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Winkelmeier L, Heit JJ, Broocks G, Prüter J, Heitkamp C, Schell M, Albers GW, Lansberg MG, Wintermark M, Kemmling A, Stracke CP, Guenego A, Paech D, Fiehler J, Faizy TD. Association between occlusion location, net water uptake and ischemic lesion growth in large vessel anterior circulation strokes. J Cereb Blood Flow Metab 2024; 44:1352-1361. [PMID: 38329032 PMCID: PMC11342730 DOI: 10.1177/0271678x241232193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/28/2023] [Accepted: 01/14/2024] [Indexed: 02/09/2024]
Abstract
Ischemic lesion net water uptake (NWU) represents a quantitative imaging biomarker for cerebral edema in acute ischemic stroke. Data on NWU for distinct occlusion locations remain scarce, but might help to improve the prognostic value of NWU. In this retrospective multicenter cohort study, we compared NWU between patients with proximal large vessel occlusion (pLVO; ICA or proximal M1) and distal large vessel occlusion (dLVO; distal M1 or M2). NWU was quantified by densitometric measurements of the early ischemic region. Arterial collateral status was assessed using the Maas scale. Regression analysis was used to investigate the relationship between occlusion location, NWU and ischemic lesion growth. A total of 685 patients met inclusion criteria. Early ischemic lesion NWU was higher in patients with pLVO compared with dLVO (7.7% vs 3.9%, P < .001). The relationship between occlusion location and NWU was partially mediated by arterial collateral status. NWU was associated with absolute ischemic lesion growth between admission and follow-up imaging (β estimate, 5.50, 95% CI, 3.81-7.19, P < .001). This study establishes a framework for the relationship between occlusion location, arterial collateral status, early ischemic lesion NWU and ischemic lesion growth. Future prognostic thresholds for NWU might be optimized by adjusting for the occlusion location.
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Affiliation(s)
- Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Department of Neuroradiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Prüter
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Heitkamp
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Schell
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gregory W Albers
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Maarten G Lansberg
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson, Houston, Texas, USA
| | - André Kemmling
- Department of Neuroradiology, University Marburg, Marburg, Germany
| | | | - Adrien Guenego
- Department of Neuroradiology, Erasme Medical Center, Brussels, Belgium
| | - Daniel Paech
- Clinic for Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Ghozy S, Amoukhteh M, Hasanzadeh A, Jannatdoust P, Shafie M, Valizadeh P, Hassankhani A, Abbas AS, Kadirvel R, Kallmes DF. Net water uptake as a predictive neuroimaging marker for acute ischemic stroke outcomes: a meta-analysis. Eur Radiol 2024; 34:5308-5316. [PMID: 38276981 DOI: 10.1007/s00330-024-10599-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 12/05/2023] [Accepted: 12/23/2023] [Indexed: 01/27/2024]
Abstract
OBJECTIVE To assess the role of net water uptake (NWU) in predicting outcomes in acute ischemic stroke (AIS) patients. METHODS A systematic review and meta-analysis were performed, adhering to established guidelines. The search covered PubMed, Scopus, Web of Science, and Embase databases until July 1, 2023. Eligible studies reporting quantitative ischemic lesion NWU in admission CT scans of AIS patients, stratified based on outcomes, were included. Data analysis was performed using R software version 4.2.1. RESULTS Incorporating 17 original studies with 2217 AIS patients, NWU was significantly higher in patients with poor outcomes compared to those with good outcomes (difference of medians: 5.06, 95% CI: 3.00-7.13, p < 0.001). Despite excluding one outlier study, considerable heterogeneity persisted among the included studies (I2 = 90.8%). The meta-regression and subgroup meta-analyses demonstrated significantly higher NWU in patients with poor functional outcome, as assessed by modified Rankin Scale (difference of medians: 3.83, 95% CI: 1.98-5.68, p < 0.001, I2 = 72.9%), malignant edema/infarct (difference of medians: 8.30, 95% CI: 4.01-12.58, p < 0.001, I2 = 95.6%), and intracranial hemorrhage (difference of medians: 5.43, 95% CI: 0.44-10.43, p = 0.03, I2 = 91.1%). CONCLUSION NWU on admission CT scans shows promise as a predictive marker for outcomes in AIS patients. Prospective, multicenter trials with standardized, automated NWU measurement are crucial for robustly predicting diverse clinical outcomes. CLINICAL RELEVANCE STATEMENT The potential of net water uptake as a biomarker for predicting outcomes in acute ischemic stroke patients holds significant promise. Further validation through additional research could lead to its integration into clinical practice, potentially improving the accuracy of clinical decision-making and allowing for the development of more precise patient care strategies. KEY POINTS • Net water uptake, a CT-based biomarker, quantifies early brain edema after acute ischemic stroke. • Net water uptake is significantly higher in poor outcome acute ischemic stroke patients. • Net water uptake on CT scans holds promise in predicting diverse acute ischemic stroke outcomes.
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Affiliation(s)
- Sherief Ghozy
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Melika Amoukhteh
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | - Alireza Hasanzadeh
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Payam Jannatdoust
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Mahan Shafie
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Parya Valizadeh
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Amir Hassankhani
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA.
| | - Alzhraa Salah Abbas
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Ramanathan Kadirvel
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
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Wang Z, Ji K, Fang Q. Endovascular thrombectomy with or without intravenous alteplase in large-core ischemic stroke: a systematic review and meta-analysis. Neurol Sci 2024:10.1007/s10072-024-07653-y. [PMID: 38896187 DOI: 10.1007/s10072-024-07653-y] [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: 02/29/2024] [Accepted: 06/11/2024] [Indexed: 06/21/2024]
Abstract
The role of bridging intravenous thrombolysis (IVT) with alteplase before endovascular thrombectomy (EVT) in treating large core ischemic stroke remains uncertain. We aimed to compare clinical outcomes and safety of EVT with or without bridging IVT in patients with anterior circulation large vessel occlusion (ACLVO) and baseline Alberta Stroke Program Early CT Score (ASPECTS) ≤ 5. We systematically searched PubMed, Web of Science, Cochrane Library, and Embase from inception until November 2023. The primary outcome was 90-day functional independence (modified Rankin Scale [mRS] 0-2). Secondary outcomes included 90-day independent ambulation (mRS 0-3), successful recanalization, any intracranial hemorrhage (ICH), symptomatic ICH (sICH) and 90-day mortality. A random-effects model was used for data pooling. Five high-quality studies, incorporating 2124 patients (41% treated with bridging IVT), were included. Across both unadjusted and adjusted analyses, no significant differences were found between the bridging IVT and EVT-alone groups in terms of functional independence (odds ratios [OR] = 1.36, 95% confidence interval [CI]: 0.90-2.07, P = 0.14; adjusted OR [aOR] = 1.19, 95% CI: 0.68-2.09, P = 0.53) or independent ambulation (OR = 1.14, 95% CI: 0.80-1.62, P = 0.47; aOR = 1.18, 95% CI: 1.00-1.39, P = 0.05) at 90 days. Furthermore, no differences were observed in successful recanalization, any ICH, sICH, and 90-day mortality between the two treatment groups. Bridging IVT exhibits similar functional and safety outcomes compared to EVT alone in ACLVO patients with baseline ASPECTS ≤ 5. Further research is warranted to confirm these findings.
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Affiliation(s)
- Zekun Wang
- Department of Neurology, The First Affiliated Hospital of Soochow University, No.899 Pinghai Road, Gusu District, Suzhou, 215031, Jiangsu Province, China.
| | - Kangxiang Ji
- Department of Neurology, The First Affiliated Hospital of Soochow University, No.899 Pinghai Road, Gusu District, Suzhou, 215031, Jiangsu Province, China
| | - Qi Fang
- Department of Neurology, The First Affiliated Hospital of Soochow University, No.899 Pinghai Road, Gusu District, Suzhou, 215031, Jiangsu Province, China.
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Wu RR, Cao YZ, Xu XQ, Jia ZY, Zhao LB, Shi HB, Liu S, Wu FY, Lu SS. ASPECTS-based net water uptake outperforms target mismatch for outcome prediction in patients with acute ischemic stroke and late therapeutic window. Eur Radiol 2023; 33:9130-9138. [PMID: 37498384 DOI: 10.1007/s00330-023-09965-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 05/18/2023] [Accepted: 05/25/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVE To compare the prognostic value of net water uptake (NWU) and target mismatch (TM) on CT perfusion (CTP) in acute ischemic stroke (AIS) patients with late time window. METHODS One hundred and nine consecutive AIS patients with anterior-circulation large vessel occlusion presenting within 6-24 h from onset/last seen well were enrolled. Automated Alberta Stroke Program Early CT Score-based NWU (ASPECTS-NWU) was calculated from admission CT. The correlation between ASPECTS-NWU and CTP parameters was assessed. Predictors for favorable outcome (modified Rankin Scale score ≤ 2) at 90 days were assessed using logistic regression analysis. The ability of outcome prediction between ASPECTS-NWU and TM (an ischemic core < 70 mL, a mismatch ratio ≥ 1.8, and an absolute difference ≥ 15 mL) was compared using receiver operating characteristic (ROC) curve. RESULTS A higher level of ASPECTS-NWU was associated with a larger ischemic core (r = 0.66, p < 0.001) and a larger hypoperfusion volume (r = 0.38, p < 0.001). ASPECTS-NWU performed better than TM for outcome stratification (area under the curve [AUC], 0.738 vs 0.583, p = 0.004) and was the only independent neuroimaging marker associated with favorable outcomes compared with CTP parameters (odds ratio, 0.73; 95% confidence interval [CI] 0.62-0.87, p < 0.001). An outcome prediction model including ASPECTS-NWU and clinical variables (National Institutes of Health Stroke Scale scores and age) yielded an AUC of 0.828 (95% CI 0.744-0.893; sensitivity 65.4%; specificity 87.7%). CONCLUSION ASPECTS-NWU performed better than TM for outcome prediction in AIS patients with late time window and might be an alternative imaging biomarker to CTP for patient selection. CLINICAL RELEVANCE STATEMENT Automated Alberta Stroke Program Early CT Score-based net water uptake outperforms target mismatch on CT perfusion for the outcome prediction in patients with acute ischemic stroke and can be an alternative imaging biomarker for patient selection in late therapeutic window. KEY POINTS • A higher ASPECTS-based net water uptake was associated with larger ischemic cores and hypoperfusion volumes on CT perfusion. • ASPECTS-based net water uptake outperformed target mismatch for outcome prediction in acute ischemic stroke with extended therapeutic window. • ASPECTS-based net water uptake can be an alternative biomarker to target mismatch for selecting acute ischemic stroke patients with late therapeutic window.
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Affiliation(s)
- Rong-Rong Wu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No.300 Guangzhou Road, Gulou district, Nanjing, Jiangsu Province, China
| | - Yue-Zhou Cao
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Xiao-Quan Xu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No.300 Guangzhou Road, Gulou district, Nanjing, Jiangsu Province, China
| | - Zheng-Yu Jia
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Lin-Bo Zhao
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Hai-Bin Shi
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Fei-Yun Wu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No.300 Guangzhou Road, Gulou district, Nanjing, Jiangsu Province, China.
| | - Shan-Shan Lu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No.300 Guangzhou Road, Gulou district, Nanjing, Jiangsu Province, China.
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ASPECTS-based net water uptake predicts poor reperfusion and poor clinical outcomes in patients with ischemic stroke. Eur Radiol 2022; 32:7026-7035. [PMID: 35980434 DOI: 10.1007/s00330-022-09077-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/27/2022] [Accepted: 08/01/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate the value of automated Alberta Stroke Program Early CT Score (ASPECTS)-based net water uptake (NWU) to predict tissue-level reperfusion status and 90-day functional outcomes in acute ischemic stroke (AIS) patients after reperfusion therapy. METHODS One hundred and twelve patients with AIS who received reperfusion therapy were enrolled. ASPECTS-NWU was calculated from admission CT (NWUadmission) and follow-up CT (NWUFCT), and the difference (ΔNWU) was calculated. Tissue-level reperfusion status was evaluated via follow-up arterial spin labeling imaging. The relationship between ASPECTS-NWU and tissue-level reperfusion was evaluated. Predictors of 90-day unfavorable outcomes (modified Rankin Scale score > 2) were assessed by multivariate logistic regression analysis and receiver operating characteristic (ROC) curves. RESULTS Poor reperfusion was observed in 40 patients (35.7%) after therapy. Those patients had significantly elevated NWUFCT (median, 14.15% vs. 8.08%, p = 0.018) and higher ΔNWU (median, 4.12% vs. -2.03%, p < 0.001), compared to patients with good reperfusion. High ΔNWU was a significant marker of poor reperfusion despite successful recanalization. National Institutes of Health Stroke Scale score at admission (odds ratio [OR], 1.11; 95% confidence interval [CI] 1.03-1.20, p = 0.007) and ΔNWU (OR, 1.07; 95% CI 1.02-1.13, p = 0.008) were independently associated with unfavorable outcomes. An outcome prediction model including both parameters yields an area under the curve of 0.762 (sensitivity 70.3%, specificity, 84.2%). CONCLUSIONS Elevated NWUFCT and higher ΔNWU were associated with poor tissue-level reperfusion after therapy. Higher ΔNWU was an independent predictor of poor reperfusion and unfavorable neurological outcomes despite successful recanalization. KEY POINTS • ASPECTS-NWU may provide pathophysiological information about tissue-level reperfusion status and offer prognostic benefits for patients with AIS after reperfusion therapy. • Elevated NWUFCT and higher ΔNWU were correlated with poor tissue-level reperfusion after therapy. • A higher ΔNWU is an independent predictor of poor reperfusion and 90-day unfavorable outcomes despite successful recanalization.
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Kumar A, Chen Y, Corbin A, Hamzehloo A, Abedini A, Vardar Z, Carey G, Bhatia K, Heitsch L, Derakhshan JJ, Lee JM, Dhar R. Automated Measurement of Net Water Uptake From Baseline and Follow-Up CTs in Patients With Large Vessel Occlusion Stroke. Front Neurol 2022; 13:898728. [PMID: 35832178 PMCID: PMC9271791 DOI: 10.3389/fneur.2022.898728] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/06/2022] [Indexed: 11/13/2022] Open
Abstract
Quantifying the extent and evolution of cerebral edema developing after stroke is an important but challenging goal. Lesional net water uptake (NWU) is a promising CT-based biomarker of edema, but its measurement requires manually delineating infarcted tissue and mirrored regions in the contralateral hemisphere. We implement an imaging pipeline capable of automatically segmenting the infarct region and calculating NWU from both baseline and follow-up CTs of large-vessel occlusion (LVO) patients. Infarct core is extracted from CT perfusion images using a deconvolution algorithm while infarcts on follow-up CTs were segmented from non-contrast CT (NCCT) using a deep-learning algorithm. These infarct masks were flipped along the brain midline to generate mirrored regions in the contralateral hemisphere of NCCT; NWU was calculated as one minus the ratio of densities between regions, removing voxels segmented as CSF and with HU outside thresholds of 20-80 (normal hemisphere and baseline CT) and 0-40 (infarct region on follow-up). Automated results were compared with those obtained using manually-drawn infarcts and an ASPECTS region-of-interest based method that samples densities within the infarct and normal hemisphere, using intraclass correlation coefficient (ρ). This was tested on serial CTs from 55 patients with anterior circulation LVO (including 66 follow-up CTs). Baseline NWU using automated core was 4.3% (IQR 2.6-7.3) and correlated with manual measurement (ρ = 0.80, p < 0.0001) and ASPECTS (r = -0.60, p = 0.0001). Automatically segmented infarct volumes (median 110-ml) correlated to manually-drawn volumes (ρ = 0.96, p < 0.0001) with median Dice similarity coefficient of 0.83 (IQR 0.72-0.90). Automated NWU was 24.6% (IQR 20-27) and highly correlated to NWU from manually-drawn infarcts (ρ = 0.98) and the sampling-based method (ρ = 0.68, both p < 0.0001). We conclude that this automated imaging pipeline is able to accurately quantify region of infarction and NWU from serial CTs and could be leveraged to study the evolution and impact of edema in large cohorts of stroke patients.
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Affiliation(s)
- Atul Kumar
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Yasheng Chen
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Aaron Corbin
- Saint Louis University School of Medicine, Saint Louis, MO, United States
| | - Ali Hamzehloo
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Amin Abedini
- Department of Radiology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Zeynep Vardar
- Department of Radiology, University of Massachusetts Medical School, Worcester, MA, United States
| | - Grace Carey
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Kunal Bhatia
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Laura Heitsch
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Jamal J. Derakhshan
- Department of Radiology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Jin-Moo Lee
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
| | - Rajat Dhar
- Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States,*Correspondence: Rajat Dhar
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Review of net water uptake in the management of acute ischemic stroke. Eur Radiol 2022; 32:5517-5524. [DOI: 10.1007/s00330-022-08658-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/24/2022] [Accepted: 02/12/2022] [Indexed: 12/15/2022]
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Evaluation of Mannitol Intervention Effects on Ischemic Cerebral Edema in Mice Using Swept Source Optical Coherence Tomography. PHOTONICS 2022. [DOI: 10.3390/photonics9020081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cerebral edema is a serious complication of ischemic cerebrovascular disease and mannitol is a commonly used dehydrating agent for relieving cerebral edema. However, the edema state and surrounding vascular perfusion level during mannitol treatment remains unclear, which affects the clinical application of the medicine. In this paper, we demonstrated the role of swept-source optical coherence tomography (OCT) in the evaluation of mannitol efficacy using mouse models. The OCT-based angiography and attenuation imaging technology were used to obtain the cerebral vascular perfusion level and cerebral edema state at different times. Vascular parameters and edema parameters were quantified and compared. Experimental results show that mannitol can significantly reduce the water content in the central region of edema, effectively inhibiting the rapid growth of the edema area, and restoring cerebral blood flow. On average, the edema area decreased by 33% after 2 h, and the vascular perfusion density increased by 12% after 5 h. This work helps to provide a valuable theoretical basis and research ideas for the clinical treatment of cerebral edema.
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