprehensive Stroke Center, Hospital Clínic of Barcelona, 08036 Barcelona, Spain; (S.R.); (A.R.-V.); (X.U.)
| | - Alejandro Rodríguez-Vázquez
- Comprehensive Stroke Center, Hospital Clínic of Barcelona, 08036 Barcelona, Spain; (S.R.); (A.R.-V.); (X.U.)
| | - Xabier Urra
- Comprehensive Stroke Center, Hospital Clínic of Barcelona, 08036 Barcelona, Spain; (S.R.); (A.R.-V.); (X.U.)
| | - Adrià Arboix
- Cerebrovascular Division, Department of Neurology, Hospital Universitari del Sagrat Cor, Universitat de Barcelona, 08034 Barcelona, Spain
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16
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Nagaraja N, Farooqui A, Albayram M, Reddy VN. Neurological deterioration and computed tomography perfusion changes with increased time to peak in lacunar stroke. Brain Circ 2022; 8:17-23. [PMID: 35372724 PMCID: PMC8973445 DOI: 10.4103/bc.bc_68_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 01/12/2022] [Accepted: 01/27/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES: Lacunar strokes can have fluctuations and progression in the acute period leading to poor outcomes. Our study sought to evaluate if, in lacunar strokes, neurological deterioration (ND) was associated with blood pressure (BP) variations, stroke size, or increased time to peak (TTP) on admission computed tomography perfusion (CTP). METHODS: Patients with lacunar stroke who had magnetic resonance imaging and CTP performed were enrolled in the study. ND was defined as ≥1-point worsening on a modified National Institutes of Health Stroke Scale (NIHSS) score or the Medical Research Council scale compared to baseline assessment. The difference in BP between the day of admission and the day of ND was calculated. Multivariate logistic regression analysis, adjusted for pertinent clinical and imaging covariates, was performed to determine predictors of ND. RESULTS: Among 409 patients screened, 49 were eligible for the study. There was no difference in age, gender, race, medical history, admission BP, and the modified NIHSS score between patients with and without ND. In unadjusted analysis, patients with ND tended to have increased TTP in the stroke area compared to the control (12 [63%] vs. 11 [37%], P = 0.07). On multivariate analysis adjusted for covariates, presence of an increased TTP on CTP was a predictor of ND (odds ratio [95% confidence interval] = 4.80 [1.15–20.10], P = 0.03). CONCLUSION: The presence of an increased TTP on CTP corresponding to the stroke lesion on diffusion-weighted imaging is a predictor of ND in patients with lacunar stroke. Larger studies are needed to confirm our findings.
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17
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Detection of impending perfusion deficits by intraoperative computed tomography (iCT) in aneurysm surgery of the anterior circulation. Acta Neurochir (Wien) 2021; 163:3501-3514. [PMID: 34643806 PMCID: PMC8599411 DOI: 10.1007/s00701-021-05022-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/02/2021] [Indexed: 11/22/2022]
Abstract
Background The aim of our study was to evaluate the additional benefit of intraoperative computed tomography (iCT), intraoperative computed tomography angiography (iCTA), and intraoperative computed tomography perfusion (iCTP) in the intraoperative detection of impending ischemia to established methods (indocyanine green videoangiography (ICGVA), microDoppler, intraoperative neuromonitoring (IONM)) for initiating timely therapeutic measures. Methods Patients with primary aneurysms of the anterior circulation between October 2016 and December 2019 were included. Data of iCT modalities compared to other techniques (ICGVA, microDoppler, IONM) was recorded with emphasis on resulting operative conclusions leading to inspection of clip position, repositioning, or immediate initiation of conservative treatment strategies. Additional variables analyzed included patient demographics, aneurysm-specific characteristics, and clinical outcome. Results Of 194 consecutive patients, 93 patients with 100 aneurysms received iCT imaging. While IONM and ICGVA were normal, an altered vessel patency in iCTA was detected in 5 (5.4%) and a mismatch in iCTP in 7 patients (7.5%). Repositioning was considered appropriate in 2 patients (2.2%), where immediate improvement in iCTP could be documented. In a further 5 cases (5.4%), intensified conservative therapy was immediately initiated treating the reduced CBP as clip repositioning was not considered causal. In terms of clinical outcome at last FU, mRS0 was achieved in 85 (91.4%) and mRS1-2 in 7 (7.5%) and remained mRS4 in one patient with SAH (1.1%). Conclusions Especially iCTP can reveal signs of impending ischemia in selected cases and enable the surgeon to promptly initiate therapeutic measures such as clip repositioning or intraoperative onset of maximum conservative treatment, while established tools might fail to detect those intraoperative pathologic changes.
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18
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Hong L, Ling Y, Su Y, Yang L, Lin L, Parsons M, Cheng X, Dong Q. Hemispheric cerebral blood flow predicts outcome in acute small subcortical infarcts. J Cereb Blood Flow Metab 2021; 41:2534-2545. [PMID: 34435912 PMCID: PMC8504947 DOI: 10.1177/0271678x211029884] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The association between baseline perfusion measures and clinical outcomes in patients with acute small subcortical infarcts (SSIs) has not been studied in detail. Post-processed acute perfusion CT and follow-up diffusion-weighted imaging of 71 patients with SSIs were accurately co-registered. Relative perfusion values were calculated from the perfusion values of the infarct lesion divided by those of the mirrored contralateral area. The association between perfusion measures with clinical outcomes and the interaction with intravenous thrombolysis were studied. Additionally, the perfusion measures for patients having perfusion CT before and after thrombolysis were compared. Higher contralateral hemispheric cerebral blood flow (CBF) was the only independent predictor of an excellent clinical outcome (modified Rankin Scale of 0-1) at 3 months (OR = 1.3, 95% CI 1.1-1.4, P = 0.001) amongst all the perfusion parameters, and had a significant interaction with thrombolysis (P = 0.04). Patients who had perfusion CT after thrombolysis demonstrated a better perfusion profile (relative CBF ≥1) than those who had perfusion CT before thrombolysis (After:45.5%, Before:21.1%, P = 0.03). This study implies that for patients with SSIs, hemispheric CBF is a predictor of clinical outcome and has an influence on the effect of intravenous thrombolysis.
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Affiliation(s)
- Lan Hong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Yifeng Ling
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Ya Su
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Lumeng Yang
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Longting Lin
- Department of Neurology, Liverpool Hospital, University of New South Wales South Western Sydney Clinical School, The Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - Mark Parsons
- Department of Neurology, Liverpool Hospital, University of New South Wales South Western Sydney Clinical School, The Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - Xin Cheng
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Qiang Dong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
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19
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Nicolas-Jilwan M, Wintermark M. Automated Brain Perfusion Imaging in Acute Ischemic Stroke: Interpretation Pearls and Pitfalls. Stroke 2021; 52:3728-3738. [PMID: 34565174 DOI: 10.1161/strokeaha.121.035049] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Recent advancements in computed tomography technology, including improved brain coverage and automated processing of the perfusion data, have reinforced the use of perfusion computed tomography imaging in the routine evaluation of patients with acute ischemic stroke. The DAWN (Diffusion Weighted Imaging or Computerized Tomography Perfusion Assessment With Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention) and DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3) trials have established the benefit of endovascular thrombectomy in patients with acute ischemic stroke with anterior circulation large vessel occlusion up to 24 hours of last seen normal, using perfusion imaging-based patient selection. The compelling data has prompted stroke centers to increasingly introduce automated perfusion computed tomography imaging in the routine evaluation of patients with acute ischemic stroke. We present a comprehensive overview of the acquisition and interpretation of automated perfusion imaging in patients with acute ischemic stroke with a special emphasis on the interpretation pearls, pitfalls, and stroke mimicking conditions.
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Affiliation(s)
- Manal Nicolas-Jilwan
- Division of Neuroradiology, Department of Radiology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia (M.N.-J.)
| | - Max Wintermark
- Division of Neuroimaging and Neurointervention, Department of Radiology, Stanford Healthcare, CA (M.W.)
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20
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Reidler P, Stueckelschweiger L, Puhr-Westerheide D, Feil K, Kellert L, Dimitriadis K, Tiedt S, Herzberg M, Rémi J, Liebig T, Fabritius MP, Kunz WG. Performance of Automated Attenuation Measurements at Identifying Large Vessel Occlusion Stroke on CT Angiography. Clin Neuroradiol 2021; 31:763-772. [PMID: 32939563 PMCID: PMC8463515 DOI: 10.1007/s00062-020-00956-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 08/17/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE Computed tomography angiography (CTA) is routinely used to detect large-vessel occlusion (LVO) in patients with suspected acute ischemic stroke; however, visual analysis is time consuming and prone to error. To evaluate solutions to support imaging triage, we tested performance of automated analysis of CTA source images (CTASI) at identifying patients with LVO. METHODS Stroke patients with LVO were selected from a prospectively acquired cohort. A control group was selected from consecutive patients with clinically suspected stroke without signs of ischemia on CT perfusion (CTP) or infarct on follow-up. Software-based automated segmentation and Hounsfield unit (HU) measurements were performed on CTASI for all regions of the Alberta Stroke Program Early CT score (ASPECTS). We derived different parameters from raw measurements and analyzed their performance to identify patients with LVO using receiver operating characteristic curve analysis. RESULTS The retrospective analysis included 145 patients, 79 patients with LVO stroke and 66 patients without stroke. The parameters hemispheric asymmetry ratio (AR), ratio between highest and lowest regional AR and M2-territory AR produced area under the curve (AUC) values from 0.95-0.97 (all p < 0.001) for detecting presence of LVO in the total population. Resulting sensitivity (sens)/specificity (spec) defined by the Youden index were 0.87/0.97-0.99. Maximum sens/spec defined by the specificity threshold ≥0.70 were 0.91-0.96/0.77-0.83. Performance in a small number of patients with isolated M2 occlusion was lower (AUC: 0.72-0.85). CONCLUSION Automated attenuation measurements on CTASI identify proximal LVO stroke patients with high sensitivity and specificity. This technique can aid in accurate and timely patient selection for thrombectomy, especially in primary stroke centers without CTP capacity.
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Affiliation(s)
- Paul Reidler
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - Lena Stueckelschweiger
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Daniel Puhr-Westerheide
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Katharina Feil
- Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- German Center for Vertigo and Balance Disorders, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Konstantinos Dimitriadis
- Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- Institute for Stroke and Dementia Research, LMU Munich, Feodor-Lynen-Str. 17, 81377, Munich, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, LMU Munich, Feodor-Lynen-Str. 17, 81377, Munich, Germany
| | - Moriz Herzberg
- Department of Neuroradiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Jan Rémi
- Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Thomas Liebig
- Department of Neuroradiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Matthias P Fabritius
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
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21
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Acute Reperfusion Therapies for Acute Ischemic Stroke. J Clin Med 2021; 10:jcm10163677. [PMID: 34441973 PMCID: PMC8396980 DOI: 10.3390/jcm10163677] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/04/2021] [Accepted: 08/13/2021] [Indexed: 02/08/2023] Open
Abstract
The field of acute stroke treatment has made tremendous progress in reducing the overall burden of disability. Understanding the pathophysiology of acute ischemic injury, neuroimaging to quantify the extent of penumbra and infarction, and acute stroke reperfusion therapies have together contributed to these advancements. In this review we highlight advancements in reperfusion therapies for acute ischemic stroke.
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22
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Automated Processing of Head CT Perfusion Imaging for Ischemic Stroke Triage: A Practical Guide to Quality Assurance and Interpretation. AJR Am J Roentgenol 2021; 217:1401-1416. [PMID: 34259036 DOI: 10.2214/ajr.21.26139] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Recent successful trials of thrombectomy launched a shift to imaging-based patient selection for stroke intervention. Many centers have adopted CT perfusion imaging (CTP) as a routine part of stroke workflow, and the demand for emergent CTP interpretation is growing. Fully automated CTP postprocessing software that rapidly generates standardized color-coded CTP summary maps with minimal user input and with easy accessibility of the software output is increasingly being adopted. Such automated postprocessing greatly streamlines clinical workflow and CTP interpretation for radiologists and other frontline physicians. However, the straightforward interface overshadows the computational complexity of the underlying postprocessing workflow, which, if not carefully examined, predisposes the interpreting physician to diagnostic errors. Using case examples, this article aims to familiarize the general radiologist with interpreting automated CTP software data output in the context of contemporary stroke management, providing a discussion of CTP acquisition and postprocessing, a stepwise guide for CTP quality assurance and troubleshooting, and a framework for avoiding clinically significant CTP interpretative pitfalls in commonly encountered clinical scenarios. Interpreting radiologists should apply the outlined approach for quality assurance and develop a comprehensive search pattern for the identified pitfalls, to ensure accurate CTP interpretation and optimize patient selection for reperfusion.
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23
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Wu D, Ren H, Li Q. Self-Supervised Dynamic CT Perfusion Image Denoising With Deep Neural Networks. IEEE TRANSACTIONS ON RADIATION AND PLASMA MEDICAL SCIENCES 2021. [DOI: 10.1109/trpms.2020.2996566] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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24
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Lucas L, Gariel F, Menegon P, Aupy J, Thomas B, Tourdias T, Sibon I, Renou P. Acute Ischemic Stroke or Epileptic Seizure? Yield of CT Perfusion in a "Code Stroke" Situation. AJNR Am J Neuroradiol 2021; 42:49-56. [PMID: 33431502 DOI: 10.3174/ajnr.a6925] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 08/27/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The clinical differentiation between acute ischemic stroke and epileptic seizure may be challenging, and making the correct diagnosis could avoid unnecessary reperfusion therapy. We examined the accuracy of CTP in discriminating epileptic seizures from acute ischemic stroke without identified arterial occlusion. MATERIALS AND METHODS We retrospectively identified consecutive patients in our emergency department who underwent CTP in the 4.5 hours following the development of an acute focal neurologic deficit who were discharged with a final diagnosis of acute ischemic stroke or epileptic seizure. RESULTS Among 95 patients, the final diagnosis was epileptic seizure in 45 and acute ischemic stroke in 50. CTP findings were abnormal in 73% of the patients with epileptic seizure and 40% of those with acute ischemic stroke. Hyperperfusion was observed more frequently in the seizure group (36% versus 2% for acute ischemic stroke) with high specificity (98%) but low sensitivity (35%) for the diagnosis of epileptic seizure. Hypoperfusion was found in 38% of cases in each group and was not confined to a vascular territory in 24% of patients in the seizure group and 2% in the acute ischemic stroke group. The interobserver agreement was good (κ = 0.60) for hypo-, hyper-, and normoperfusion patterns and moderate (κ = 0.41) for the evaluation of vascular systematization. CONCLUSIONS CTP patterns helped to differentiate acute ischemic stroke from epileptic seizure in a "code stroke" situation. Our results indicate that a hyperperfusion pattern, especially if not restricted to a vascular territory, may suggest reconsideration of intravenous thrombolysis therapy.
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Affiliation(s)
- L Lucas
- From the Department of Neurology (L.L., I.S., P.R.), Stroke Unit .,Epileptology, and Clinical Neuroscience (L.L., J.A., B.T., T.T., I.S.), University of Bordeaux, Bordeaux, France
| | - F Gariel
- Departments of Neuroradiology (F.G., B.T., T.T.)
| | | | - J Aupy
- Epileptology, and Clinical Neuroscience (L.L., J.A., B.T., T.T., I.S.), University of Bordeaux, Bordeaux, France.,Institut des Matériaux Jean Rouxel, (J.A.), Union Mutualiste Retraite, Centre national de la recherche scientifique, University of Bordeaux, Bordeaux, France
| | - B Thomas
- Departments of Neuroradiology (F.G., B.T., T.T.).,Epileptology, and Clinical Neuroscience (L.L., J.A., B.T., T.T., I.S.), University of Bordeaux, Bordeaux, France
| | - T Tourdias
- Departments of Neuroradiology (F.G., B.T., T.T.).,Epileptology, and Clinical Neuroscience (L.L., J.A., B.T., T.T., I.S.), University of Bordeaux, Bordeaux, France
| | - I Sibon
- From the Department of Neurology (L.L., I.S., P.R.), Stroke Unit.,Epileptology, and Clinical Neuroscience (L.L., J.A., B.T., T.T., I.S.), University of Bordeaux, Bordeaux, France
| | - P Renou
- From the Department of Neurology (L.L., I.S., P.R.), Stroke Unit
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25
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Garcia-Esperon C, Visser M, Churilov L, Miteff F, Bivard A, Lillicrap T, Levi CR, Spratt NJ, Parsons MW. Role of Computed Tomography Perfusion in Identification of Acute Lacunar Stroke Syndromes. Stroke 2020; 52:339-343. [PMID: 33370180 DOI: 10.1161/strokeaha.120.030455] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Lacunar syndromes correlate with a lacunar stroke on imaging in 50% to 60% of cases. Computed tomography perfusion (CTP) is becoming the preferred imaging modality for acute stroke triage. We aimed to estimate the sensitivity, specificity, and predictive values for noncontrast computed tomography and CTP in lacunar syndromes, and for cortical, subcortical, and posterior fossa regions. METHODS A retrospective analysis of confirmed ischemic stroke patients who underwent acute CTP and follow-up magnetic resonance imaging between 2010 and 2018 was performed. Brain noncontrast computed tomography and CTP were assessed independently by 2 stroke neurologists. Receiver operating characteristic curve analysis was performed to estimate sensitivity, specificity, and area under the curve (AUC) for the detection of strokes in patients with lacunar syndromes using different CTP maps. RESULTS We found 106 clinical lacunar syndromes, but on diffusion-weighted imaging, these consisted of 59 lacunar, 33 cortical, and 14 posterior fossa strokes. The discrimination of ischemia identification was very poor using noncontrast computed tomography in all 3 regions, but good for cortical (AUC, 0.82) and poor for subcortical and posterior regions (AUCs, 0.55 and 0.66) using automated core-penumbra maps. The addition of delay time and mean transient time maps substantially increased subcortical (AUC, 0.80) and slightly posterior stroke detection (AUC, 0.69). CONCLUSIONS Analysis of mean transient time and delay time maps in combination with core-penumbra maps improves detection of subcortical and posterior strokes.
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Affiliation(s)
- Carlos Garcia-Esperon
- Department of Neurology, John Hunter Hospital, University of Newcastle, Australia (C.G.-E., F.M., N.J.S.).,Hunter Medical Research Institute and University of Newcastle, Australia (C.G.-E., F.M., T.L., C.R.L., N.J.S., M.W.P.)
| | - Milanka Visser
- Department of Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (M.V., L.C., A.B., M.W.P.)
| | - Leonid Churilov
- Department of Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (M.V., L.C., A.B., M.W.P.).,Department of Medicine, Austin Health, Melbourne Medical School, Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia (L.C.)
| | - Ferdinand Miteff
- Department of Neurology, John Hunter Hospital, University of Newcastle, Australia (C.G.-E., F.M., N.J.S.).,Hunter Medical Research Institute and University of Newcastle, Australia (C.G.-E., F.M., T.L., C.R.L., N.J.S., M.W.P.)
| | - Andrew Bivard
- Department of Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (M.V., L.C., A.B., M.W.P.)
| | - Thomas Lillicrap
- Hunter Medical Research Institute and University of Newcastle, Australia (C.G.-E., F.M., T.L., C.R.L., N.J.S., M.W.P.)
| | - Christopher R Levi
- Hunter Medical Research Institute and University of Newcastle, Australia (C.G.-E., F.M., T.L., C.R.L., N.J.S., M.W.P.).,Maridulu budyari gumal, The Sydney Partnership for Health Education Research & Enterprise (SPHERE), University of New South Wales, Australia (C.R.L.)
| | - Neil J Spratt
- Department of Neurology, John Hunter Hospital, University of Newcastle, Australia (C.G.-E., F.M., N.J.S.).,Hunter Medical Research Institute and University of Newcastle, Australia (C.G.-E., F.M., T.L., C.R.L., N.J.S., M.W.P.)
| | - Mark W Parsons
- Hunter Medical Research Institute and University of Newcastle, Australia (C.G.-E., F.M., T.L., C.R.L., N.J.S., M.W.P.).,Department of Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (M.V., L.C., A.B., M.W.P.)
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26
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A Case of Ischemic Stroke Incidental to the Postelectroconvulsive Therapy Period. J ECT 2020; 36:144-146. [PMID: 32040020 DOI: 10.1097/yct.0000000000000657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Electroconvulsive therapy (ECT) is a routine treatment for multiple psychiatric disorders including treatment-refractory mood and psychotic disorders. Although ECT is generally a safe and well-tolerated intervention, rare cerebrovascular and cardiovascular complications have been reported. The hemodynamic changes during the ECT seizure are well-recognized, with an initial parasympathetically mediated decrease in heart rate and blood pressure followed by a sympathetically mediated increase in these parameters. Despite intraoperative or postoperative blood pressure fluctuations, the risk of a hypertensive intracerebral bleed during ECT is very low and the risk of ischemic stroke after ECT appears to be even rarer. The authors present a case of a patient who developed an ischemic stroke after ECT treatment. Before stroke, the patient had been undergoing ECT routinely for over 2 years without alarming complications. Ischemic strokes are a rare but serious complication of ECT treatment.
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27
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Arba F, Mair G, Phillips S, Sandercock P, Wardlaw JM. Improving Clinical Detection of Acute Lacunar Stroke: Analysis From the IST-3. Stroke 2020; 51:1411-1418. [PMID: 32268853 PMCID: PMC7185055 DOI: 10.1161/strokeaha.119.028402] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Supplemental Digital Content is available in the text. We aim to identify factors associated with imaging-confirmed lacunar strokes and improve their rapid clinical identification early after symptom onset using data from the IST-3 (Third International Stroke Trial).
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Affiliation(s)
- Francesco Arba
- From the Stroke Unit, AOU Careggi, Florence, Italy (F.A.)
| | - Grant Mair
- Division of Neuroimaging Sciences, Brain Research Imaging Centre, University of Edinburgh, United Kingdom (G.M., J.M.W.).,Brain Research Imaging Centre, SINAPSE Collaboration, United Kingdom (G.M., J.M.W.).,Centre for Clinical Brain Sciences, University of Edinburgh, Western General Hospital, United Kingdom (G.M., P.S., J.M.W.)
| | - Stephen Phillips
- Division of Neurology, Department of Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada (S.P.)
| | - Peter Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Western General Hospital, United Kingdom (G.M., P.S., J.M.W.)
| | - Joanna M Wardlaw
- Division of Neuroimaging Sciences, Brain Research Imaging Centre, University of Edinburgh, United Kingdom (G.M., J.M.W.).,Brain Research Imaging Centre, SINAPSE Collaboration, United Kingdom (G.M., J.M.W.).,Centre for Clinical Brain Sciences, University of Edinburgh, Western General Hospital, United Kingdom (G.M., P.S., J.M.W.)
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Wong ML, Flower EN, Edlow JA. A Primer on Computed Tomography Perfusion Imaging for the Emergency Physician. J Emerg Med 2020; 58:260-268. [PMID: 32156437 DOI: 10.1016/j.jemermed.2019.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 11/20/2019] [Accepted: 12/04/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Brain noncontrast computed tomography (CT), CT angiography, and magnetic resonance imaging have been used clinically for decades, and emergency physicians have a good understanding of their indications, the meaning of their results, and some facility with the interpretation of CT. However, brain CT perfusion (CTP) is relatively new and emergency physicians are less familiar with its basic concepts, indications, and role in managing patients with neurological emergencies. OBJECTIVE We will review the parameters of clinical interest on a CTP report, and how to incorporate them into clinical decision-making. DISCUSSION Endovascular therapies paired with CTP have opened up a new frontier in stroke management for severely debilitated stroke patients. It is important for emergency physicians to have an understanding of CTP and how to use it clinically. CONCLUSION Taking care of patients with large-vessel occlusions is multidisciplinary, and emergency physicians need to understand CTP imaging and its clinical utility.
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Affiliation(s)
- Matthew L Wong
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Elisa N Flower
- Harvard Medical School, Boston, Massachusetts; Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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29
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Demeestere J, Wouters A, Christensen S, Lemmens R, Lansberg MG. Review of Perfusion Imaging in Acute Ischemic Stroke: From Time to Tissue. Stroke 2020; 51:1017-1024. [PMID: 32008460 DOI: 10.1161/strokeaha.119.028337] [Citation(s) in RCA: 116] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jelle Demeestere
- From the Department of Neurosciences, Experimental Neurology, KU Leuven - University of Leuven, Belgium (J.D., A.W., R.L.).,VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium (J.D., A.W., R.L.).,Department of Neurology, University Hospitals Leuven, Belgium (J.D., A.W., R.L.)
| | - Anke Wouters
- From the Department of Neurosciences, Experimental Neurology, KU Leuven - University of Leuven, Belgium (J.D., A.W., R.L.).,VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium (J.D., A.W., R.L.).,Department of Neurology, University Hospitals Leuven, Belgium (J.D., A.W., R.L.)
| | - Soren Christensen
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA (S.C., M.G.L.)
| | - Robin Lemmens
- From the Department of Neurosciences, Experimental Neurology, KU Leuven - University of Leuven, Belgium (J.D., A.W., R.L.).,VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium (J.D., A.W., R.L.).,Department of Neurology, University Hospitals Leuven, Belgium (J.D., A.W., R.L.)
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA (S.C., M.G.L.)
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30
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Griffin AS, Mariano R, Hauck SK, Hauck EF. Inferolateral thalamic ischemia secondary to PCA P2 perforator occlusion mimics MCA stroke syndrome. Neurosurg Rev 2019; 43:339-342. [PMID: 31709467 DOI: 10.1007/s10143-019-01211-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/11/2019] [Accepted: 11/04/2019] [Indexed: 11/24/2022]
Abstract
Paramedian thalamic strokes following occlusion of the posterior medial (paramedian) thalamic perforators have been previously described in great detail. However, the stroke syndrome associated with occlusion of posterior lateral (inferolateral) thalamic perforators is less commonly known. We present an illustrative case of an inferolateral thalamic perforator stroke mimicking a middle cerebral artery (MCA) syndrome and provide a review of the literature. A 62-year-old male presented with dysarthria, contralateral hemisensory loss, and contralateral weakness, concerning for possible MCA stroke. However, close examination revealed the hemiparesis to be ataxic in nature. Imaging revealed a left PCA P2 segment occlusion and lacunar infarction of the ventral lateral (VL) and ventral posterior (VP) thalamus, the main thalamic destination of cerebellar and sensory pathways. The case is unique because the P1 segment and posterior communicating artery (Pcom) remained patent, resulting in selective occlusion of only the posterior lateral (inferolateral) thalamic perforators at the P2 level. Acute loss of the posterior lateral (inferolateral) thalamic perforators at the proximal P2 segment results in a ventral lateral and ventral posterior thalamic stroke characterized by contralateral hemisensory loss, contralateral ataxic hemiparesis, and dysarthria. It is important to recognize the inferolateral thalamic stroke syndrome, as it may be mistaken clinically for an MCA occlusion. The benefit of mechanical thrombectomy for this type of stroke is not well established and should be considered carefully.
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Affiliation(s)
- Andrew S Griffin
- Department of Neurosurgery, Duke University Medical Center, Box 3807, Erwin Road, Durham, NC, 27710, USA.
| | - Rowena Mariano
- Department of Neurosurgery, Duke University Medical Center, Box 3807, Erwin Road, Durham, NC, 27710, USA
| | - Soeren K Hauck
- Department of Neurosurgery, University of Hannover, Hanover, Germany
| | - Erik F Hauck
- Department of Neurosurgery, Duke University Medical Center, Box 3807, Erwin Road, Durham, NC, 27710, USA
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Vagal A, Wintermark M, Nael K, Bivard A, Parsons M, Grossman AW, Khatri P. Automated CT perfusion imaging for acute ischemic stroke: Pearls and pitfalls for real-world use. Neurology 2019; 93:888-898. [PMID: 31636160 DOI: 10.1212/wnl.0000000000008481] [Citation(s) in RCA: 119] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 08/19/2019] [Indexed: 11/15/2022] Open
Abstract
Recent positive trials have thrust acute cerebral perfusion imaging into the routine evaluation of acute ischemic stroke. Updated guidelines state that in patients with anterior circulation large vessel occlusions presenting beyond 6 hours from time last known well, advanced imaging selection including perfusion-based selection is necessary. Centers that receive patients with acute stroke must now have the capability to perform and interpret CT or magnetic resonance perfusion imaging or provide rapid transfer to centers with the capability of selecting patients for a highly impactful endovascular therapy, particularly in delayed time windows. Many stroke centers are quickly incorporating the use of automated perfusion processing software to interpret perfusion raw data. As CT perfusion (CTP) is being assimilated in real-world clinical practice, it is essential to understand the basics of perfusion acquisition, quantification, and interpretation. It is equally important to recognize the common technical and clinical diagnostic challenges of automated CTP including ischemic core and penumbral misclassifications that could result in underestimation or overestimation of the core and penumbra volumes. This review highlights the pitfalls of automated CTP along with practical pearls to address the common challenges. This is particularly tailored to aid the acute stroke clinician who must interpret automated perfusion studies in an emergency setting to make time-dependent treatment decisions for patients with acute ischemic stroke.
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Affiliation(s)
- Achala Vagal
- From the Departments of Radiology (A.V), Neurology (P.K), and Neurosurgery (A.G), University of Cincinnati Medical Center, OH; Department of Radiology (M.W), Stanford University and Healthcare, CA, Department of Neurology (M.P., A.B.), Royal Melbourne Hospital, Melbourne Brain Centre, University of Melbourne, Australia; and Department of Radiology (K.N.), Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Max Wintermark
- From the Departments of Radiology (A.V), Neurology (P.K), and Neurosurgery (A.G), University of Cincinnati Medical Center, OH; Department of Radiology (M.W), Stanford University and Healthcare, CA, Department of Neurology (M.P., A.B.), Royal Melbourne Hospital, Melbourne Brain Centre, University of Melbourne, Australia; and Department of Radiology (K.N.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kambiz Nael
- From the Departments of Radiology (A.V), Neurology (P.K), and Neurosurgery (A.G), University of Cincinnati Medical Center, OH; Department of Radiology (M.W), Stanford University and Healthcare, CA, Department of Neurology (M.P., A.B.), Royal Melbourne Hospital, Melbourne Brain Centre, University of Melbourne, Australia; and Department of Radiology (K.N.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Andrew Bivard
- From the Departments of Radiology (A.V), Neurology (P.K), and Neurosurgery (A.G), University of Cincinnati Medical Center, OH; Department of Radiology (M.W), Stanford University and Healthcare, CA, Department of Neurology (M.P., A.B.), Royal Melbourne Hospital, Melbourne Brain Centre, University of Melbourne, Australia; and Department of Radiology (K.N.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mark Parsons
- From the Departments of Radiology (A.V), Neurology (P.K), and Neurosurgery (A.G), University of Cincinnati Medical Center, OH; Department of Radiology (M.W), Stanford University and Healthcare, CA, Department of Neurology (M.P., A.B.), Royal Melbourne Hospital, Melbourne Brain Centre, University of Melbourne, Australia; and Department of Radiology (K.N.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Aaron W Grossman
- From the Departments of Radiology (A.V), Neurology (P.K), and Neurosurgery (A.G), University of Cincinnati Medical Center, OH; Department of Radiology (M.W), Stanford University and Healthcare, CA, Department of Neurology (M.P., A.B.), Royal Melbourne Hospital, Melbourne Brain Centre, University of Melbourne, Australia; and Department of Radiology (K.N.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Pooja Khatri
- From the Departments of Radiology (A.V), Neurology (P.K), and Neurosurgery (A.G), University of Cincinnati Medical Center, OH; Department of Radiology (M.W), Stanford University and Healthcare, CA, Department of Neurology (M.P., A.B.), Royal Melbourne Hospital, Melbourne Brain Centre, University of Melbourne, Australia; and Department of Radiology (K.N.), Icahn School of Medicine at Mount Sinai, New York, NY
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Rudilosso S, Laredo C, Mancosu M, Moya-Planas N, Zhao Y, Chirife O, Chamorro Á, Urra X. Cerebral perfusion and compensatory blood supply in patients with recent small subcortical infarcts. J Cereb Blood Flow Metab 2019; 39:1326-1335. [PMID: 29436885 PMCID: PMC6668517 DOI: 10.1177/0271678x18758548] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 12/05/2017] [Accepted: 01/09/2018] [Indexed: 12/15/2022]
Abstract
Hypoperfusion is the typical perfusion pattern associated with recent small subcortical infarcts of the brain, but other perfusion patterns may be present in patients with these infarcts. Using CT perfusion, we studied 67 consecutive patients who had a small subcortical infarct at a follow-up MRI study to investigate the correlation between the perfusion pattern and the clinical and radiological course. On CT perfusion map analysis, 51 patients (76%) had focal hypoperfusion, 4 patients (6%) had hyperperfusion and the remaining 12 patients (18%) showed no abnormalities. On dynamic sequential imaging analysis obtained from the source perfusion images, 32 patients (48%) had a sustained hypoperfusion pattern, 11 patients (16%) had a reperfusion pattern, and 18 patients (27%) had a delayed compensation pattern. Systolic blood pressure was higher in patients with sustained hypoperfusion although the perfusion pattern was independent of the final volume of infarction. These results reinforce the notion that mechanisms other than hypoperfusion are at play in patients with small subcortical infarcts including the intervention of compensatory sources of blood flow. The ultimate clinical significance of these perfusion patterns remains to be determined in larger series of patients assessed longitudinally.
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Affiliation(s)
- Salvatore Rudilosso
- Functional Unit of Cerebrovascular
Diseases,
Hospital
Clínic, Barcelona, Spain
| | - Carlos Laredo
- Functional Unit of Cerebrovascular
Diseases,
Hospital
Clínic, Barcelona, Spain
- Institut d'Investigacions Biomèdiques
August Pi i Sunyer, Barcelona, Spain
| | - Marco Mancosu
- Department of Neurology, AOU Policlinico
Universitario, Monserrato (Cagliari), Italy
| | - Nuria Moya-Planas
- Institut d'Investigacions Biomèdiques
August Pi i Sunyer, Barcelona, Spain
| | - Yashu Zhao
- Functional Unit of Cerebrovascular
Diseases,
Hospital
Clínic, Barcelona, Spain
| | - Oscar Chirife
- Department of Radiology,
Hospital
Clínic, Barcelona, Spain
| | - Ángel Chamorro
- Functional Unit of Cerebrovascular
Diseases,
Hospital
Clínic, Barcelona, Spain
- Institut d'Investigacions Biomèdiques
August Pi i Sunyer, Barcelona, Spain
| | - Xabier Urra
- Functional Unit of Cerebrovascular
Diseases,
Hospital
Clínic, Barcelona, Spain
- Institut d'Investigacions Biomèdiques
August Pi i Sunyer, Barcelona, Spain
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Wake-up stroke and CT perfusion: effectiveness and safety of reperfusion therapy. Neurol Sci 2018; 39:1705-1712. [DOI: 10.1007/s10072-018-3486-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 06/29/2018] [Indexed: 11/25/2022]
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Radiologic Cerebral Reperfusion at 24 h Predicts Good Clinical Outcome. Transl Stroke Res 2018; 10:178-188. [PMID: 29949087 DOI: 10.1007/s12975-018-0637-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 05/08/2018] [Accepted: 06/04/2018] [Indexed: 12/11/2022]
Abstract
Cerebral reperfusion and arterial recanalization are radiological features of the effectiveness of thrombolysis in acute ischemic stroke (AIS) patients. Here, an investigation of the prognostic role of early recanalization/reperfusion on clinical outcome was performed. In AIS patients (n = 55), baseline computerized tomography (CT) was performed ≤ 8 h from symptom onset, whereas CT determination of reperfusion/recanalization was assessed at 24 h. Multiple linear and logistic regression models were used to correlate reperfusion/recanalization with radiological (i.e., hemorrhagic transformation, ischemic core, and penumbra volumes) and clinical outcomes (assessed as National Institutes of Health Stroke Scale [NIHSS] reduction ≥ 8 points or a NIHSS ≤ 1 at 24 h and as modified Rankin Scale [mRS] < 2 at 90 days). At 24 h, patients achieving radiological reperfusion were n = 24, while the non-reperfused were n = 31. Among non-reperfused, n = 15 patients were recanalized. Radiological reperfusion vs. recanalization was also confirmed by early increased levels of circulating inflammatory biomarkers (i.e., serum osteopontin). In multivariate analysis, ischemic lesion volume reduction was associated with both recanalization (β = 0.265; p = 0.014) and reperfusion (β = 0.461; p < 0.001), but only reperfusion was independently associated with final infarct volume (β = - 0.333; p = 0.007). Only radiological reperfusion at 24 h predicted good clinical response at day 1 (adjusted OR 16.054 [1.423-181.158]; p = 0.025) and 90-day good functional outcome (adjusted OR 25.801 [1.483-448.840]; p = 0.026). At ROC curve analysis the AUC of reperfusion was 0.777 (p < 0.001) for the good clinical response at 24 h and 0.792 (p < 0.001) for 90-day clinical outcome. Twenty-four-hour radiological reperfusion assessed by CT is associated with good clinical response on day 1 and good functional outcome on day 90 in patients with ischemic stroke.
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Furlanis G, Ajčević M, Stragapede L, Lugnan C, Ridolfi M, Caruso P, Naccarato M, Ukmar M, Manganotti P. Ischemic Volume and Neurological Deficit: Correlation of Computed Tomography Perfusion with the National Institutes of Health Stroke Scale Score in Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2018; 27:2200-2207. [PMID: 29724610 DOI: 10.1016/j.jstrokecerebrovasdis.2018.04.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/27/2018] [Accepted: 04/03/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The National Institutes of Health Stroke Scale (NIHSS) is the most adopted stroke patients' evaluation tool in emergency settings to assess the severity of stroke and to determine the patients' eligibility for specific treatments. Computed tomography perfusion (CTP) is crucial to identify salvageable tissue that can benefit from the reperfusion treatment. The aim of this study is to identify the relation between the NIHSS scores and the hypoperfused volumes evaluated by CTP in patients with hyperacute ischemic stroke. METHODS This retrospective study was conducted on 105 patients with ischemic stroke who underwent NIHSS assessment and CTP in the hyperacute phase. Hypoperfused volume was evaluated by CTP maps processed with semi-automatic algorithm. An analysis was conducted to determine the degree of correlation between the NIHSS scores and the ischemic lesion volumes and to investigate the relation between the anterior and the posterior circulation strokes, as well as between the right and the left hemispheric strokes. RESULTS A significant correlation was found between ischemic volume and NIHSS score at baseline (r = .82; P < .0001) in the entire cohort. A high NIHSS-volume correlation was identified in the anterior circulation stroke (r = .76; P < .0001); whereas, it was nonsignificant in the posterior circulation stroke. NIHSS score and volume correlated for the left and the right hemispheric strokes (r = .83 and .81; P < .0001), showing a slightly higher slope in the left. CONCLUSION This study showed a strong correlation between the baseline NIHSS score and the ischemic volume estimated by CTP. We confirmed that NIHSS is a reliable predictor of perfusion deficits in acute ischemic stroke. CTP allows fast imaging assessment in the hyperacute phase. The results highlight the importance of these diagnostic tools in the assessment of stroke severity and in acute decision-making.
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Affiliation(s)
- Giovanni Furlanis
- Clinical Unit of Neurology, Department of Medical Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy.
| | - Miloš Ajčević
- Clinical Unit of Neurology, Department of Medical Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Lara Stragapede
- Clinical Unit of Neurology, Department of Medical Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Carlo Lugnan
- Clinical Unit of Neurology, Department of Medical Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Mariana Ridolfi
- Clinical Unit of Neurology, Department of Medical Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Paola Caruso
- Clinical Unit of Neurology, Department of Medical Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Marcello Naccarato
- Clinical Unit of Neurology, Department of Medical Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Maja Ukmar
- Radiology Unit, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
| | - Paolo Manganotti
- Clinical Unit of Neurology, Department of Medical Sciences, University Hospital and Health Services of Trieste, University of Trieste, Trieste, Italy
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Is CT perfusion helpful in the treatment allocation of patients with acute ischemic stroke? An expert-opinion analysis. Neurol Sci 2017; 38:1771-1777. [PMID: 28726048 DOI: 10.1007/s10072-017-3051-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 06/23/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Intravenous tPA is the standard treatment for acute ischemic stroke within 4.5 hours of symptom onset. Neuroradiological selection is currently based upon non-contrast- brain CT scan (NCCT). AIMS To verify, in an "expert-opinion setting", the possible usefulness of CT perfusion (CTP) in decision-making toward i.v. thrombolysis. PATIENTS AND METHOD One hundred and three consecutive patients with acute ischemic stroke who underwent NCCT and CTP were re-evaluated by an expert in cerebrovascular disease, to verify if adding CTP information would have changed expert's opinion. RESULTS After CTP, a definitive decision was made for 20 more patients, changing the proportion of patients candidate to i.v. tPA from 44% to 51%, and reducing uncertainty from 29% to 10%. CTP results were useful inmilder stroke (p = 0.01). CONCLUSIONS In a "real world" setting, CT perfusion could be useful for clinical decision, in particular for milder stroke.
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37
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Morelli N, Rota E, Michieletti E, Guidetti D. The "Vexata Quaestio" on Lacunar Stroke: The Role of CT Perfusion Imaging. AJNR Am J Neuroradiol 2017; 38:E11-E12. [PMID: 27737862 DOI: 10.3174/ajnr.a4983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
| | | | | | - D Guidetti
- Neurology Unit Guglielmo da Saliceto Hospital Piacenza, Italy
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