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Winder AJ, Stanley EA, Fiehler J, Forkert ND. Challenges and Potential of Artificial Intelligence in Neuroradiology. Clin Neuroradiol 2024; 34:293-305. [PMID: 38285239 DOI: 10.1007/s00062-024-01382-7] [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: 10/13/2023] [Accepted: 01/03/2024] [Indexed: 01/30/2024]
Abstract
PURPOSE Artificial intelligence (AI) has emerged as a transformative force in medical research and is garnering increased attention in the public consciousness. This represents a critical time period in which medical researchers, healthcare providers, insurers, regulatory agencies, and patients are all developing and shaping their beliefs and policies regarding the use of AI in the healthcare sector. The successful deployment of AI will require support from all these groups. This commentary proposes that widespread support for medical AI must be driven by clear and transparent scientific reporting, beginning at the earliest stages of scientific research. METHODS A review of relevant guidelines and literature describing how scientific reporting plays a central role at key stages in the life cycle of an AI software product was conducted. To contextualize this principle within a specific medical domain, we discuss the current state of predictive tissue outcome modeling in acute ischemic stroke and the unique challenges presented therein. RESULTS AND CONCLUSION Translating AI methods from the research to the clinical domain is complicated by challenges related to model design and validation studies, medical product regulations, and healthcare providers' reservations regarding AI's efficacy and affordability. However, each of these limitations is also an opportunity for high-impact research that will help to accelerate the clinical adoption of state-of-the-art medical AI. In all cases, establishing and adhering to appropriate reporting standards is an important responsibility that is shared by all of the parties involved in the life cycle of a prospective AI software product.
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Affiliation(s)
- Anthony J Winder
- Department of Radiology, University of Calgary, Calgary, Canada.
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada.
| | - Emma Am Stanley
- Department of Radiology, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- Biomedical Engineering Graduate Program, University of Calgary, Calgary, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Canada
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nils D Forkert
- Department of Radiology, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Canada
- Department of Clinical Neuroscience, University of Calgary, Calgary, Canada
- Department of Electrical and Software Engineering, University of Calgary, Calgary, Canada
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2
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Beyeler M, Pohle F, Weber L, Mueller M, Kurmann CC, Mujanovic A, Clénin L, Piechowiak EI, Meinel TR, Bücke P, Jung S, Seiffge D, Pilgram-Pastor SM, Dobrocky T, Arnold M, Gralla J, Fischer U, Mordasini P, Kaesmacher J. Long-Term Effect of Mechanical Thrombectomy in Stroke Patients According to Advanced Imaging Characteristics. Clin Neuroradiol 2024; 34:105-114. [PMID: 37642685 PMCID: PMC10881753 DOI: 10.1007/s00062-023-01337-4] [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: 03/05/2023] [Accepted: 07/13/2023] [Indexed: 08/31/2023]
Abstract
PURPOSE Data on long-term effect of mechanical thrombectomy (MT) in patients with large ischemic cores (≥ 70 ml) are scarce. Our study aimed to assess the long-term outcomes in MT-patients according to baseline advanced imaging parameters. METHODS We performed a single-centre retrospective cohort study of stroke patients receiving MT between January 1, 2010 and December 31, 2018. We assessed baseline imaging to determine core and mismatch volumes and hypoperfusion intensity ratio (with low ratio reflecting good collateral status) using RAPID automated post-processing software. Main outcomes were cross-sectional long-term mortality, functional outcome and quality of life by May 2020. Analysis were stratified by the final reperfusion status. RESULTS In total 519 patients were included of whom 288 (55.5%) have deceased at follow-up (median follow-up time 28 months, interquartile range 1-55). Successful reperfusion was associated with lower long-term mortality in patients with ischemic core volumes ≥ 70 ml (adjusted hazard ratio (aHR) 0.20; 95% confidence interval (95% CI) 0.10-0.44) and ≥ 100 ml (aHR 0.26; 95% CI 0.08-0.87). The effect of successful reperfusion on long-term mortality was significant only in the presence of relevant mismatch (aHR 0.17; 95% CI 0.01-0.44). Increasing reperfusion grade was associated with a higher rate of favorable outcomes (mRS 0-3) also in patients with ischemic core volume ≥ 70 ml (aOR 3.58, 95% CI 1.64-7.83). CONCLUSION Our study demonstrated a sustainable benefit of better reperfusion status in patients with large ischemic core volumes. Our results suggest that patient deselection based on large ischemic cores alone is not advisable.
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Affiliation(s)
- Morin Beyeler
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland.
| | - Fabienne Pohle
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Loris Weber
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Madlaine Mueller
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Christoph C Kurmann
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Adnan Mujanovic
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Leander Clénin
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Eike Immo Piechowiak
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Thomas Raphael Meinel
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Philipp Bücke
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - David Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Sara M Pilgram-Pastor
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Tomas Dobrocky
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
- Neurology Department, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland.
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Gravino G, Samaha S, Patel J, Babatola F, Chandran A. CT (neuro)angiography protocols for ischaemic and haemorrhagic strokes: a regional evaluation and technical note from a tertiary neuroscience centre. Clin Radiol 2024; 79:41-46. [PMID: 37957077 DOI: 10.1016/j.crad.2023.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 09/20/2023] [Accepted: 10/17/2023] [Indexed: 11/15/2023]
Affiliation(s)
- G Gravino
- Neuroradiology Department, The Walton Centre for Neurology and Neurosurgery, Liverpool, UK.
| | - S Samaha
- Neuroradiology Department, The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - J Patel
- Neuroradiology Department, The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - F Babatola
- Neuroradiology Department, The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - A Chandran
- Neuroradiology Department, The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
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Gohla G, Schwarz R, Bier G, Estler A, Bongers MN, Ditt H, Fritz J, Kemmling A, Ernemann U, Horger M. A novel fully automated method for measuring ASPECTS to improve stroke diagnosis: Comparison to traditional ASPECTS. J Neuroimaging 2024; 34:145-151. [PMID: 37807097 DOI: 10.1111/jon.13159] [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: 06/23/2023] [Revised: 09/20/2023] [Accepted: 09/24/2023] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND AND PURPOSE To compare the accuracy of subjective Alberta Stroke Program Early CT Score (sASPECTS) evaluation and that of an automated prototype software (aASPECTS) on nonenhanced CT (NECT) in patients with early anterior territory stroke and controls using side-to-side quantification of hypoattenuated brain areas. METHODS We retrospectively analyzed the NECT scans of 42 consecutive patients with ischemic stroke before reperfusion and 42 controls using first sASPECTS and subsequently aASPECTS. We assessed the differences in Alberta Stroke Program Early CT Score (ASPECTS) and calculated the sensitivity and specificity of NECT with CT perfusion, whereas cerebral blood volume (CBV) served as the reference standard for brain infarction. RESULTS The clot was located in the middle cerebral artery (MCA) in 47.6% of cases and the internal carotid artery (ICA) in 28.6% of cases. Ten cases presented combined ICA and MCA occlusions. The stroke was right sided in 52.4% of cases and left sided in 47.6%. Reader-based NECT analysis yielded a median sASPECTS of 10. The median CBV-based ASPECTS was 7. Compared to the area of decreased CBV, sASPECTS yielded a sensitivity of 12.5% and specificity of 86.8%. The software prototype (aASPECTS) yielded an overall sensitivity of 65.5% and a specificity of 92.2%. The interreader agreement for ASPECTS evaluation of admission NECT and follow-up CT was almost perfect (κ = .93). The interreader agreement of the CBV color map evaluation was substantial (κ = .77). CONCLUSIONS aASPECTS of NECT can outperform sASPECTS for stroke detection.
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Affiliation(s)
- Georg Gohla
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls-University Tübingen, Tübingen, Germany
| | - Ricarda Schwarz
- Department of Diagnostic and Interventional Radiology, Eberhard Karls-University Tübingen, Tübingen, Germany
| | - Georg Bier
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls-University Tübingen, Tübingen, Germany
- Radiology Salzstraße, Muenster, Germany
| | - Arne Estler
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls-University Tübingen, Tübingen, Germany
| | - Malte N Bongers
- Department of Diagnostic and Interventional Radiology, Eberhard Karls-University Tübingen, Tübingen, Germany
| | - Hendrik Ditt
- Siemens AG Healthcare; Imaging & Therapy Systems Computed Tomography & Radiation Oncology, Forchheim, Germany
| | - Jan Fritz
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - André Kemmling
- Institute of Neuroradiology, Philipps University of Marburg, Marburg, Germany
| | - Ulrike Ernemann
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls-University Tübingen, Tübingen, Germany
| | - Marius Horger
- Department of Diagnostic and Interventional Radiology, Eberhard Karls-University Tübingen, Tübingen, Germany
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Sequeiros JM, Rodriguez-Calienes A, Chavez-Malpartida SS, Morán-Mariños C, Alvarado-Gamarra G, Malaga M, Quincho-Lopez A, Hernadez-Fernandez W, Pacheco-Barrios K, Ortega-Gutierrez S, Hoit D, Arthur AS, Alexandrov AV, Alva-Diaz C, Elijovich L. Stroke imaging modality for endovascular therapy in the extended window: systematic review and meta-analysis. J Neurointerv Surg 2023; 15:e46-e53. [PMID: 35725306 DOI: 10.1136/neurintsurg-2022-018896] [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: 03/07/2022] [Accepted: 06/08/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND In anterior circulation large vessel occlusion (LVO) in the extended time window, the guidelines recommend advanced imaging (ADVI) to select patients for endovascular therapy (EVT). However, questions remain regarding its availability and applicability in the real world. It is unclear whether an approach to the extended window EVT that does not use ADVI would be equivalent. METHODS In April 2022, a literature search was performed to identified randomized controlled trials (RCT) and observational studies describing 90-day outcomes. We performed a meta-analysis of the proportion of aggregate using a random effect to estimate rates of functional independence, defined as modified Rankin Scale (mRS) score ≤2 at 90 days, mean mRS, mortality and symptomatic intracranial hemorrhage (sICH) stratified by imaging modality. RESULTS Four RCTs and 28 observational studies were included. The pooled proportion of functional independence among patients selected by ADVI was 44% (95% CI 39% to 48%; I2=80%) and 48% (95% CI 41% to 55%; I2=75%) with non-contrast CT/CT angiography (NCCT/CTA) (p=0.36). Mean mRS with ADVI was 2.88 (95% CI 2.36 to 3.41; I2=0.0%) and 2.79 (95% CI 2.31 to 3.27; I2=0.0%) with NCCT (p=0.79). Mortality in patients selected by ADVI was 13% (95% CI 10% to 17%; I2=81%) and 16% (95% CI 12% to 22%; I2=69%) with NCCT (p=0.29). sICH with ADVI was 4% (95% CI 3% to 7%; I2=73%) and 6% with NCCT/CTA (95% CI 4% to 8%; I2=6%, p=0.27). CONCLUSIONS Our study suggests that, in anterior circulation LVO, the rates of functional independence may be similar when patients are selected using ADVI or NCCT for EVT in the extended time window. A simplified triage protocol does not seem to increase mortality or sICH. PROTOCOL REGISTRATION NUMBER: (PROSPERO ID: CRD42021236092).
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Affiliation(s)
- Joel M Sequeiros
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Aaron Rodriguez-Calienes
- Grupo de Investigacion Neurociencia, Efectividad Clinica y Salud Publica, Universidad Científica del Sur, Lima, Peru
| | - Sandra S Chavez-Malpartida
- Facultad de Medicina Humana, Universidad Nacional Mayor de San Marcos, Lima, Peru
- Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru
- Servicio de Neurologia, Departamento de Medicina y Oficina de Apoyo a la Docencia e Investigacion, Hospital Daniel Alcides Carrion, Callao, Peru
| | - Cristian Morán-Mariños
- Unidad de Investigacion en Bibliometria, Universidad San Ignacio de Loyola, Lima, Peru
- Servicio de Neumologia, Hospital Nacional Dos de Mayo, Lima, Peru
| | - Giancarlo Alvarado-Gamarra
- Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru
- Departamento de Pediatria, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
- Departamento de Pediatria, Instituto de Investigación Nutricional, Lima, Peru
| | - Marco Malaga
- Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru
| | - Alvaro Quincho-Lopez
- Facultad de Medicina Humana, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Wendy Hernadez-Fernandez
- Servicio de Neurologia, Departamento de Medicina y Oficina de Apoyo a la Docencia e Investigacion, Hospital Daniel Alcides Carrion, Callao, Peru
| | - Kevin Pacheco-Barrios
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
- Vicerrectorado de Investigacion, Unidad de Investigacion para la Generacion y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Daniel Hoit
- Department of Neurosurgery, University of Tennessee Health Science Center - Semmens Murphy Clinic, Memphis, TN, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center - Semmens Murphy Clinic, Memphis, TN, USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Carlos Alva-Diaz
- Grupo de Investigacion Neurociencia, Efectividad Clinica y Salud Publica, Universidad Científica del Sur, Lima, Peru
- Servicio de Neurologia, Departamento de Medicina y Oficina de Apoyo a la Docencia e Investigacion, Hospital Daniel Alcides Carrion, Callao, Peru
| | - Lucas Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of Neurosurgery, University of Tennessee Health Science Center - Semmens Murphy Clinic, Memphis, TN, USA
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Abdalkader M, Siegler JE, Lee JS, Yaghi S, Qiu Z, Huo X, Miao Z, Campbell BC, Nguyen TN. Neuroimaging of Acute Ischemic Stroke: Multimodal Imaging Approach for Acute Endovascular Therapy. J Stroke 2023; 25:55-71. [PMID: 36746380 PMCID: PMC9911849 DOI: 10.5853/jos.2022.03286] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/04/2023] [Indexed: 02/04/2023] Open
Abstract
Advances in acute ischemic stroke (AIS) treatment have been contingent on innovations in neuroimaging. Neuroimaging plays a pivotal role in the diagnosis and prognosis of ischemic stroke and large vessel occlusion, enabling triage decisions in the emergent care of the stroke patient. Current imaging protocols for acute stroke are dependent on the available resources and clinicians' preferences and experiences. In addition, differential application of neuroimaging in medical decision-making, and the rapidly growing evidence to support varying paradigms have outpaced guideline-based recommendations for selecting patients to receive intravenous or endovascular treatment. In this review, we aimed to discuss the various imaging modalities and approaches used in the diagnosis and treatment of AIS.
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Affiliation(s)
- Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston, MA, USA,Correspondence: Mohamad Abdalkader Department of Radiology, Boston Medical Center, One Boston Medical Center Place, Boston, MA 02118, USA Tel: +1-617-614-4272 E-mail:
| | - James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - Jin Soo Lee
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, RI, USA
| | - Zhongming Qiu
- Department of Neurology, The 903rd Hospital of The Chinese People’s Liberation Army, Hangzhou, China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bruce C.V. Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Thanh N. Nguyen
- Department of Radiology, Boston Medical Center, Boston, MA, USA,Department of Neurology, Boston Medical Center, Boston, MA, USA
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Endovascular Thrombectomy for Acute Basilar Artery Occlusion: Latest Findings and Critical Thinking on Future Study Design. Transl Stroke Res 2022; 13:913-922. [PMID: 35349051 DOI: 10.1007/s12975-022-01008-5] [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: 01/20/2022] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
Abstract
Randomized controlled trials (RCTs) have demonstrated powerful efficacy of endovascular thrombectomy (EVT) for large vessel occlusion in the anterior circulation. The effect of EVT for acute basilar artery occlusion (BAO) in the posterior circulation remains unproven. Here, we highlight the latest findings of observational studies and RCTs of EVT for BAO, with a focus on the predictors of functional outcomes, the limitations of recent RCTs, and critical thinking on future study design. Pooled data from large retrospective studies showed 36.4% favorable outcome at 3 months and 4.6% symptomatic intracranial hemorrhage (sICH). Multivariate logistic regression analysis revealed that higher baseline NIHSS score, pc-ASPECTS < 8, extensive baseline infarction, large pontine infarct, and sICH were independent predictors of poor outcome. Two recent randomized trial BEST (Endovascular treatment vs. standard medical treatment for vertebrobasilar artery occlusion) and BASICS (Basilar Artery International Cooperation Study) failed to demonstrate significant benefit of EVT within 6 or 8 h after stroke symptom onset. The limitations of these studies include slow enrollment, selection bias, high crossover rate, and inclusion of patients with mild deficit. To improve enrollment and minimize risk of diluting the overall treatment effect, futile recanalization and re-occlusion, optimal inclusion/exclusion criteria, including enrollment within 24 h of last known well, NIHSS score ≥ 10, pc-ASPECTS ≥ 8, no large pontine infarct, and the use of rescue therapy for underlying atherosclerotic stenosis, should be considered for future clinical trials.
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Chalet L, Boutelier T, Christen T, Raguenes D, Debatisse J, Eker OF, Becker G, Nighoghossian N, Cho TH, Canet-Soulas E, Mechtouff L. Clinical Imaging of the Penumbra in Ischemic Stroke: From the Concept to the Era of Mechanical Thrombectomy. Front Cardiovasc Med 2022; 9:861913. [PMID: 35355966 PMCID: PMC8959629 DOI: 10.3389/fcvm.2022.861913] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 02/11/2022] [Indexed: 01/01/2023] Open
Abstract
The ischemic penumbra is defined as the severely hypoperfused, functionally impaired, at-risk but not yet infarcted tissue that will be progressively recruited into the infarct core. Early reperfusion aims to save the ischemic penumbra by preventing infarct core expansion and is the mainstay of acute ischemic stroke therapy. Intravenous thrombolysis and mechanical thrombectomy for selected patients with large vessel occlusion has been shown to improve functional outcome. Given the varying speed of infarct core progression among individuals, a therapeutic window tailored to each patient has recently been proposed. Recent studies have demonstrated that reperfusion therapies are beneficial in patients with a persistent ischemic penumbra, beyond conventional time windows. As a result, mapping the penumbra has become crucial in emergency settings for guiding personalized therapy. The penumbra was first characterized as an area with a reduced cerebral blood flow, increased oxygen extraction fraction and preserved cerebral metabolic rate of oxygen using positron emission tomography (PET) with radiolabeled O2. Because this imaging method is not feasible in an acute clinical setting, the magnetic resonance imaging (MRI) mismatch between perfusion-weighted imaging and diffusion-weighted imaging, as well as computed tomography perfusion have been proposed as surrogate markers to identify the penumbra in acute ischemic stroke patients. Transversal studies comparing PET and MRI or using longitudinal assessment of a limited sample of patients have been used to define perfusion thresholds. However, in the era of mechanical thrombectomy, these thresholds are debatable. Using various MRI methods, the original penumbra definition has recently gained a significant interest. The aim of this review is to provide an overview of the evolution of the ischemic penumbra imaging methods, including their respective strengths and limitations, as well as to map the current intellectual structure of the field using bibliometric analysis and explore future directions.
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Affiliation(s)
- Lucie Chalet
- Univ Lyon, CarMeN Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Olea Medical, La Ciotat, France
| | | | - Thomas Christen
- Grenoble Institut Neurosciences, INSERM, U1216, Univ. Grenoble Alpes, Grenoble, France
| | | | - Justine Debatisse
- Univ Lyon, CarMeN Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Omer Faruk Eker
- CREATIS, CNRS UMR-5220, INSERM U1206, Université Lyon 1, Villeurbanne, France
- Neuroradiology Department, Hospices Civils of Lyon, Lyon, France
| | - Guillaume Becker
- Univ Lyon, CarMeN Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Norbert Nighoghossian
- Univ Lyon, CarMeN Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Stroke Department, Hospices Civils of Lyon, Lyon, France
| | - Tae-Hee Cho
- Univ Lyon, CarMeN Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Stroke Department, Hospices Civils of Lyon, Lyon, France
| | - Emmanuelle Canet-Soulas
- Univ Lyon, CarMeN Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Laura Mechtouff
- Univ Lyon, CarMeN Laboratory, INSERM, INRA, INSA Lyon, Université Claude Bernard Lyon 1, Lyon, France
- Stroke Department, Hospices Civils of Lyon, Lyon, France
- *Correspondence: Laura Mechtouff
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Comparative Studies of Cerebral Reperfusion Injury in the Posterior and Anterior Circulations After Mechanical Thrombectomy. Transl Stroke Res 2022; 13:556-564. [PMID: 35006533 PMCID: PMC9232466 DOI: 10.1007/s12975-021-00977-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 12/10/2021] [Accepted: 12/13/2021] [Indexed: 11/17/2022]
Abstract
Cerebral reperfusion injury is the major complication of mechanical thrombectomy (MT) for acute ischemic stroke (AIS). Contrast extravasation (CE) and intracranial hemorrhage (ICH) are the key radiographical features of cerebral reperfusion injury. The aim of this study was to investigate CE and ICH after MT in the anterior and posterior circulation, and their effect on functional outcome. This is a retrospective study of all consecutive patients who were treated with MT for AIS at University of California Irvine Medical Center between January 1, 2014, and December 31, 2017. Patient characteristics, clinical features, procedural variables, contrast extravasation, ICH, and outcomes after MT were analyzed. A total of 131 patients with anterior circulation (AC) stroke and 25 patients with posterior circulation (PC) stroke underwent MT during the study period. There was no statistically significant difference in admission NIHSS score, blood pressure, rate of receiving intravenous tPA, procedural variables, contrast extravasation, and symptomatic ICH between the 2 groups. Patients with PC stroke had a similar rate of favorable outcome (mRS 0–2) but significantly higher mortality (40.0% vs. 10.7%, p < 0.01) than patients with AC stroke. Multivariate regression analysis identified initial NIHSS score (OR 1.1, CI 1.0–1.2, p = 0.01), number of passes with stent retriever (OR 2.1, CI 1.3–3.6, p < 0.01), and PC stroke (OR 9.3, CI 2.5–35.1, p < 0.01) as independent risk factors for death. There was no significant difference in functional outcomes between patients with and without evidence of cerebral reperfusion injury after MT. We demonstrated that AC and PC stroke had similar rates of cerebral reperfusion injury and favorable outcome after MT. Cerebral reperfusion injury is not a significant independent risk factor for poor functional outcome.
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10
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Eun J, Lee MH, Im SH, Joo WI, Ahn JG, Yoo DS, Park HK. Effects of an Infection Control Protocol for Coronavirus Disease in Emergency Mechanical Thrombectomy. J Korean Neurosurg Soc 2021; 65:224-235. [PMID: 34879638 PMCID: PMC8918251 DOI: 10.3340/jkns.2021.0053] [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: 02/24/2021] [Accepted: 08/17/2021] [Indexed: 11/27/2022] Open
Abstract
Objective Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, neurointerventionists have been increasingly concerned regarding the prevention of infection and time delay in performing emergency thrombectomy procedures in patients with acute stroke. This study aimed to analyze the effects of changes in mechanical thrombectomy protocol before and after the COVID-19 pandemic on procedure time and patient outcomes and to identify factors that significantly impact procedure time.
Methods The last-normal-to-door, first-abnormal-to-door, door-to-imaging, door-to-puncture, and puncture-to-recanalization times of 88 patients (45 treated with conventional pre-COVID-19 protocol and 43 with COVID-19 protection protocol) were retrospectively analyzed. The recanalization time, success rate of mechanical thrombectomy, and modified Rankin score of patients at discharge were assessed. A multivariate analysis was conducted to identify variables that significantly influenced the time delay in the door-to-puncture time and total procedure time.
Results The door-to-imaging time significantly increased under the COVID-19 protection protocol (p=0.0257) compared to that with the conventional pre-COVID-19 protocol. This increase was even more pronounced in patients who were suspected to be COVID-19-positive than in those who were negative. The door-to-puncture time showed no statistical difference between the conventional and COVID-19 protocol groups (p=0.5042). However, in the multivariate analysis, the last-normal-to-door time and door-to-imaging time were shown to affect the door-to-puncture time (p=0.0068 and 0.0097). The total procedure time was affected by the occlusion site, last-normal-to-door time, door-to-imaging time, and type of anesthesia (p=0.0001, 0.0231, 0.0103, and 0.0207, respectively).
Conclusion The COVID-19 protection protocol significantly impacted the door-to-imaging time. Shortening the door-to-imaging time and performing the procedure under local anesthesia, if possible, may be required to reduce the door-to-puncture and door-to-recanalization times. The effect of various aspects of the protection protocol on emergency thrombectomy should be further studied.
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Affiliation(s)
- Jin Eun
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Min-Hyung Lee
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang-Hyuk Im
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Won-Il Joo
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae-Geun Ahn
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Do-Sung Yoo
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hae-Kwan Park
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Grøan M, Ospel J, Ajmi S, Sandset EC, Kurz MW, Skjelland M, Advani R. Time-Based Decision Making for Reperfusion in Acute Ischemic Stroke. Front Neurol 2021; 12:728012. [PMID: 34790159 PMCID: PMC8591257 DOI: 10.3389/fneur.2021.728012] [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: 06/20/2021] [Accepted: 09/16/2021] [Indexed: 11/13/2022] Open
Abstract
Decision making in the extended time windows for acute ischemic stroke can be a complex and time-consuming process. The process of making the clinical decision to treat has been compounded by the availability of different imaging modalities. In the setting of acute ischemic stroke, time is of the essence and chances of a good outcome diminish by each passing minute. Navigating the plethora of advanced imaging modalities means that treatment in some cases can be inefficaciously delayed. Time delays and individually based non-programmed decision making can prove challenging for clinicians. Visual aids can assist such decision making aimed at simplifying the use of advanced imaging. Flow charts are one such visual tool that can expedite treatment in this setting. A systematic review of existing literature around imaging modalities based on site of occlusion and time from onset can be used to aid decision making; a more program-based thought process. The use of an acute reperfusion flow chart helping navigate the myriad of imaging modalities can aid the effective treatment of patients.
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Affiliation(s)
- Mathias Grøan
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Johanna Ospel
- Department of Radiology, Basel University Hospital, Basel, Switzerland.,Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Soffien Ajmi
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway.,University of Stavanger, Stavanger, Norway
| | - Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway.,Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Martin W Kurz
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway.,Neuroscience Research Group, Stavanger University Hospital, Stavanger, Norway
| | - Mona Skjelland
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Rajiv Advani
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway.,Neuroscience Research Group, Stavanger University Hospital, Stavanger, Norway
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12
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Shi J, Li W, Zhang F, Park JH, An H, Guo S, Duan Y, Wu D, Hayakawa K, Lo EH, Ji X. CCL2 (C-C Motif Chemokine Ligand 2) Biomarker Responses in Central Versus Peripheral Compartments After Focal Cerebral Ischemia. Stroke 2021; 52:3670-3679. [PMID: 34587791 PMCID: PMC8545911 DOI: 10.1161/strokeaha.120.032782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background and Purpose Inflammatory mediators in blood have been proposed as potential biomarkers in stroke. However, a direct relationship between these circulating factors and brain-specific ischemic injury remains to be fully defined. Methods An unbiased screen in a nonhuman primate model of stroke was used to find out the most responsive circulating biomarker flowing ischemic stroke. Then this phenomenon was checked in human beings and mice. Finally, we observed the temporospatial responsive characteristics of this biomarker after ischemic brain injury in mice to evaluate the direct relationship between this circulating factor and central nervous system–specific ischemic injury. Results In a nonhuman primate model, an unbiased screen revealed CCL2 (C-C motif chemokine ligand 2) as a major response factor in plasma after stroke. In mouse models of focal cerebral ischemia, plasma levels of CCL2 showed a transient response, that is, rapidly elevated by 2 to 3 hours postischemia but then renormalized back to baseline levels by 24 hours. However, a different CCL2 temporal profile was observed in whole brain homogenate, cerebrospinal fluid, and isolated brain microvessels, with a progressive increase over 24 hours, demonstrating a mismatch between brain versus plasma responses. In contrast to the lack of correlation with central nervous system responses, 2 peripheral compartments showed transient profiles that matched circulating plasma signatures. CCL2 protein in lymph nodes and adipose tissue was significantly increased at 2 hours and renormalized by 24 hours. Conclusions These findings may provide a cautionary tale for biomarker pursuits in plasma. Besides a direct central nervous system response, peripheral organs may also contribute to blood signatures in complex and indirect ways.
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Affiliation(s)
- Jingfei Shi
- Cerebrovascular and Neuroscience Research Institute, Xuanwu Hospital, Capital Medical University, Beijing, China.,Neuroprotection Research Laboratories, Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Wenlu Li
- Neuroprotection Research Laboratories, Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Fang Zhang
- Neuroprotection Research Laboratories, Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ji Hyun Park
- Neuroprotection Research Laboratories, Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hong An
- Cerebrovascular and Neuroscience Research Institute, Xuanwu Hospital, Capital Medical University, Beijing, China.,Neuroprotection Research Laboratories, Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Shuzhen Guo
- Neuroprotection Research Laboratories, Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yunxia Duan
- Cerebrovascular and Neuroscience Research Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Di Wu
- Cerebrovascular and Neuroscience Research Institute, Xuanwu Hospital, Capital Medical University, Beijing, China.,Neuroprotection Research Laboratories, Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kazuhide Hayakawa
- Neuroprotection Research Laboratories, Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Eng H. Lo
- Neuroprotection Research Laboratories, Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Xunming Ji
- Cerebrovascular and Neuroscience Research Institute, Xuanwu Hospital, Capital Medical University, Beijing, China.,Departments of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
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Head and Neck CTA Utilization: Analysis of Ordering Frequency and Nonroutine Results Communication, With Focus on the Fifty Most Common Emergency Department Clinical Presentations. AJR Am J Roentgenol 2021; 218:544-551. [PMID: 34585611 DOI: 10.2214/ajr.21.26543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Utilization of head and neck CTA in the emergency department (ED) has grown disproportionately to other neuroimaging examinations. Objective: To characterize utilization of head and neck CTA in the ED, comparing utilization and frequency of nonroutine results communication among patients' chief concerns. Methods: All adult ED visits for a single healthcare system from January 2014 to December 2017 were retrospectively reviewed. Variables recorded included chief concerns, whether head and neck CTA was performed, and, if so, whether the report documented nonroutine results communication. The fifty chief concerns resulting in the highest number of head and neck CTA examinations were identified. Frequencies of head and neck CTA ordering and of nonroutine results communication were calculated. A subset of reports documenting nonroutine communication were manually reviewed. Results: Head and neck CTA was ordered in 2.5% (17,903) of 708,145 ED visits in 236,476 patients (mean age 48.9±20.5 years; 110,952 male, 125,521 female, 3 unknown sex). Head and neck CTA was ordered for 833 distinct chief concerns. Nonroutine results communication was documented for 17.6% (31,55/17,903) of examinations. Among the fifty chief concerns associated with the highest number of examinations, frequency of ordering head and neck CTA ranged from <0.5% (five concerns) to 55.2% (stroke code), and frequency of nonroutine communication ranged from 5.6% (transient ischemic attack) to 67.5% (unresponsive). Chief concerns not among the fifty most common accounted for 50.0% (8956/17903) of examinations; these exhibited a collective frequency of nonroutine communication of 4.8% (429/8956). Manual review of 11.1% (350/3155) of reports with a nonroutine communication indicated an acute finding related to the indication in 51.1%, non-emergent but potentially explanatory finding in 28.0%, incidental finding in 28.0%, and communication of negative results in 6.9%. Conclusion: Head and neck CTA is ordered in 2.5% of ED visits for a wide range of chief concerns. Frequencies of ordering and of nonroutine results communication are highly variable among chief concerns. Acute indication-related findings account for half of nonroutine radiologist communications. Clinical Impact: Insight into patterns regarding head and neck CTA ordering and nonroutine results may help optimize patient selection and radiologist communications in the ED setting.
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Controversies in Imaging of Patients with Acute Ischemic Stroke: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2021; 217:1027-1037. [PMID: 34106758 DOI: 10.2214/ajr.21.25846] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The development of reperfusion therapies has profoundly impacted stroke care, initially with the advent of IV thrombolytic (IVT) treatment and, more recently, with the development and refinement of endovascular treatment (EVT). Progress in neuroimaging has supported the paradigm shift of stroke care, and advanced neuroimaging now has a fundamental role in triaging patients for both IVT and EVT. As the standard of care for acute ischemic stroke (AIS) evolves, controversies remain in certain clinical scenarios. This article explores the use of multimodality imaging for treatment selection of AIS in the context of recent guidelines, highlighting controversial topics and providing guidance for clinical practice. Results of major randomized trials supporting EVT are reviewed. Advantages and disadvantages of CT, CTA, MRI, and MRA in stroke diagnosis are summarized, with attention to level 1 evidence supporting the role of vascular imaging and perfusion imaging. Patient selection is compared between approaches based on time thresholds and physiologic approaches based on infarct core measurement using imaging. Moreover, various imaging approaches to core measurement are described. As ongoing studies push treatment boundaries, advanced imaging is expected to help identify a widening range of patients who may benefit from therapy.
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15
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Zameer S, Siddiqui AS, Riaz R. Multimodality Imaging in Acute Ischemic Stroke. Curr Med Imaging 2021; 17:567-577. [PMID: 33256582 DOI: 10.2174/1573405616666201130094948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 09/22/2020] [Accepted: 10/14/2020] [Indexed: 11/22/2022]
Abstract
Stroke is the most common cause of mortality and morbidity worldwide. The prognosis of stroke depends upon the area affected and its early treatment. Time is of the essence in the care of stroke patients as it is estimated that approximately 1.9 million neurons, 14 billion synapses, and 12 km myelinated nerve fibers are lost per minute. Therefore, early diagnosis and prompt treatment are necessary. The primary goal of imaging in acute stroke is to diagnose the underlying cause, estimate the area affected, predict response towards thrombolytic therapy and to exclude the conditions mimicking stroke. With advancements in radiology, multiple imaging modalities are available for diagnosis and predicting prognosis. None of them is considered alone to be perfect. In this era of multimodality imaging, the decision of choosing appropriate techniques depends upon purpose and availability. Non-Contrast Computed Tomography is time effective, and helps in excluding other causes, Trans Cranial Doppler is time-effective and cost-effective with wide availability, however, is operator dependent and less sensitive. It holds a great future in sonothrombolysis. Magnetic Resonance Imaging is so far considered to be the most superior one in terms of early diagnosis, planning for interventional treatment and predicting the response of treatment. However, it is limited due to high cost and lack of availability. The current review gives a detailed account of all imaging modalities available for imaging stroke and their associated pros and cons.
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Affiliation(s)
- Shahla Zameer
- Department of Radiology, Pakistan Institute of Medical Sciences, Islamabad, Pakistan
| | | | - Ramish Riaz
- Department of Radiology, Pakistan Institute of Medical Sciences, Islamabad, Pakistan
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16
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Natera-Villalba E, Cruz-Culebras A, García-Madrona S, Vera-Lechuga R, de Felipe-Mimbrera A, Matute-Lozano C, Gómez-López A, Ros-Castelló V, Sánchez-Sánchez A, Martínez-Poles J, Nedkova-Hristova V, Escribano-Paredes JB, García-Bermúdez I, Méndez J, Fandiño E, Masjuan J. Mechanical thrombectomy beyond 6 hours in acute ischaemic stroke with large vessel occlusion in the carotid artery territory: experience at a tertiary hospital. NEUROLOGÍA (ENGLISH EDITION) 2021; 38:236-245. [PMID: 34092537 DOI: 10.1016/j.nrleng.2020.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 08/04/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Thrombectomy in the carotid artery territory was recently shown to be effective up to 24 hours after symptoms onset. METHODS We conducted a retrospective review of a prospective registry of patients treated at our stroke reference centre between November 2016 and April 2019 in order to assess the safety and effectiveness of mechanical thrombectomy performed beyond 6 hours after symptoms onset in patients with acute ischaemic stroke and large vessel occlusion in the carotid artery territory. RESULTS Data were gathered from 59 patients (55.9% women; median age, 71 years). In 33 cases, stroke was detected upon awakening; 57.6% of patients were transferred from another hospital. Median baseline NIHSS score was 16, and median ASPECTS score was 8, with 94.9% of patients presenting > 50% of salvageable tissue. Satisfactory recanalisation was achieved in 88.1% of patients, beyond 24 hours after onset in 5 cases. At 90 days of follow-up, 67.8% were functionally independent; those who were not were older and presented higher prevalence of atrial fibrillation, greater puncture-to-recanalisation time, and higher NIHSS scores, both at baseline and at discharge. CONCLUSION In our experience, mechanical thrombectomy beyond 6 hours was associated with good 90-day functional outcomes. Age, NIHSS score, puncture-to-recanalisation time, and presence of atrial fibrillation affected functional prognosis. The efficacy of the treatment beyond 24 hours after onset merits study.
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Affiliation(s)
- E Natera-Villalba
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain.
| | - A Cruz-Culebras
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - S García-Madrona
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - R Vera-Lechuga
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - A de Felipe-Mimbrera
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - C Matute-Lozano
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - A Gómez-López
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - V Ros-Castelló
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - A Sánchez-Sánchez
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J Martínez-Poles
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - V Nedkova-Hristova
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J B Escribano-Paredes
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - I García-Bermúdez
- Servicio de Radiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J Méndez
- Servicio de Radiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - E Fandiño
- Servicio de Radiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J Masjuan
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain; Servicio de Neurología, Hospital Ramón y Cajal, Departamento de Medicina, Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, Spain
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17
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Martinez G, Katz JM, Pandya A, Wang JJ, Boltyenkov A, Malhotra A, Mushlin AI, Sanelli PC. Cost-Effectiveness Study of Initial Imaging Selection in Acute Ischemic Stroke Care. J Am Coll Radiol 2021; 18:820-833. [PMID: 33387454 PMCID: PMC8186007 DOI: 10.1016/j.jacr.2020.12.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/04/2020] [Accepted: 12/06/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE National guidelines recommend prompt identification of candidates for acute ischemic stroke (AIS) treatment, requiring timely neuroimaging with CT and/or MRI. CT is often preferred because of its widespread availability and rapid acquisition. Despite higher diagnostic accuracy of MRI, it commonly involves complex workflows that could potentially cause treatment time delays. The purpose of this study was to analyze the impact on outcomes of imaging utilization before treatment decisions at comprehensive stroke centers for patients presenting with suspected AIS in the anterior circulation with last-known-well-to-arrival time 0 to 24 hours. METHODS A decision simulation model based on the American Heart Association's recommendations for AIS care pathways was developed from a health care perspective to compare initial imaging strategies: (1) stepwise-CT: noncontrast CT (NCCT) at the time of presentation, with CT angiography (CTA) ± CT perfusion (CTP) only in select patients (initial imaging to exclude hemorrhage and extensive ischemia) for mechanical thrombectomy (MT) evaluation; (2) stepwise-hybrid: NCCT at the time of presentation, with MR angiography (MRA) ± MR perfusion (MRP) only for MT evaluation; (3) stepwise-advanced: NCCT + CTA at presentation, with MR diffusion-weighted imaging (MR DWI) + MRP only for MT evaluation; (4) comprehensive-CT: NCCT + CTA + CTP at the time of presentation; and (5) comprehensive-MR: MR DWI + MRA + MRP at the time of presentation. Model parameters were defined using evidence-based data. Cost-effectiveness and sensitivity analyses were performed. RESULTS The cost-effectiveness analyses revealed that comprehensive-CT and comprehensive-MR yield the highest lifetime quality-adjusted life-years (QALYs) (4.81 and 4.82, respectively). However, the incremental cost-effectiveness ratio of comprehensive-MR is $233,000/QALY compared with comprehensive-CT. Stepwise-CT, stepwise-hybrid, and stepwise-advanced strategies are dominated, yielding lower QALYs and higher costs compared with comprehensive-CT. CONCLUSIONS Performing comprehensive-CT at presentation is the most cost-effective initial imaging strategy at comprehensive stroke centers.
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Affiliation(s)
- Gabriela Martinez
- Siemens Healthineers, Malvern, Pennsylvania; Department of Radiology, Northwell Health, Manhasset, New York; Feinstein Institutes for Medical Research, Manhasset, New York.
| | - Jeffrey M Katz
- Chief, Neurovascular Services and Director Comprehensive Stroke Center at North Shore University Hospital, Department of Neurology, North Shore University Hospital, Manhasset, New York; Director of Neuroendovascular surgery, Neurology Service Line, Northwell Health, Manhasset, New York; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Ankur Pandya
- T. H. Trustee (unpaid), Society for Medical Decision Making, T.H Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Jason J Wang
- Feinstein Institutes for Medical Research, Manhasset, New York; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Artem Boltyenkov
- Siemens Healthineers, Malvern, Pennsylvania; Department of Radiology, Northwell Health, Manhasset, New York; Feinstein Institutes for Medical Research, Manhasset, New York
| | - Ajay Malhotra
- Radiology & Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Alvin I Mushlin
- Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Pina C Sanelli
- Department of Radiology, Northwell Health, Manhasset, New York; Feinstein Institutes for Medical Research, Manhasset, New York; Radiology & Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut; Healthcare Policy and Research, Weill Cornell Medical College, New York, New York; Vice Chair of Research, Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
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Automated estimation of ischemic core prior to thrombectomy: comparison of two current algorithms. Neuroradiology 2021; 63:1645-1649. [PMID: 33580356 DOI: 10.1007/s00234-021-02651-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/17/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Endovascular thrombectomy (EVT) improves clinical outcomes in ischemic stroke with large vessel occlusion. Clinical benefits are inversely proportional to size of the pre-treatment ischemic core. This study compared estimated ischemic core volumes by two different CT perfusion (CTP) automated algorithms to the gold standard follow-up infarct volume using diffusion-weighted imaging (DWI) to assess for congruence, and thus eligibility for EVT. METHODS Retrospective, single-center cohort study of 102 patients presenting to a comprehensive stroke center between 2012 and 2018. Inclusion criteria were CT perfusion prior to EVT, successful EVT with mTIBI 2b-3 reperfusion, and DWI post-EVT. CTP data were retrospectively processed by two algorithms: "delay and dispersion insensitive deconvolution" (DISD, RAPID software) versus "delay and dispersion corrected single value decomposition" (ddSVD, Mistar software), using commercially available software. Core volumes were compared to follow up DWI using independent software (MRIcron). Agreement between each algorithm and DWI was estimated using Lin's concordance coefficient and analyzed using reduced major axis regression. RESULTS We included 102 patients. Both algorithms had excellent agreement with DWI (Lin's concordance coefficients: DISD 0.8 (95% CI: 0.73; 0.87), ddSVD 0.92 (95% CI: 0.89; 0.95). Compared to ddSVD (reduced major axis slope = 0.95), DISD exhibited a larger extent of proportional bias (slope = 1.12). CONCLUSION The ddSVD algorithm better correlates with DWI follow-up infarct volume than DISD processing. The DISD algorithm overestimated larger ischemic cores which may lead to patient exclusion from thrombectomy based on selection by core volume.
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Natera-Villalba E, Cruz-Culebras A, García-Madrona S, Vera-Lechuga R, de Felipe-Mimbrera A, Matute-Lozano C, Gómez-López A, Ros-Castelló V, Sánchez-Sánchez A, Martínez-Poles J, Nedkova-Hristova V, Escribano-Paredes JB, García-Bermúdez I, Méndez J, Fandiño E, Masjuan J. Mechanical thrombectomy beyond 6hours in acute ischaemic stroke with large vessel occlusion in the carotid artery territory: Experience at a tertiary hospital. Neurologia 2021; 38:S0213-4853(20)30298-X. [PMID: 33551125 DOI: 10.1016/j.nrl.2020.08.019] [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: 02/04/2020] [Revised: 07/06/2020] [Accepted: 08/04/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Thrombectomy in the carotid artery territory was recently shown to be effective up to 24hours after symptoms onset. METHODS We conducted a retrospective review of a prospective registry of patients treated at our stroke reference centre between November 2016 and April 2019 in order to assess the safety and effectiveness of mechanical thrombectomy performed beyond 6hours after symptoms onset in patients with acute ischaemic stroke and large vessel occlusion in the carotid artery territory. RESULTS Data were gathered from 59 patients (55.9% women; median age, 71 years). In 33 cases, stroke was detected upon awakening; 57.6% of patients were transferred from another hospital. Median baseline NIHSS score was 16, and median ASPECTS score was 8, with 94.9% of patients presenting>50% of salvageable tissue. Satisfactory recanalisation was achieved in 88.1% of patients, beyond 24hours after onset in 5 cases. At 90 days of follow-up, 67.8% were functionally independent; those who were not were older and presented higher prevalence of atrial fibrillation, greater puncture-to-recanalisation time, and higher NIHSS scores, both at baseline and at discharge. CONCLUSION In our experience, mechanical thrombectomy beyond 6hours was associated with good 90-day functional outcomes. Age, NIHSS score, puncture-to-recanalisation time, and presence of atrial fibrillation affected functional prognosis. The efficacy of the treatment beyond 24hours after onset merits study.
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Affiliation(s)
- E Natera-Villalba
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España.
| | - A Cruz-Culebras
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - S García-Madrona
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - R Vera-Lechuga
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - A de Felipe-Mimbrera
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - C Matute-Lozano
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - A Gómez-López
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - V Ros-Castelló
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - A Sánchez-Sánchez
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - J Martínez-Poles
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - V Nedkova-Hristova
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - J B Escribano-Paredes
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - I García-Bermúdez
- Servicio de Radiología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - J Méndez
- Servicio de Radiología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - E Fandiño
- Servicio de Radiología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - J Masjuan
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España; Servicio de Neurología, Hospital Ramón y Cajal, Departamento de Medicina, Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, España
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Delgado Acosta F, Jiménez Gómez E, Bravo Rey I, Bolivar A, Valverde Moyano R, Oteros Fernández R. Endovascular stroke treatment after 6-24 hours only needs non-contrast CT. Acta Neurol Scand 2021; 143:171-177. [PMID: 32969024 DOI: 10.1111/ane.13348] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 08/21/2020] [Accepted: 09/10/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Imaging selected patients with proximal anterior circulation stroke who demonstrate limited infarct may benefit from endovascular treatment beyond conventional time limits. Our aim was to evaluate the results of the EVT group series arriving between 6 and 24 hours from the onset of symptoms with (ASPECTS) ≥7 to our hospital (with 24/7 interventional neuroradiology) comparing them with those obtained in our prospectively registered series arriving between 0 and 6 hours. MATERIALS AND METHODS The inclusion criteria were ≥18 years, an interval between stroke and endovascular treatment of 6-24 hours, prestroke score mRS 0-2, no intracranial haemorrhage, (NIHSS) scale 8-22 and infarct evaluated by CT scan ≥7 in ASPECTS scale. Data, including patient demographics, neuroimaging findings, procedural details, recanalization rates and 90-day mRS, were collected. RESULTS Twelve of the 14 (85.71%) endovascular group patients who came to our centre between 6 and 24 hours had good outcomes at 90 days. To confirm our findings, we evaluated patients treated at our centre who met the selection criteria from January 2017 to September 2019. In this period, 382 patients with large vessel occlusion were treated endovascularly. 56 patients met all the criteria for inclusion and exclusion for our study. 31 of these 56 patients (56.36%) obtained a (mRS) scale ≤2 at three months. There was no significant difference (P = 0.063). CONCLUSION In circumstances of difficult access to MRI or CT perfusion, a computed tomography of ASPECTS ≥7 is sufficient to indicate endovascular treatment in a stroke of known onset between 6 and 24 hours.
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21
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Recanalization Therapy for Acute Ischemic Stroke with Large Vessel Occlusion: Where We Are and What Comes Next? Transl Stroke Res 2021; 12:369-381. [PMID: 33409732 PMCID: PMC8055567 DOI: 10.1007/s12975-020-00879-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/15/2020] [Accepted: 11/18/2020] [Indexed: 12/18/2022]
Abstract
In the past 5 years, the success of multiple randomized controlled trials of recanalization therapy with endovascular thrombectomy has transformed the treatment of acute ischemic stroke with large vessel occlusion. The evidence from these trials has now established endovascular thrombectomy as standard of care. This review will discuss the chronological evolution of large vessel occlusion treatment from early medical therapy with tissue plasminogen activator to the latest mechanical thrombectomy. Additionally, it will highlight the potential areas in endovascular thrombectomy for acute ischemic stroke open to exploration and further progress in the next decade.
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22
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Soto JM, Reed LK, Benardete EA. Successful endovascular removal of a chondroblastic osteosarcoma embolus within the left middle cerebral artery. Proc (Bayl Univ Med Cent) 2020; 33:451-452. [PMID: 32675984 DOI: 10.1080/08998280.2020.1747326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/18/2020] [Accepted: 03/23/2020] [Indexed: 12/21/2022] Open
Abstract
A 57-year-old woman with metastatic chondroblastic osteosarcoma developed sudden-onset right-sided weakness and aphasia. She was found to have an occluded left middle cerebral artery (M1 segment) and underwent endovascular stroke intervention with return to a normal neurological exam within 24 h. Histologic analysis of the embolus was consistent with chondroblastic osteosarcoma.
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Affiliation(s)
- Jose M Soto
- Department of Neurosurgery, Baylor Scott and White HealthTempleTexas
| | - Laura K Reed
- Department of Neurosurgery, Baylor Scott and White HealthTempleTexas
| | - Ethan A Benardete
- Department of Neurosurgery, Baylor Scott and White HealthTempleTexas
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