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Bernard K, Dickson D, Anglin BL, Leandro Heien M, Polt R, Morrison HW, Falk T. PACAP glycosides promote cell outgrowth in vitro and reduce infarct size after stroke in a preclinical model. Neurosci Lett 2024; 836:137883. [PMID: 38914278 DOI: 10.1016/j.neulet.2024.137883] [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: 05/17/2024] [Revised: 06/17/2024] [Accepted: 06/18/2024] [Indexed: 06/26/2024]
Abstract
Pituitary Adenylate Cyclase Activating Polypeptide (PACAP) is a pleiotropic peptide known to promote many beneficial processes following neural damage and cell death after stroke. Despite PACAP's known neurotrophic and anti-inflammatory properties, it has not realized its translational potential due to a poor pharmacokinetic profile (non-linear PK/PD), and limited Blood-Brain Barrier Penetration (BBB) permeability. We have previously shown that glycosylation of PACAP increases stability and enhances BBB penetration. In addition, our prior studies showed reduced neuronal cell death and neuroinflammation in models of Parkinson's disease and Traumatic Brain Injury (TBI). In this study we show that a PACAP(1-27) glucoside retains the known neurotrophic activity of native PACAP(1-27)in vitro and a 5-day daily treatment regimen (100 nM) leads to neurite-like extensions in PC12 cells. In addition, we show that intraperitoneal injection of a PACAP(1-27) lactoside (10 mg/kg) with improved BBB-penetration, given 1-hour after reperfusion in a Transient Middle Cerebral Artery Occlusion (tMCAO) mouse model, reduces the infarct size after the ischemic injury in males significantly by ∼ 36 %, and the data suggest a dose-dependency. In conclusion, our data support further development of PACAP glycopeptides as promising novel drug candidates for the treatment of stroke, an area with an urgent clinical need.
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Affiliation(s)
- Kelsey Bernard
- Physiological Sciences Graduate Program, The University of Arizona, Tucson, AZ 85724, United States
| | - Denali Dickson
- College of Nursing, The University of Arizona, Tucson, AZ 85724, United States
| | - Bobbi L Anglin
- Department of Chemistry & Biochemistry, The University of Arizona, Tucson, AZ 85721, United States
| | - M Leandro Heien
- Department of Chemistry & Biochemistry, The University of Arizona, Tucson, AZ 85721, United States
| | - Robin Polt
- Department of Chemistry & Biochemistry, The University of Arizona, Tucson, AZ 85721, United States
| | - Helena W Morrison
- College of Nursing, The University of Arizona, Tucson, AZ 85724, United States
| | - Torsten Falk
- Physiological Sciences Graduate Program, The University of Arizona, Tucson, AZ 85724, United States; Department of Neurology, The University of Arizona, Tucson, AZ 85724, United States; Department of Pharmacology, the University of Arizona, Tucson, AZ 85724, United States.
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Lattanzi S, Cuccurullo C, Orlandi N, Borzì G, Bigliardi G, Maffei S, Giovannini G, Meletti S. Futile recanalization is associated with increased risk of post-stroke epilepsy. J Neurol Sci 2024; 462:123067. [PMID: 38823064 DOI: 10.1016/j.jns.2024.123067] [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: 04/04/2024] [Revised: 05/13/2024] [Accepted: 05/27/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Endovascular treatment (EVT) is the standard of care of ischaemic stroke due to occlusion of large vessels. Although EVT can significantly improve short- and long-term outcomes, functional dependence can persist despite the achievement of a successful recanalization. The evidence about the predictors of post-stroke epilepsy (PSE) in patients with stroke treated by EVT is limited. We aimed to evaluate the relationship between futile recanalization and the risk of PSE. METHODS We retrospectively identified consecutive adults with first-ever ischaemic stroke of anterior circulation who were treated with EVT. Futile recanalization was defined as poor 3-month functional status (modified Rankin scale score ≥ 3) despite complete or near-complete recanalization. Study outcome was the occurrence of PSE during the follow-up. RESULTS The study included 327 patients with anterior circulation ischaemic stroke treated with EVT. Futile recanalization occurred in 116 (35.5%) patients and 26 (8.0%) developed PSE during a median follow-up of 35 [interquartile range, 22.7-55.2] months. Futile recanalization was more common among patients who developed PSE compared to those who did not (76.9% versus 31.9%; p < 0.001). Futile recanalization [hazard ratio (HR) = 5.63, 95% confidence interval (CI): 1.88-16.84; p = 0.002], large artery atherosclerosis (HR = 3.48, 95% CI: 1.44-8.40; p = 0.006), cortical involvement (HR = 15.51, 95% CI: 2.06-116.98; p = 0.008), and acute symptomatic status epilepticus (HR = 14.40, 95% CI: 2.80-73.98; p = 0.001) increased the risk of PSE. CONCLUSIONS Futile recanalization after EVT is associated with increased risk of PSE in patients with ischaemic stroke due to occlusion of large vessel of the anterior circulation.
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Affiliation(s)
- Simona Lattanzi
- Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy; IRCCS INRCA, Ancona, Italy.
| | - Claudia Cuccurullo
- Neurology and Stroke Unit, Ospedale del Mare Hospital, ASL Napoli 1, Naples, Italy
| | - Niccolò Orlandi
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy; Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Giuseppe Borzì
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy; Stroke Unit, OCB Hospital, AOU, Modena, Italy
| | - Guido Bigliardi
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy; Stroke Unit, OCB Hospital, AOU, Modena, Italy
| | - Stefania Maffei
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy; Stroke Unit, OCB Hospital, AOU, Modena, Italy
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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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Sun D, Nguyen TN, Pan Y, Wang M, Abdalkader M, Masoud HE, Ma A, Tong X, Ma G, Sun X, Song L, Ma N, Gao F, Mo D, Miao Z, Huo X. Unsuccessful Recanalization versus Medical Management of Patients with Large Ischemic Core : Analysis of the ANGEL-ASPECT Randomized Trial. Clin Neuroradiol 2024; 34:441-450. [PMID: 38319347 DOI: 10.1007/s00062-024-01384-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/05/2024] [Indexed: 02/07/2024]
Abstract
PURPOSE The outcomes of patients with large ischemic core who fail to recanalize with endovascular therapy (EVT) compared to medical management (MM) are uncertain. The objective was to evaluate the clinical and safety outcomes of patients who underwent EVT in patients with large ischemic core and unsuccessful recanalization. METHODS This was a post hoc analysis of the ANGEL-ASPECT randomized trial. Unsuccessful recanalization was defined as patients who underwent EVT with eTICI 0-2a. The primary endpoint was 90-day very poor outcome (mRS 5-6). Multivariable logistic regression was conducted controlling for ASPECTS, occlusion location, intravenous thrombolysis, and time to treatment. RESULTS Of 455 patients 225 were treated with MM. Of 230 treated with EVT, 43 (19%) patients had unsuccessful recanalization. There was no difference in 90-day very poor outcomes (39.5% vs. 40%, aOR 0.93, 95% confidence interval, CI 0.47-1.85, p = 0.95), sICH (7.0% vs. 2.7%, aOR 2.81, 95% CI 0.6-13.29, p = 0.19), or mortality (30% vs. 20%, aOR 1.65, 95% CI 0.89-3.06, p = 0.11) between the unsuccessful EVT and MM groups, respectively. There were higher rates of ICH (55.8% vs. 17.3%, p < 0.001), infarct core volume growth (142.7 ml vs. 90.5 ml, β = 47.77, 95% CI 20.97-74.57 ml, p < 0.001), and decompressive craniectomy (18.6% vs. 3.6%, p < 0.001) in the unsuccessful EVT versus MM groups. CONCLUSION In a randomized trial of patients with large ischemic core undergoing EVT with unsuccessful recanalization, there was no difference in very poor outcomes, sICH or death versus medically managed patients. In the unsuccessful EVT group, there were higher rates of any ICH, volume of infarct core growth, and decompressive craniectomy.
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Affiliation(s)
- Dapeng Sun
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
| | - Thanh N Nguyen
- Neurology, Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, USA
| | - Yuesong Pan
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Mengxing Wang
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Mohamad Abdalkader
- Neurology, Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, USA
| | - Hesham E Masoud
- Neurology, SUNY Upstate Medical University Hospital, Syracuse, NY, USA
| | - Alice Ma
- Neurosurgery, Royal North Shore Hospital, Sydney, Australia
| | - Xu Tong
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
| | - Gaoting Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xuan Sun
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
| | - Ligang Song
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
| | - Feng Gao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
| | - Dapeng Mo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
| | - Zhongrong Miao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China.
| | - Xiaochuan Huo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China.
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
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Salsano G, Salsano A, Del Sette B, D’Alonzo A, Sassos D, Alexandre A, Pedicelli A, Di Iorio R, Colò F, Castellan L. Endovascular thrombectomy versus intravenous thrombolysis for primary distal, medium vessel occlusion in acute ischemic stroke. Open Med (Wars) 2024; 19:20240966. [PMID: 38756249 PMCID: PMC11097045 DOI: 10.1515/med-2024-0966] [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: 01/08/2024] [Revised: 04/17/2024] [Accepted: 04/17/2024] [Indexed: 05/18/2024] Open
Abstract
Introduction In the absence of clinical trials, the benefit of endovascular therapy (EVT) on the treatment of acute ischemic stroke (AIS) with primary distal and medium vessel occlusions (DMVO) is still not well defined. The aim of the study is to evaluate EVT with or without intravenous thrombolysis (EVT ± IVT) in primary DMVO stroke in comparison with a control cohort treated with IVT alone. Methods We analysed all consecutive AIS with proven primary DMVO. Primary endpoints were excellent outcome, functional independence at 3 months follow-up, and early neurologic improvement at 1 day after treatment. Results One hundred and fourteen patients with DMVO strokes were included between 2019 and 2023. Propensity-weighted analysis showed no significant differences in EVT ± IVT vs IVT for the excellent outcome (adjusted OR [aOR], 1.575; 95% CI, 0.706-3.513), functional independence (aOR, 2.024; 95% CI, 0.845-4.848), early neurological improvement (aOR, 2.218; 95% CI, 0.937-5.247), mortality (aOR, 0.498; 95% CI, 0.177-1.406), symptomatic intracranial haemorrhage (aOR, 0.493; 95% CI, 0.102-2.385), and subarachnoid haemorrhage (aOR, 0.560; 95% CI, 0.143-2.187). The type of revascularization did not influence the percentage of cerebral volume lost (adjusted linear regression estimate, -19.171, t value, 11.562; p = 0.104). Conclusions This study supports the hypothesis that patients with primary DMVO stroke treated with EVT (±IVT) or IVT alone have comparable outcomes.
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Affiliation(s)
- Giancarlo Salsano
- Department of Radiology and Interventional Radiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Bruno Del Sette
- Department of Radiology and Interventional Radiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Alessio D’Alonzo
- Department of Radiology and Interventional Radiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Davide Sassos
- Clinica Neurologica IRCCS Azienda Ospedaliera Universitaria San Martino, IST, Genoa, Italy
| | - Andrea Alexandre
- UOSA Neuroradiology Unit, Department of Radiology, Radiotherapy and Oncology and Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessandro Pedicelli
- UOSA Neuroradiology Unit, Department of Radiology, Radiotherapy and Oncology and Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Riccardo Di Iorio
- Neurology Unit, Department of Aging, Neurological, Orthopedic and Head and Neck Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesca Colò
- Department of Neurosciences, Catholic University School of Medicine, Rome, Italy
| | - Lucio Castellan
- Department of Radiology and Interventional Radiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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Ospel JM, Rex N, Oueidat K, McDonough R, Rinkel L, Baird G, Collins S, Jindal G, Alvin MD, Boxerman J, Barber P, Jayaraman M, Smith W, Amirault-Capuano A, Hill MD, Goyal M, McTaggart R. Infarcts Due to Large Vessel Occlusions Continue to Grow Despite Near-Complete Reperfusion After Endovascular Treatment. J Stroke 2024; 26:260-268. [PMID: 38836273 PMCID: PMC11164585 DOI: 10.5853/jos.2023.02621] [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: 08/11/2023] [Revised: 01/09/2024] [Accepted: 02/01/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND AND PURPOSE Infarcts in acute ischemic stroke (AIS) patients may continue to grow even after reperfusion, due to mechanisms such as microvascular obstruction and reperfusion injury. We investigated whether and how much infarcts grow in AIS patients after near-complete (expanded Thrombolysis in Cerebral Infarction [eTICI] 2c/3) reperfusion following endovascular treatment (EVT), and to assess the association of post-reperfusion infarct growth with clinical outcomes. METHODS Data are from a single-center retrospective observational cohort study that included AIS patients undergoing EVT with near-complete reperfusion who received diffusion-weighted magnetic resonance imaging (MRI) within 2 hours post-EVT and 24 hours after EVT. Association of infarct growth between 2 and 24 hours post-EVT and 24-hour National Institutes of Health Stroke Scale (NIHSS) as well as 90-day modified Rankin Scale score was assessed using multivariable logistic regression. RESULTS Ninety-four of 155 (60.6%) patients achieved eTICI 2c/3 and were included in the analysis. Eighty of these 94 (85.1%) patients showed infarct growth between 2 and 24 hours post-reperfusion. Infarct growth ≥5 mL was seen in 39/94 (41.5%) patients, and infarct growth ≥10 mL was seen in 20/94 (21.3%) patients. Median infarct growth between 2 and 24 hours post-reperfusion was 4.5 mL (interquartile range: 0.4-9.2 mL). Post-reperfusion infarct growth was associated with the 24-hour NIHSS in multivariable analysis (odds ratio: 1.16 [95% confidence interval 1.09-1.24], P<0.01). CONCLUSION Infarcts continue to grow after EVT, even if near-complete reperfusion is achieved. Investigating the underlying mechanisms may inform future therapeutic approaches for mitigating the process and help improve patient outcome.
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Affiliation(s)
- Johanna M. Ospel
- Department of Radiology, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Nathaniel Rex
- Department of Radiology, University of Calgary, Calgary, AB, Canada
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | - Karim Oueidat
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | | | - Leon Rinkel
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Grayson Baird
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | - Scott Collins
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | - Gaurav Jindal
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | - Matthew D. Alvin
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | - Jerrold Boxerman
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | - Phil Barber
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Mahesh Jayaraman
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | - Wendy Smith
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | | | - Michael D. Hill
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Mayank Goyal
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Ryan McTaggart
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
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7
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Ospel JM, Rinkel L, Ganesh A, Demchuk A, Heran M, Sauvageau E, Joshi M, Haussen D, Jayaraman M, Coutts S, Yu A, Puetz V, Iancu D, Bang OY, Tarpley J, Holmin S, Kelly M, Tymianski M, Hill M, Goyal M. How Do Quantitative Tissue Imaging Outcomes in Acute Ischemic Stroke Relate to Clinical Outcomes? J Stroke 2024; 26:252-259. [PMID: 38836272 PMCID: PMC11164591 DOI: 10.5853/jos.2023.02180] [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: 07/08/2023] [Revised: 12/24/2023] [Accepted: 01/15/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND AND PURPOSE Infarct volume and other imaging markers are increasingly used as surrogate measures for clinical outcome in acute ischemic stroke research, but how improvements in these imaging surrogates translate into better clinical outcomes is currently unclear. We investigated how changes in infarct volume at 24 hours alter the probability of achieving good clinical outcome (modified Rankin Scale [mRS] 0-2). METHODS Data are from endovascular thrombectomy patients from the randomized controlled ESCAPE-NA1 (Efficacy and Safety of Nerinetide for the Treatment of Acute Ischaemic Stroke) trial. Infarct volume at 24 hours was manually segmented on non-contrast computed tomography or diffusion-weighted magnetic resonance imaging. Probabilities of achieving good outcome based on infarct volume were obtained from a multivariable logistic regression model. The probability of good outcome was plotted against infarct volume using linear spline regression. RESULTS A total of 1,099 patients were included in the analysis (median final infarct volume 24.9 mL [interquartile range: 6.6-92.2]). The relationship between total infarct volume and good outcome probability was nearly linear for infarct volumes between 0 mL and 250 mL. In this range, a 10% increase in the probability of achieving mRS 0-2 required a decrease in infarct volume of approximately 34.0 mL (95% confidence interval: -32.5 to -35.6). At infarct volumes above 250 mL, the probability of achieving mRS 0-2 probability was near zero. The relationships of tissue-specific infarct volumes and parenchymal hemorrhage volume generally showed similar patterns, although variability was high. CONCLUSION There seems to be a near-linear association between total infarct volume and probability of achieving good outcome for infarcts up to 250 mL, whereas patients with infarct volumes greater than 250 mL are highly unlikely to have a favorable outcome.
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Affiliation(s)
- Johanna M. Ospel
- Department of Diagnostic Imaging, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Leon Rinkel
- Department of Diagnostic Imaging, University of Calgary, Calgary, AB, Canada
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Aravind Ganesh
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Andrew Demchuk
- Department of Diagnostic Imaging, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Manraj Heran
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Hospital, Jacksonville, FL, USA
| | - Manish Joshi
- Department of Diagnostic Imaging, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Diogo Haussen
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Mahesh Jayaraman
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Shelagh Coutts
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Amy Yu
- University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Volker Puetz
- University Hospital Carl Gustav Carus at the Technische Universität Dresden, Department of Neurology and Dresden Neurovascular Center, Dresden, Germany
| | - Dana Iancu
- Centre Hospitalier de l’Université de Montréal, Montreal, QC, Canada
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea
| | - Jason Tarpley
- Providence Little Company of Mary Medical Center, Providence Saint John’s Health Center and The Pacific Neuroscience Institute, Torrance, CA, USA
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet and Departments of Neuroradiology and Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Michael Kelly
- Royal University Hospital, University of Saskatchewan, Saskatoon, SK, Canada
| | | | - Michael Hill
- Department of Diagnostic Imaging, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Mayank Goyal
- Department of Diagnostic Imaging, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - the ESCAPE-NA1 Investigators
- Department of Diagnostic Imaging, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
- Lyerly Neurosurgery, Baptist Hospital, Jacksonville, FL, USA
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA
- University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- University Hospital Carl Gustav Carus at the Technische Universität Dresden, Department of Neurology and Dresden Neurovascular Center, Dresden, Germany
- Centre Hospitalier de l’Université de Montréal, Montreal, QC, Canada
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea
- Providence Little Company of Mary Medical Center, Providence Saint John’s Health Center and The Pacific Neuroscience Institute, Torrance, CA, USA
- Department of Clinical Neuroscience, Karolinska Institutet and Departments of Neuroradiology and Neurology, Karolinska University Hospital, Stockholm, Sweden
- Royal University Hospital, University of Saskatchewan, Saskatoon, SK, Canada
- NoNO Inc., Toronto, ON, Canada
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Liu Y, Shah P, Yu Y, Horsey J, Ouyang J, Jiang B, Yang G, Heit JJ, McCullough-Hicks ME, Hugdal SM, Wintermark M, Michel P, Liebeskind DS, Lansberg MG, Albers GW, Zaharchuk G. A Clinical and Imaging Fused Deep Learning Model Matches Expert Clinician Prediction of 90-Day Stroke Outcomes. AJNR Am J Neuroradiol 2024; 45:406-411. [PMID: 38331959 DOI: 10.3174/ajnr.a8140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 12/07/2023] [Indexed: 02/10/2024]
Abstract
BACKGROUND AND PURPOSE Predicting long-term clinical outcome in acute ischemic stroke is beneficial for prognosis, clinical trial design, resource management, and patient expectations. This study used a deep learning-based predictive model (DLPD) to predict 90-day mRS outcomes and compared its predictions with those made by physicians. MATERIALS AND METHODS A previously developed DLPD that incorporated DWI and clinical data from the acute period was used to predict 90-day mRS outcomes in 80 consecutive patients with acute ischemic stroke from a single-center registry. We assessed the predictions of the model alongside those of 5 physicians (2 stroke neurologists and 3 neuroradiologists provided with the same imaging and clinical information). The primary analysis was the agreement between the ordinal mRS predictions of the model or physician and the ground truth using the Gwet Agreement Coefficient. We also evaluated the ability to identify unfavorable outcomes (mRS >2) using the area under the curve, sensitivity, and specificity. Noninferiority analyses were undertaken using limits of 0.1 for the Gwet Agreement Coefficient and 0.05 for the area under the curve analysis. The accuracy of prediction was also assessed using the mean absolute error for prediction, percentage of predictions ±1 categories away from the ground truth (±1 accuracy [ACC]), and percentage of exact predictions (ACC). RESULTS To predict the specific mRS score, the DLPD yielded a Gwet Agreement Coefficient score of 0.79 (95% CI, 0.71-0.86), surpassing the physicians' score of 0.76 (95% CI, 0.67-0.84), and was noninferior to the readers (P < .001). For identifying unfavorable outcome, the model achieved an area under the curve of 0.81 (95% CI, 0.72-0.89), again noninferior to the readers' area under the curve of 0.79 (95% CI, 0.69-0.87) (P < .005). The mean absolute error, ±1ACC, and ACC were 0.89, 81%, and 36% for the DLPD. CONCLUSIONS A deep learning method using acute clinical and imaging data for long-term functional outcome prediction in patients with acute ischemic stroke, the DLPD, was noninferior to that of clinical readers.
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Affiliation(s)
- Yongkai Liu
- From the Department of Radiology (Y.L., P.S., Y.Y., J.O., B.J., J.J.H., S.M.H., G.Z.), Stanford University, Stanford, Calfornia
| | - Preya Shah
- From the Department of Radiology (Y.L., P.S., Y.Y., J.O., B.J., J.J.H., S.M.H., G.Z.), Stanford University, Stanford, Calfornia
| | - Yannan Yu
- From the Department of Radiology (Y.L., P.S., Y.Y., J.O., B.J., J.J.H., S.M.H., G.Z.), Stanford University, Stanford, Calfornia
| | - Jai Horsey
- Meharry Medical College (J.H.), Nashville, Tennessee
| | - Jiahong Ouyang
- From the Department of Radiology (Y.L., P.S., Y.Y., J.O., B.J., J.J.H., S.M.H., G.Z.), Stanford University, Stanford, Calfornia
- Department of Electrical Engineering (J.O.), Stanford University, Stanford, California
| | - Bin Jiang
- From the Department of Radiology (Y.L., P.S., Y.Y., J.O., B.J., J.J.H., S.M.H., G.Z.), Stanford University, Stanford, Calfornia
| | - Guang Yang
- National Heart and Lung Institute (G.Y.), Imperial College London, London, UK
| | - Jeremy J Heit
- From the Department of Radiology (Y.L., P.S., Y.Y., J.O., B.J., J.J.H., S.M.H., G.Z.), Stanford University, Stanford, Calfornia
| | - Margy E McCullough-Hicks
- Department of Neurology (M.E.M.-H.), University of Minnesota Medical School, Minneapolis, Minnesota
| | - Stephen M Hugdal
- From the Department of Radiology (Y.L., P.S., Y.Y., J.O., B.J., J.J.H., S.M.H., G.Z.), Stanford University, Stanford, Calfornia
| | - Max Wintermark
- Department of Neuroradiology (M.W.), University of Texas MD Anderson Center, Houston, Texas
| | - Patrik Michel
- Neurology Service (P.M), Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Switzerland
| | - David S Liebeskind
- Department of Neurology (D.S.L.), University of California, Los Angeles, Los Angeles, Calfornia
| | | | - Gregory W Albers
- Department of Neurology (M.G.L., G.W.A.), Stanford, Stanford, Calfornia
| | - Greg Zaharchuk
- From the Department of Radiology (Y.L., P.S., Y.Y., J.O., B.J., J.J.H., S.M.H., G.Z.), Stanford University, Stanford, Calfornia
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9
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Rex N, Oueidat K, Ospel J, McDonough R, Rinkel L, Baird GL, Collins S, Jindal G, Alvin MD, Boxerman J, Barber P, Jayaraman M, Smith W, Amirault-Capuano A, Hill M, Goyal M, McTaggart R. Modeling diffusion-weighted imaging lesion expansion between 2 and 24 h after endovascular thrombectomy in acute ischemic stroke. Neuroradiology 2024; 66:621-629. [PMID: 38277008 DOI: 10.1007/s00234-024-03294-2] [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: 08/11/2023] [Accepted: 01/10/2024] [Indexed: 01/27/2024]
Abstract
PURPOSE Diffusion-weighted imaging (DWI) lesion expansion after endovascular thrombectomy (EVT) is not well characterized. We used serial diffusion-weighted magnetic resonance imaging (MRI) to measure lesion expansion between 2 and 24 h after EVT. METHODS In this single-center observational analysis of patients with acute ischemic stroke due to large vessel occlusion, DWI was performed post-EVT (< 2 h after closure) and 24-h later. DWI lesion expansion was evaluated using multivariate generalized linear mixed modeling with various clinical moderators. RESULTS We included 151 patients, of which 133 (88%) had DWI lesion expansion, defined as a positive change in lesion volume between 2 and 24 h. In an unadjusted analysis, median baseline DWI lesion volume immediately post-EVT was 15.0 mL (IQR: 6.6-36.8) and median DWI lesion volume 24 h post-EVT was 20.8 mL (IQR: 9.4-66.6), representing a median change of 6.1 mL (IQR: 1.5-17.7), or a 39% increase. There were no significant associations among univariable models of lesion expansion. Adjusted models of DWI lesion expansion demonstrated that relative lesion expansion (defined as final/initial DWI lesion volume) was consistent across eTICI scores (0-2a, 0.52%; 2b, 0.49%; 2c-3, 0.42%, p = 0.69). For every 1 mL increase in lesion volume, there was 2% odds of an increase in 90-day mRS (OR: 1.021, 95%CI [1.009, 1.034], p < 0.001). CONCLUSION We observed substantial lesion expansion post-EVT whereby relative lesion expansion was consistent across eTICI categories, and greater absolute lesion expansion was associated with worse clinical outcome. Our findings suggest that alternate endpoints for cerebroprotectant trials may be feasible.
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Affiliation(s)
- Nathaniel Rex
- Department of Diagnostic Imaging, Brown University, 593 Eddy Street Providence, Providence, RI, 02903, USA
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Karim Oueidat
- Department of Diagnostic Imaging, Brown University, 593 Eddy Street Providence, Providence, RI, 02903, USA
| | - Johanna Ospel
- Department of Radiology, University of Calgary, Calgary, Canada
| | | | - Leon Rinkel
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Grayson L Baird
- Department of Diagnostic Imaging, Brown University, 593 Eddy Street Providence, Providence, RI, 02903, USA
| | - Scott Collins
- Department of Diagnostic Imaging, Brown University, 593 Eddy Street Providence, Providence, RI, 02903, USA
| | - Gaurav Jindal
- Department of Diagnostic Imaging, Brown University, 593 Eddy Street Providence, Providence, RI, 02903, USA
| | - Matthew D Alvin
- Department of Diagnostic Imaging, Brown University, 593 Eddy Street Providence, Providence, RI, 02903, USA
| | - Jerrold Boxerman
- Department of Diagnostic Imaging, Brown University, 593 Eddy Street Providence, Providence, RI, 02903, USA
| | - Phil Barber
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Mahesh Jayaraman
- Department of Diagnostic Imaging, Brown University, 593 Eddy Street Providence, Providence, RI, 02903, USA
| | - Wendy Smith
- Department of Diagnostic Imaging, Brown University, 593 Eddy Street Providence, Providence, RI, 02903, USA
| | - Amanda Amirault-Capuano
- Department of Diagnostic Imaging, Brown University, 593 Eddy Street Providence, Providence, RI, 02903, USA
| | - Michael Hill
- Department of Clinical Neuroscience, University of Calgary, Calgary, Canada
| | - Mayank Goyal
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Ryan McTaggart
- Department of Diagnostic Imaging, Brown University, 593 Eddy Street Providence, Providence, RI, 02903, USA.
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10
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Wang M, Farouki Y, Hulscher F, Mine B, Bonnet T, Elens S, Suarez JV, Jodaitis L, Ligot N, Naeije G, Lubicz B, Guenego A. Severely Hypoperfused Brain Tissue Correlates with Final Infarct Volume Despite Recanalization in DMVO Stroke. J Belg Soc Radiol 2023; 107:90. [PMID: 38023296 PMCID: PMC10668880 DOI: 10.5334/jbsr.3269] [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: 07/11/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives We sought to assess whether there were any parameter(s) on baseline computed-tomography-perfusion (CTP) strongly correlating with final-infarct-volume, and infarct volume progression after endovascular recanalization of acute ischemic stroke (AIS) with primary distal, medium vessel occlusion (DMVO). Materials and Methods We performed a retrospective analysis of consecutive AIS patients who were successfully recanalized by thrombectomy for DMVO. By comparing baseline CTP and follow-up MRI, we evaluated the correlation between baseline infarct and hypoperfusion volumes, and final infarct volume and infarct volume progression. We also examined their effect on good clinical outcome at 3 months (defined as an mRS score of 0 to 2). Results Between January 2018 and January 2021, 38 patients met the inclusion criteria (76% [29/38] female, median age 75 [66-86] years). Median final infarct volume and infarct volume progression were 8.4 mL [IQR: 5.2-44.4] and 7.2 mL [IQR: 4.3-29.1] respectively. TMax > 10 sec volume was strongly correlated with both (r = 0.831 and r = 0.771 respectively, p < 0.0001), as well as with good clinical outcome (-0.5, p = 0.001). A higher baseline TMax > 10 sec volume increased the probability of a higher final-infarct-volume (r2 = 0.690, coefficient = 0.83 [0.64-1.00], p < 0.0001), whereas it decreased the probability of good clinical outcome at 3 months (odds ratio = -0.67 [-1.17 to -0.18], p = 0.008). Conclusion TMax > 10 sec volume on baseline CTP correlates strongly with final infarct volume as well as with clinical outcome after mechanical thrombectomy for an AIS with DMVO.
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Affiliation(s)
- Maud Wang
- Department of Radiology, Leuven University Hospital, Leuven, Belgium
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Yousra Farouki
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Franny Hulscher
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Benjamin Mine
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Thomas Bonnet
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Stephanie Elens
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Juan Vazquez Suarez
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Lise Jodaitis
- Department of Neurology, Erasme University Hospital, Brussels, Belgium
| | - Noemie Ligot
- Department of Neurology, Erasme University Hospital, Brussels, Belgium
| | - Gilles Naeije
- Department of Neurology, Erasme University Hospital, Brussels, Belgium
| | - Boris Lubicz
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Adrien Guenego
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
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11
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Hernandez Petzsche MR, Boeckh-Behrens T, Bernkopf K, Henze S, Maegerlein C, Sepp D, Zimmer C, Wunderlich S, Ikenberg B, Berndt MT. Breaking with a dogma: persisting diffusion restrictions (pDWI) in follow-up after endovascular treatment for stroke. J Neurointerv Surg 2023; 15:1129-1135. [PMID: 36539271 DOI: 10.1136/jnis-2022-019678] [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: 09/26/2022] [Accepted: 11/24/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Post-stroke diffusion weighted imaging (DWI) signal transformation of the infarct core, which results in high apparent diffusion coefficient (ADC) values and variable DWI signal intensity, is completed no later than 1 month after onset of ischemia. We observed frequent exceptions to this timeline of change in DWI signal, which led to uncertainties in further clinical patient management. METHODS A prospective single-center study of patients treated with mechanical thrombectomy of a large vessel occlusion in the anterior circulation was conducted. Patients received high-resolution MRI at 3T, including DWI, in the acute post-stroke phase and in the follow-up after 3-12 months. RESULTS Overall, 78 patients (45 men) of mean age 63.6 years were evaluated. We identified persisting or new diffusion restriction in 29 of the 78 patients (37.2%) on follow-up imaging. Diffusion restrictions in a different location from the infarct core, representing new (sub-)acute ischemia, were observed in four patients (5.1%). Smaller areas of persisting diffusion restriction (pDWI lesions with high DWI signal and reduced ADC values) within the former infarct core were observed in 25 patients (32.1%) without clinical evidence of recurrent stroke, but with worse outcome scores at follow-up compared with patients without pDWI lesions. The presence of pDWI lesions is associated with a large primary infarct core (multivariate regression OR 1.03 (95% CI 1.01 to 1.05); p<0.01), mediating the relationship between pDWI lesions and clinical outcome. CONCLUSION Smaller foci of persisting diffusion restriction (pDWI lesions) in the follow-up after endovascular treatment for stroke are frequent and likely represent a slowed ADC signal progression within a formerly large infarct core.
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Affiliation(s)
- Moritz Roman Hernandez Petzsche
- Department of diagnostic and interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Tobias Boeckh-Behrens
- Department of diagnostic and interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Kathleen Bernkopf
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Simone Henze
- Department of diagnostic and interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Christian Maegerlein
- Department of diagnostic and interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Dominik Sepp
- Department of diagnostic and interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Claus Zimmer
- Department of diagnostic and interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Silke Wunderlich
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Benno Ikenberg
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Maria Teresa Berndt
- Department of diagnostic and interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
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12
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Xiang W, Wei H, Liang Z, Zhang M, Sun Z, Lv Y, Zhang C, Zheng H. FLAIR vascular hyperintensity combined with asymmetrical prominent veins in acute anterior circulation ischemic stroke: prediction of collateral circulation and clinical outcome. Eur J Med Res 2023; 28:446. [PMID: 37853442 PMCID: PMC10585931 DOI: 10.1186/s40001-023-01445-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/11/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND To investigate the value of fluid-attenuated inversion recovery vascular hyperintensity (FVH) within asymmetrical prominent veins sign (APVS) on susceptibility-weighted imaging predicting collateral circulation and prognosis in patients with acute anterior circulation ischemic stroke. METHOD Patients with severe stenosis or occlusion of ICA or MCA M1, who underwent MRI within 72 h from stroke onset were reviewed. The Alberta Stroke Program Early CT Score was used to evaluate the volume of infarction on DWI, the degree of FVH and APVS. Spearman correlation analysis was used to evaluate the correlation between FVH and APVS. All patients were divided into the good prognosis group and the poor prognosis group according to the score of the modified ranking scale (mRS) 90 days after the stroke. Logistic regression analysis was used to explore the relationship between FVH and APVS and functional prognosis, while receiver operating characteristic (ROC) curves were plotted to assess the value of FVH and APVS in predicting prognosis. RESULTS Spearman correlation analysis revealed moderate positive correlations between FVH and APVS (r = 0.586, P < 0.001). The poor prognosis group had a higher rate of a history of atrial fibrillation, a larger cerebral infarction volume, a higher NIHSS score at admission, and a higher FVH and APVS score compared with the good prognosis group (all P < 0.05). A further logistic regression indicated that the NIHSS score, cerebral infarction volume, FVH and APVS were independent risk factors for a poor functional prognosis. In terms of FVH, APVS, alone and their combination for the diagnosis of poor prognosis, the sensitivity, specificity, area under the ROC curve (AUC), and 95% confidence interval (CI) were 86.8%, 83.3%, 0.899 (95% CI 0.830-0.968); 60.5%, 93.7%, 0.818 (95% CI 0.723-0.912); 86.8%, 89.6%, 0.921 (95% CI 0.860-0.981), respectively. CONCLUSION The presence of FVH and APVS can provide a comprehensive assessment of collateral circulation from the perspective of veins and arteries, and the correlation between the two is positively correlated. Both of them were independent risk factors for poor prognosis, their combination is complementary and can improve the predictive value.
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Affiliation(s)
- Wei Xiang
- Department of Neurology, Yantai Yuhuangding Hospital Affiliated to Qingdao University, No. 20 East Yuhuangding Road, Yantai, 264000, Shandong, China
- Yantai Regional Sub-Center of China National Clinical Research Center for Neurological Diseases, Yantai, China
| | - Hongchun Wei
- Department of Neurology, Yantai Yuhuangding Hospital Affiliated to Qingdao University, No. 20 East Yuhuangding Road, Yantai, 264000, Shandong, China
- Yantai Regional Sub-Center of China National Clinical Research Center for Neurological Diseases, Yantai, China
| | - Zhigang Liang
- Department of Neurology, Yantai Yuhuangding Hospital Affiliated to Qingdao University, No. 20 East Yuhuangding Road, Yantai, 264000, Shandong, China.
- Yantai Regional Sub-Center of China National Clinical Research Center for Neurological Diseases, Yantai, China.
| | - Manman Zhang
- The Second Clinical Medical College, Binzhou Medical University, Yantai, China
| | - Zhongwen Sun
- Department of Neurology, Yantai Yuhuangding Hospital Affiliated to Qingdao University, No. 20 East Yuhuangding Road, Yantai, 264000, Shandong, China
- Yantai Regional Sub-Center of China National Clinical Research Center for Neurological Diseases, Yantai, China
| | - Yaodong Lv
- Department of Neurology, Yantai Yuhuangding Hospital Affiliated to Qingdao University, No. 20 East Yuhuangding Road, Yantai, 264000, Shandong, China
- Yantai Regional Sub-Center of China National Clinical Research Center for Neurological Diseases, Yantai, China
| | - Chengzhou Zhang
- Department of Radiology, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, China
| | - Huaguang Zheng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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13
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Jo H, Kim C, Gwon D, Lee J, Lee J, Park KM, Park S. Combining clinical and imaging data for predicting functional outcomes after acute ischemic stroke: an automated machine learning approach. Sci Rep 2023; 13:16926. [PMID: 37805568 PMCID: PMC10560215 DOI: 10.1038/s41598-023-44201-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 10/04/2023] [Indexed: 10/09/2023] Open
Abstract
This study aimed to develop and validate an automated machine learning (ML) system that predicts 3-month functional outcomes in acute ischemic stroke (AIS) patients by combining clinical and neuroimaging features. Functional outcomes were categorized as unfavorable (modified Rankin Scale ≥ 3) or not. A clinical model employing optimal clinical features (Model_A), a convolutional neural network model incorporating imaging data (Model_B), and an integrated model combining both imaging and clinical features (Model_C) were developed and tested to predict unfavorable outcomes. The developed models were compared with each other and with traditional risk-scoring models. The dataset comprised 4147 patients from a multicenter stroke registry, with 1268 (30.6%) experiencing unfavorable outcomes. Age, initial NIHSS, and early neurologic deterioration were identified as the most important clinical features. The ML model prediction achieved an area under the curves of 0.757 (95% CI 0.726-0.789) for Model_A, 0.725 (95% CI 0.693-0.755) for Model_B, and 0.786 (95% CI 0.757-0.814) for Model_C in the test set. The integrated models outperformed traditional risk-scoring models by 0.21 (95% CI 0.16-0.25) for HIAT and 0.15 (95% CI 0.11-0.19) for THRIVE. In conclusion, the integrated ML system enhanced stroke outcome prediction by combining imaging data and clinical features, outperforming traditional risk-scoring models.
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Affiliation(s)
- Hongju Jo
- Department of CGMS Sensor, Sensor R&D Center, i-SENS, Seoul, Republic of Korea
| | - Changi Kim
- Integrated Major in Innovative Medical Science, Seoul National University Graduate School, Seoul, Republic of Korea
| | - Dowan Gwon
- Department of Digital&Biohealth, Group of AI/DX Business, KT, Seoul, Republic of Korea
| | - Jaeho Lee
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Joonwon Lee
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, Haeundae-gu, 48108, Busan, Republic of Korea
| | - Kang Min Park
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, Haeundae-gu, 48108, Busan, Republic of Korea
| | - Seongho Park
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Haeundae-ro 875, Haeundae-gu, 48108, Busan, Republic of Korea.
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14
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Liu Y, Yu Y, Ouyang J, Jiang B, Yang G, Ostmeier S, Wintermark M, Michel P, Liebeskind DS, Lansberg MG, Albers GW, Zaharchuk G. Functional Outcome Prediction in Acute Ischemic Stroke Using a Fused Imaging and Clinical Deep Learning Model. Stroke 2023; 54:2316-2327. [PMID: 37485663 PMCID: PMC11229702 DOI: 10.1161/strokeaha.123.044072] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 06/21/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND Predicting long-term clinical outcome based on the early acute ischemic stroke information is valuable for prognostication, resource management, clinical trials, and patient expectations. Current methods require subjective decisions about which imaging features to assess and may require time-consuming postprocessing. This study's goal was to predict ordinal 90-day modified Rankin Scale (mRS) score in acute ischemic stroke patients by fusing a Deep Learning model of diffusion-weighted imaging images and clinical information from the acute period. METHODS A total of 640 acute ischemic stroke patients who underwent magnetic resonance imaging within 1 to 7 days poststroke and had 90-day mRS follow-up data were randomly divided into 70% (n=448) for model training, 15% (n=96) for validation, and 15% (n=96) for internal testing. Additionally, external testing on a cohort from Lausanne University Hospital (n=280) was performed to further evaluate model generalization. Accuracy for ordinal mRS, accuracy within ±1 mRS category, mean absolute prediction error, and determination of unfavorable outcome (mRS score >2) were evaluated for clinical only, imaging only, and 2 fused clinical-imaging models. RESULTS The fused models demonstrated superior performance in predicting ordinal mRS score and unfavorable outcome in both internal and external test cohorts when compared with the clinical and imaging models. For the internal test cohort, the top fused model had the highest area under the curve of 0.92 for unfavorable outcome prediction and the lowest mean absolute error (0.96 [95% CI, 0.77-1.16]), with the highest proportion of mRS score predictions within ±1 category (79% [95% CI, 71%-88%]). On the external Lausanne University Hospital cohort, the best fused model had an area under the curve of 0.90 for unfavorable outcome prediction and outperformed other models with an mean absolute error of 0.90 (95% CI, 0.79-1.01), and the highest percentage of mRS score predictions within ±1 category (83% [95% CI, 78%-87%]). CONCLUSIONS A Deep Learning-based imaging model fused with clinical variables can be used to predict 90-day stroke outcome with reduced subjectivity and user burden.
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Affiliation(s)
- Yongkai Liu
- Department of Radiology (Y.L., Y.Y., J.O., B.J., S.O., G.Z.)
| | - Yannan Yu
- Department of Radiology (Y.L., Y.Y., J.O., B.J., S.O., G.Z.)
| | - Jiahong Ouyang
- Department of Radiology (Y.L., Y.Y., J.O., B.J., S.O., G.Z.)
- Department of Electrical Engineering (J.O.), Stanford University, CA
| | - Bin Jiang
- Department of Radiology (Y.L., Y.Y., J.O., B.J., S.O., G.Z.)
| | - Guang Yang
- National Heart and Lung Institute, Imperial College London, United Kingdom (G.Y.)
| | - Sophie Ostmeier
- Department of Radiology (Y.L., Y.Y., J.O., B.J., S.O., G.Z.)
| | - Max Wintermark
- Department of Neuroradiology, University of Texas MD Anderson Center, Houston (M.W.)
| | - Patrik Michel
- Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Switzerland (P.M.)
| | | | - Maarten G Lansberg
- Department of Neurology, Stanford University, Stanford, CA (M.G.L., G.W.A.)
| | - Gregory W Albers
- Department of Neurology, Stanford University, Stanford, CA (M.G.L., G.W.A.)
| | - Greg Zaharchuk
- Department of Radiology (Y.L., Y.Y., J.O., B.J., S.O., G.Z.)
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15
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Doheim MF, Hagrass AI, Elrefaey M, Al-Bayati AR, Bhatt NR, Lang M, Starr M, Rocha M, Gross B, Nogueira RG. From therapeutic nihilism to armamentarium: A meta-analysis of randomized clinical trials assessing safety and efficacy of endovascular therapy for acute large ischemic strokes. Interv Neuroradiol 2023:15910199231170681. [PMID: 37082795 DOI: 10.1177/15910199231170681] [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: 04/22/2023] Open
Abstract
BACKGROUND Three recent randomized clinical trials (RCTs) investigated the potential benefit of endovascular therapy (EVT) in acute ischemic stroke patients presenting with large infarcts. We aimed to confirm the safety and efficacy of EVT in patients presenting with large infarcts and provide more precise estimations of the treatment effects using study-level meta-analysis. METHODS Comprehensive search of MEDLINE database through PubMed till February 2023 was performed including RCTs only. The data were then extracted from the selected studies and pooled as risk ratio (RR) with 95% confidence interval (95% CI). RESULTS There were a total of 1005 patients across the three qualifying RCTs. Regarding the functional outcomes assessed by modified Rankin Scale (mRS) score, the analyzed data demonstrated statistically significant differences in favor of thrombectomy for both independent ambulatory status (mRS 0-3: RR = 1.78, 95% CI [1.28, 2.48], p = 0.0006) and functional independence (mRS 0-2: RR = 2.54, 95% CI [1.85, 3.48], p < 0.001). The analyzed data did not demonstrate any statistically significant differences between EVT and medical management alone in terms of 90-day mortality (RR = 0.95, 95% CI [0.78, 1.16], p = 0.61), symptomatic intracranial hemorrhage (RR = 1.83, 95% CI [0.95, 3.55], p = 0.07), and need for hemicraniectomy (RR = 1.22, 95% CI [0.43, 3.41], p = 0.71). CONCLUSION This study confirms the benefit of EVT on functional outcomes of patients presenting with large ischemic infarcts without significant differences in the rates of symptomatic intracranial hemorrhage, hemicraniectomy, or 90-day mortality.
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Affiliation(s)
- Mohamed F Doheim
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Mohamed Elrefaey
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Alhamza R Al-Bayati
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nirav R Bhatt
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael Lang
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurosurgery, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Matthew Starr
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Marcelo Rocha
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Bradley Gross
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurosurgery, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Raul G Nogueira
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Jiang L, Miao Z, Chen H, Geng W, Yong W, Chen YC, Zhang H, Duan S, Yin X, Zhang Z. Radiomics Analysis of Diffusion-Weighted Imaging and Long-Term Unfavorable Outcomes Risk for Acute Stroke. Stroke 2023; 54:488-498. [PMID: 36472198 DOI: 10.1161/strokeaha.122.040418] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Diffusion-weighted imaging radiomics could be used as prognostic biomarkers in acute ischemic stroke. We aimed to identify a clinical and diffusion-weighted imaging radiomics model for individual unfavorable outcomes risk assessment in acute ischemic stroke. METHODS A total of 1716 patients with acute ischemic stroke from 2 centers were divided into a training cohort and a validation cohort. Patient outcomes were measured with the modified Rankin Scale score. An unfavorable outcome was defined as a modified Rankin Scale score greater than 2. The primary end point was all-cause mortality or outcomes 1 year after stroke. The MRI-DRAGON score was calculated based on previous publications. We extracted and selected the infarct features on diffusion-weighted imaging to construct a radiomic signature. The clinic-radiomics signature was built by measuring the Cox proportional risk regression score (CrrScore) and compared with the MRI-DRAGON score and the ClinicScore. CrrScore model performance was estimated by 1-year unfavorable outcomes prediction. RESULTS A high radiomic signature predicted a higher probability of unfavorable outcomes than a low radiomic signature in the training (hazard ratio, 3.19 [95% CI, 2.51-4.05]; P<0.0001) and validation (hazard ratio, 3.25 [95% CI, 2.20-4.80]; P<0.0001) cohorts. The diffusion-weighted imaging Alberta Stroke Program Early CT Score, age, glucose level before therapy, National Institutes of Health Stroke Scale score on admission, glycated hemoglobin' radiomic signature, hemorrhagic infarction, and malignant cerebral edema were associated with an unfavorable outcomes risk after multivariable adjustment. A CrrScore nomogram was developed to predict outcomes and had the best performance in the training (area under the curve, 0.862) and validation cohorts (area under the curve, 0.858). The CrrScore model time-dependent areas under the curve of the probability of unfavorable outcomes at 1 year in the training and validation cohorts were 0.811 and 0.801, respectively. CONCLUSIONS The CrrScore model allows the accurate prediction of patients with acute ischemic stroke outcomes and can potentially guide rehabilitation therapies for patients with different risks of unfavorable outcomes.
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Affiliation(s)
- Liang Jiang
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, China (L.J., Z.M., H.C., W.G., W.Y., Y.-C.C., X.Y.)
| | - Zhengfei Miao
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, China (L.J., Z.M., H.C., W.G., W.Y., Y.-C.C., X.Y.)
| | - Huiyou Chen
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, China (L.J., Z.M., H.C., W.G., W.Y., Y.-C.C., X.Y.)
| | - Wen Geng
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, China (L.J., Z.M., H.C., W.G., W.Y., Y.-C.C., X.Y.)
| | - Wei Yong
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, China (L.J., Z.M., H.C., W.G., W.Y., Y.-C.C., X.Y.)
| | - Yu-Chen Chen
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, China (L.J., Z.M., H.C., W.G., W.Y., Y.-C.C., X.Y.)
| | - Hong Zhang
- Department of Radiology, Affiliated Jiangning Hospital of Nanjing Medical University, China (H.Z.)
| | - Shaofeng Duan
- GE Healthcare' Precision Health Institution' China (S.D.)
| | - Xindao Yin
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, China (L.J., Z.M., H.C., W.G., W.Y., Y.-C.C., X.Y.)
| | - Zhiqiang Zhang
- Department of Radiology, Affiliated Jinling Hospital, Medical School of Nanjing University, China (Z.Z.)
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Optimizing intraluminal monofilament model of ischemic stroke in middle-aged Sprague-Dawley rats. BMC Neurosci 2022; 23:75. [PMID: 36494808 PMCID: PMC9733327 DOI: 10.1186/s12868-022-00764-2] [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: 09/29/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
Abstract
Intraluminal monofilament model of middle cerebral artery occlusion (MCAO) is widely adopted for ischemic stroke; and Sprague-Dawley (SD) rats are commonly used rodents for preclinical research. Due to the paucity of information on the appropriate monofilament size for inducing MCAO in SD rats and the importance of including middle-aged models in ischemic stroke studies, we aimed to: (i). determine an appropriate Doccol® monofilament size for middle-aged male SD rats which weighed > 500 g following 24-h transient MCAO survival as well as (ii). demonstrate the optimal Doccol® filament size for middle-aged males (≤ 500 g) and females (273-300 g) while using young adult male SD rats (372-472 g) as control for severity of infarct volume following 7-days post-MCAO. All rats were subjected to 90-min transient MCAO. We show that 0.43 mm Doccol® monofilament size is more appropriate to induce large infarct lesion and optimal functional deficit when compared to 0.45 mm and 0.47 mm at 24 h post-MCAO. Our data on infarct volumes at 7 days post-MCAO as well as the observed weight loss and functional deficits at post-MCAO days 1, 3 and 7 demonstrate that 0.41 mm, 0.37 mm and 0.39 mm are optimal Doccol® filament sizes for middle-aged male (477.3 ± 39.61 g) and female (302.6 ± 26.28 g) as well as young-adult male (362.2 ± 28.38 g) SD rats, respectively.
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18
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Bonkhoff AK, Ullberg T, Bretzner M, Hong S, Schirmer MD, Regenhardt RW, Donahue KL, Nardin MJ, Dalca AV, Giese AK, Etherton MR, Hancock BL, Mocking SJT, McIntosh EC, Attia J, Cole JW, Donatti A, Griessenauer CJ, Heitsch L, Holmegaard L, Jood K, Jimenez-Conde J, Kittner SJ, Lemmens R, Levi CR, McDonough CW, Meschia JF, Phuah CL, Ropele S, Rosand J, Roquer J, Rundek T, Sacco RL, Schmidt R, Sharma P, Slowik A, Sousa A, Stanne TM, Strbian D, Tatlisumak T, Thijs V, Vagal A, Woo D, Zand R, McArdle PF, Worrall BB, Jern C, Lindgren AG, Maguire J, Wu O, Frid P, Rost NS, Wasselius J. Deep profiling of multiple ischemic lesions in a large, multi-center cohort: Frequency, spatial distribution, and associations to clinical characteristics. Front Neurosci 2022; 16:994458. [PMID: 36090258 PMCID: PMC9453031 DOI: 10.3389/fnins.2022.994458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 08/02/2022] [Indexed: 11/17/2022] Open
Abstract
Background purpose A substantial number of patients with acute ischemic stroke (AIS) experience multiple acute lesions (MAL). We here aimed to scrutinize MAL in a large radiologically deep-phenotyped cohort. Materials and methods Analyses relied upon imaging and clinical data from the international MRI-GENIE study. Imaging data comprised both Fluid-attenuated inversion recovery (FLAIR) for white matter hyperintensity (WMH) burden estimation and diffusion-weighted imaging (DWI) sequences for the assessment of acute stroke lesions. The initial step featured the systematic evaluation of occurrences of MAL within one and several vascular supply territories. Associations between MAL and important imaging and clinical characteristics were subsequently determined. The interaction effect between single and multiple lesion status and lesion volume was estimated by means of Bayesian hierarchical regression modeling for both stroke severity and functional outcome. Results We analyzed 2,466 patients (age = 63.4 ± 14.8, 39% women), 49.7% of which presented with a single lesion. Another 37.4% experienced MAL in a single vascular territory, while 12.9% featured lesions in multiple vascular territories. Within most territories, MAL occurred as frequently as single lesions (ratio ∼1:1). Only the brainstem region comprised fewer patients with MAL (ratio 1:4). Patients with MAL presented with a significantly higher lesion volume and acute NIHSS (7.7 vs. 1.7 ml and 4 vs. 3, p FDR < 0.001). In contrast, patients with a single lesion were characterized by a significantly higher WMH burden (6.1 vs. 5.3 ml, p FDR = 0.048). Functional outcome did not differ significantly between patients with single versus multiple lesions. Bayesian analyses suggested that the association between lesion volume and stroke severity between single and multiple lesions was the same in case of anterior circulation stroke. In case of posterior circulation stroke, lesion volume was linked to a higher NIHSS only among those with MAL. Conclusion Multiple lesions, especially those within one vascular territory, occurred more frequently than previously reported. Overall, multiple lesions were distinctly linked to a higher acute stroke severity, a higher total DWI lesion volume and a lower WMH lesion volume. In posterior circulation stroke, lesion volume was linked to a higher stroke severity in multiple lesions only.
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Affiliation(s)
- Anna K. Bonkhoff
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Teresa Ullberg
- Department of Clinical Sciences Lund, Radiology, Lund University, Lund, Sweden
- Department of Radiology and Neuroradiology, Skåne University Hospital, Lund, Sweden
| | - Martin Bretzner
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- U1171 – LilNCog (JPARC) – Lille Neurosciences Cognition and University of Lille, Inserm, CHU Lille, Lille, France
| | - Sungmin Hong
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Markus D. Schirmer
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Robert W. Regenhardt
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Kathleen L. Donahue
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Marco J. Nardin
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Adrian V. Dalca
- Computer Science and Artificial Intelligence Lab, Massachusetts Institute of Technology, Boston, MA, United States
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, United States
| | - Anne-Katrin Giese
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mark R. Etherton
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Brandon L. Hancock
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, United States
| | - Steven J. T. Mocking
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, United States
| | - Elissa C. McIntosh
- Department of Psychiatry, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - John Attia
- Hunter Medical Research Institute, Newcastle, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - John W. Cole
- Department of Neurology, University of Maryland, School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore, MD, United States
| | - Amanda Donatti
- School of Medical Sciences, The Brazilian Institute of Neuroscience and Neurotechnology (BRAINN), University of Campinas (UNICAMP), Campinas, Brazil
| | - Christoph J. Griessenauer
- Department of Neurosurgery, Geisinger, Danville, PA, United States
- Department of Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
| | - Laura Heitsch
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, United States
- Department of Neurology, Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO, United States
| | - Lukas Holmegaard
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Katarina Jood
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jordi Jimenez-Conde
- Department of Neurology, Neurovascular Research Group (NEUVAS), IMIM-Hospital del Mar (Institut Hospital del Mar d’Investigacions Mèdiques), Universitat Pompeu Fabra, Barcelona, Spain
- Department of Medicine and Life Sciences (MELIS), Universitat Pompeu Fabra, Barcelona, Spain
| | - Steven J. Kittner
- Department of Neurology, University of Maryland, School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore, MD, United States
| | - Robin Lemmens
- Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience, Disease (LIND), KU Leuven - University of Leuven, Leuven, Belgium
- Laboratory of Neurobiology, Department of Neurology, Vesalius Research Center (VIB), University Hospitals Leuven, Leuven, Belgium
| | - Christopher R. Levi
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
- Department of Pharmacotherapy, Translational Research, Center for Pharmacogenomics, University of Florida, Gainesville, FL, United States
| | | | - James F. Meschia
- Department of Neurology, Clinical Division of Neurogeriatrics, Medical University Graz, Graz, Austria
| | - Chia-Ling Phuah
- Department of Neurology, Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO, United States
| | - Stefan Ropele
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
| | - Jonathan Rosand
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, United States
- Department of Neurology, Evelyn F. McKnight Brain Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Jaume Roquer
- Department of Neurology, Neurovascular Research Group (NEUVAS), IMIM-Hospital del Mar (Institut Hospital del Mar d’Investigacions Mèdiques), Universitat Pompeu Fabra, Barcelona, Spain
- Department of Medicine and Life Sciences (MELIS), Universitat Pompeu Fabra, Barcelona, Spain
| | - Tatjana Rundek
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Ralph L. Sacco
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Reinhold Schmidt
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
| | - Pankaj Sharma
- Institute of Cardiovascular Research, St Peter’s, Ashford Hospitals, Royal Holloway University of London (ICR2UL), Egham, United Kingdom
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - Alessandro Sousa
- School of Medical Sciences, The Brazilian Institute of Neuroscience and Neurotechnology (BRAINN), University of Campinas (UNICAMP), Campinas, Brazil
| | - Tara M. Stanne
- Department of Laboratory Medicine, Institute of Biomedicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Vincent Thijs
- Division of Stroke, Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Achala Vagal
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Daniel Woo
- Department of Neurology, Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Ramin Zand
- Department of Neurology, Pennsylvania State University, Hershey, PA, United States
| | - Patrick F. McArdle
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Bradford B. Worrall
- Department of Neurology, University of Virginia, Charlottesville, VA, United States
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, United States
| | - Christina Jern
- Department of Laboratory Medicine, Institute of Biomedicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Genetics and Genomics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Arne G. Lindgren
- Department of Neurology, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden
| | - Jane Maguire
- University of Technology, Faculty of Health, Sydney, NSW, Australia
| | - Ona Wu
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, United States
| | - Petrea Frid
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden
| | - Natalia S. Rost
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Johan Wasselius
- Department of Clinical Sciences Lund, Radiology, Lund University, Lund, Sweden
- Department of Radiology and Neuroradiology, Skåne University Hospital, Lund, Sweden
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Prognostic value of post-treatment fluid-attenuated inversion recovery vascular hyperintensity in ischemic stroke after endovascular thrombectomy. Eur Radiol 2022; 32:8067-8076. [PMID: 35665844 DOI: 10.1007/s00330-022-08886-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 04/10/2022] [Accepted: 05/16/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To explore the value of post-treatment fluid-attenuated inversion recovery vascular hyperintensity (FVH) in predicting clinical outcome in patients with acute ischemic stroke (AIS) after endovascular thrombectomy (EVT). METHODS This retrospective study reviewed data from consecutive patients with large vessel occlusion of anterior circulation between July 2017 and February 2021. Together with other variables, status of post-treatment FVH was assessed for each patient. Good outcome was defined as a 3-month modified Rankin Scale score of 0-2. Chi-square test, Fisher's exact test, independent-samples t test, multivariate logistic regression analysis, and receiver operating characteristic analysis were used as appropriate. RESULTS Among 84 included patients, 48 (57.1%) patients showed post-treatment FVH. Post-treatment FVH significantly correlated with incomplete recanalization (p < 0.05) and low Alberta Stroke Project Early CT Changes Score on post-treatment diffusion-weighted imaging (p < 0.05). Higher incidence of hemorrhage transformation was observed in patients with post-treatment FVH than those without (27.1% vs. 16.7%); however, the difference did not reach significance (p = 0.259). Successful recanalization (odds ratio [OR], 0.024; 95% confidence interval [CI] 0.003-0.194; p < 0.05), lower National Institutes of Health Stroke Scale scores at admission (NIHSSpre) (OR, 1.196; 95% CI, 1.017-1.406; p < 0.05), and no post-treatment FVH (OR, 74.690; 95% CI, 4.624-1206.421; p < 0.05) were found to be independent predictors of good outcomes. Combined models integrating all three independent predictors (recanalization+NIHSSpre+post-treatment FVH) significantly outperformed the combined model without post-treatment FVH (recanalization+NIHSSpre) in predicting clinical outcome (p = 0.004). CONCLUSIONS Post-treatment FVH may be an effective prognostic marker associated with clinical outcome in patients with AIS after EVT. KEY POINTS • Post-treatment FVH correlates with incomplete recanalization and higher infarct volume. • Post-treatment FVH is independently associated with an unfavorable outcome. • Post-treatment FVH may provide prognostic information in patients with AIS after EVT.
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Geng D, Xu X, Luan X, Qiu L, Chen L, Chen J, Wu B, Xu M, Ergashev A, Tang W, Li J. Differential Influence of the COVID-19 Pandemic on Mechanical Thrombectomy and Bridging Therapy for Acute Ischemic Stroke. Front Neurol 2022; 13:852423. [PMID: 35392636 PMCID: PMC8981201 DOI: 10.3389/fneur.2022.852423] [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: 01/11/2022] [Accepted: 02/18/2022] [Indexed: 11/13/2022] Open
Abstract
Background The coronavirus disease 2019 (COVID-19) pandemic is having a dramatic impact on acute stroke care. Its effects may accompany stroke care for a long time. We compared the treatment, short-term and long-term functional outcomes of patients with AIS from 2019 to 2020. Our objective was to evaluate the effect of COVID-19 epidemic on mechanical thrombectomy (MT) in patients in our hospital. Methods We collected information on subjects treated with MT in 2019–2020, including age, sex, time from the onset to arterial sheath insertion, time from the onset to recanalization, the rate of lung infection and hemorrhagic transformation, modified Rankin scale (mRS), NHISS, and ASPECTS. Results The number of patients with MT decreased significantly by 26.6% in 2020 (p = 0.025). The pretreatment ASPECTS score for 2020 was significantly higher than 2019 (p = 0.004). Besides, the patients were more likely to develop lung infection (65 vs. 54.1%, p = 0.042) and had a higher risk of hemorrhagic transformation (47.4% vs. 30.4%, p = 0.005) in 2019. The discharged mRS reflected the worse short-term functional prognosis of patients with MT in 2019 (66 vs. 44.9%, p = 0.046). In the subgroup analysis of bridging thrombolysis (BT), more patients with BT are expected to have a poor short-term functional prognosis in 2020, according to the discharged mRS (62.5 vs. 37.5%, p = 0.024). However, there was no difference in mRS at 180 days between the two groups (p = 0.094). Conclusion For patients with MT, both short- and long-term functional outcomes were not significantly affected due to the mild condition of patients admitted to hospital in 2020. For patients with BT, the COVID-19 pandemic has prolonged the green channel time of stroke, leading to a poor short-term functional prognosis of patients with stroke in the pandemic period. There was no difference in the effectiveness of direct MT and BT during the COVID-19 pandemic.
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Affiliation(s)
- Dandan Geng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xueqian Xu
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaoqian Luan
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Linan Qiu
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Liuzhu Chen
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jiahao Chen
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Beilan Wu
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Minjie Xu
- Wenzhou Medical University School of Mental Health, Wenzhou, China
| | - Akmal Ergashev
- Department of General Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wenjie Tang
- The First School of Clinical Medicine, Wenzhou Medical University, Wenzhou, China
- Wenjie Tang
| | - Jia Li
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- *Correspondence: Jia Li
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21
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Wang A, Cui T, Wang C, Zhu Q, Zhang X, Li S, Yang Y, Shang W, Wu B. Prognostic Significance of Admission Glucose Combined with Hemoglobin A1c in Acute Ischemic Stroke Patients with Reperfusion Therapy. Brain Sci 2022; 12:brainsci12020294. [PMID: 35204058 PMCID: PMC8869904 DOI: 10.3390/brainsci12020294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/07/2022] [Accepted: 02/12/2022] [Indexed: 02/05/2023] Open
Abstract
Background: Elevated admission glucose and hemoglobin A1c (HbA1c) levels have been suggested to be associated with 90-day functional outcomes in acute ischemic stroke (AIS) patients with endovascular thrombectomy (EVT). However, whether the prognostic significance of admission glucose and that of HbA1c have a joint effect on patients with intravascular thrombolysis (IVT) and/or EVT remains unclear. This study aimed to explore the association between admission glucose combined with HbA1c and outcomes in patients with reperfusion therapy. Methods: Consecutive AIS patients treated with IVT and/or EVT between 2 January 2018 and 27 February 2021 in West China hospital were enrolled. Admission glucose and HbA1c levels were measured at admission. Participants were divided into four groups according to admission glucose level (categorical variable: <7.8 and ≥7.8 mmol/L) and HbA1c level (categorical variable: <6.5% and ≥6.5%): normal glucose and normal HbA1c (NGNA), normal glucose and high HbA1c (NGHA), high glucose and normal HbA1c (HGNA), and high glucose and high HbA1c (HGHA). The primary outcome was an unfavorable functional outcome defined as a modified Rankin Scale (mRS) ≥ 3. The secondary outcome was all-cause mortality at 90 days. Results: A total of 519 patients (mean age, 69.0 ± 13.4 years; 53.8% males) were included. Patients in the HGHA group had a significantly increased risk of unfavorable functional outcome (OR, 1.81; 95%CI, 1.01–3.23) and mortality (OR, 1.75; 95%CI, 1.01–3.06) at 90 days compared with those in the NGNA group after adjustment for confounders. There was no significant association between NGHA (OR, 0.43; 95%CI, 0.12–1.53) or HGNA (OR, 1.46; 95%CI, 0.84–2.56) and outcomes compared to the NGNA group. Conclusion: The combination of high admission glucose and high HbA1c level was significantly associated with unfavorable functional outcome and mortality at 90 days in AIS patients with reperfusion therapy.
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Affiliation(s)
- Anmo Wang
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu 610041, China; (A.W.); (T.C.); (X.Z.); (S.L.); (Y.Y.); (W.S.)
| | - Ting Cui
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu 610041, China; (A.W.); (T.C.); (X.Z.); (S.L.); (Y.Y.); (W.S.)
| | - Changyi Wang
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu 610041, China;
| | - Qiange Zhu
- The Second Department of Neurology, Shanxi Provincial People’s Hospital, Xi’an 710068, China;
| | - Xuening Zhang
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu 610041, China; (A.W.); (T.C.); (X.Z.); (S.L.); (Y.Y.); (W.S.)
| | - Shucheng Li
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu 610041, China; (A.W.); (T.C.); (X.Z.); (S.L.); (Y.Y.); (W.S.)
| | - Yuan Yang
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu 610041, China; (A.W.); (T.C.); (X.Z.); (S.L.); (Y.Y.); (W.S.)
| | - Wenzuo Shang
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu 610041, China; (A.W.); (T.C.); (X.Z.); (S.L.); (Y.Y.); (W.S.)
| | - Bo Wu
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu 610041, China; (A.W.); (T.C.); (X.Z.); (S.L.); (Y.Y.); (W.S.)
- Correspondence: ; Tel.: +86-189-8060-2142
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