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Nogueira RG, Doheim MF, Al-Bayati AR, Lee JS, Haussen DC, Mohammaden M, Lang M, Starr M, Rocha M, da Câmara CP, Gross BA, Bhatt NR. Distal Medium Vessel Occlusion Strokes: Understanding the Present and Paving the Way for a Better Future. J Stroke 2024; 26:190-202. [PMID: 38836268 PMCID: PMC11164590 DOI: 10.5853/jos.2023.02649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 06/06/2024] Open
Abstract
Distal medium vessel occlusions (DMVOs) are thought to cause as many as 25% to 40% of all acute ischemic strokes and may result in substantial disability amongst survivors. Although intravenous thrombolysis (IVT) is more effective for distal than proximal vessel occlusions, the overall efficacy of IVT remains limited in DMVO with less than 50% of patients achieving reperfusion and about 1/3 to 1/4 of the patients failing to achieve functional independence. Data regarding mechanical thrombectomy (MT) among these patients remains limited. The smaller, thinner, and more tortuous vessels involved in DMVO are presumably associated with higher procedural risks whereas a lower benefit might be expected given the smaller amount of tissue territory at risk. Recent advances in technology have shown promising results in endovascular treatment of DMVOs with room for future improvement. In this review, we discuss some of the key technical and clinical considerations in DMVO treatment including the anatomical and clinical terminology, diagnostic modalities, the role of IVT and MT, existing technology, and technical challenges as well as the contemporary evidence and future treatment directions.
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Affiliation(s)
- Raul G. Nogueira
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mohamed F. Doheim
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alhamza R. Al-Bayati
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jin Soo Lee
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, Korea
| | - Diogo C. Haussen
- Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Mahmoud Mohammaden
- Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael Lang
- UPMC Stroke Institute, Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Matthew Starr
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Marcelo Rocha
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Bradley A. Gross
- UPMC Stroke Institute, Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nirav R. Bhatt
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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2
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Yang DL, Thomas R, Ford AF, Cucchiara BL, George DK, Song JW. Vessel wall imaging in the diagnosis of antiphospholipid syndrome presenting as Moyamoya syndrome-A case report. Neuroradiol J 2024:19714009241247469. [PMID: 38621702 DOI: 10.1177/19714009241247469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Abstract
Objectives: We describe a case of anti-phospholipid syndrome (APLS) vasculopathy presenting with Moyamoya syndrome (MMS) and show the associated intracranial vessel wall MRI (VWI) findings. Methods: A 37-year-old-woman presented with acute onset dizziness and left-sided weakness. Neurologic exam revealed a left facial droop and left hemiparesis. She underwent a comprehensive laboratory work-up for stroke. Neuroimaging included a CT head, CT angiogram, VWI, and digital subtraction angiography. Results: Work-up revealed a triple-positive APLS antibody profile. CT of the head showed an acute right basal ganglia infarction and right frontal subarachnoid hemorrhage. CT angiogram revealed severe stenosis of the right internal carotid artery terminus in a Moyamoya pattern. Intracranial VWI showed long-segment concentric vessel wall thickening and homogeneous vessel wall enhancement and T2-hyperintense wall edema of the stenotic right ICA terminus, M1 middle cerebral artery, and A1 anterior cerebral artery. She was treated with long-term anticoagulation with warfarin and a right superficial temporal artery to middle cerebral artery bypass. Discussion: We present intracranial VWI features of vessel wall pathology in a patient with primary APLS presenting with MMS.
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Affiliation(s)
- David L Yang
- Perelman School of Medicine, University of Pennsylvania, USA
| | - Rachel Thomas
- Department of Neurology, University of Pennsylvania, USA
| | - Alice F Ford
- Department of Neurology, University of Pennsylvania, USA
| | | | - Donna K George
- Department of Neurology, University of Pennsylvania, USA
| | - Jae W Song
- Department of Radiology, University of Pennsylvania, USA
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3
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Costamagna G, Navi BB, Beyeler M, Hottinger AF, Alberio L, Michel P. Ischemic Stroke in Cancer: Mechanisms, Biomarkers, and Implications for Treatment. Semin Thromb Hemost 2024; 50:342-359. [PMID: 37506734 DOI: 10.1055/s-0043-1771270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
Ischemic stroke is an important cause of morbidity and mortality in cancer patients. The underlying mechanisms linking cancer and stroke are not completely understood. Long-standing and more recent evidence suggests that cancer-associated prothrombotic states, along with treatment-related vascular toxicity, such as with chemotherapy and immunotherapy, contribute to an increased risk of ischemic stroke in cancer patients. Novel biomarkers, including coagulation, platelet and endothelial markers, cell-free DNA, and extracellular vesicles are being investigated for their potential to improve risk stratification and patient selection for clinical trials and to help guide personalized antithrombotic strategies. Treatment of cancer-related stroke poses unique challenges, including the need to balance the risk of recurrent stroke and other thromboembolic events with that of bleeding associated with antithrombotic therapy. In addition, how and when to restart cancer treatment after stroke remains unclear. In this review, we summarize current knowledge on the mechanisms underlying ischemic stroke in cancer, propose an etiological classification system unique to cancer-related stroke to help guide patient characterization, provide an overview of promising biomarkers and their clinical utility, and discuss the current state of evidence-based management strategies for cancer-related stroke. Ultimately, a personalized approach to stroke prevention and treatment is required in cancer patients, considering both the underlying cancer biology and the individual patient's risk profile.
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Affiliation(s)
- Gianluca Costamagna
- Stroke Unit, Neurology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, New York
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Morin Beyeler
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas F Hottinger
- Services of Neurology and Oncology, Lundin Family Brain Tumor Research Center, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Lorenzo Alberio
- Division of Hematology and Hematology Central Laboratory, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Patrik Michel
- Department of Clinical Neurosciences, Stroke Center, Neurology Service, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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4
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Bhin J, Kwak HS, Hwang SB, Chung GH. Comparison of imaging findings on three-dimensional black-blood enhanced MR imaging between intracranial atherosclerotic occlusion and thrombotic occlusion. J Stroke Cerebrovasc Dis 2023; 32:106877. [PMID: 36370507 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/20/2022] [Accepted: 11/05/2022] [Indexed: 11/11/2022] Open
Abstract
PURPOSE The purpose of this study was to compare the imaging findings on three-dimensional (3D) black-blood (BB) contrast-enhanced MR imaging between intracranial atherosclerotic occlusion (IAO) and thrombotic occlusion (TO) of the middle cerebral artery (MCA) territory. MATERIALS AND METHODS From August 2020 to September 2021, we retrospectively reviewed the BB contrast-enhanced MR imaging of patients visiting the emergency room for evaluation of acute ischemic stroke. In total, 77 patients with complete occlusion of the MCA territory on 3D BB contrast-enhanced MR imaging and cerebral angiography were enrolled in this study. We divided the IAO and TO groups according to occlusion causes based on angiography findings. RESULTS Of 77 patients, 44 (57.1%) had an IAO in the M1 and M2 and 33 had a TO. Lesion length contrast enhancement (CE) in patients with a TO was significantly longer than that in patients with an IAO (18.95 mm [IQR: 20.91] vs. 7.1 mm [8.92], p <0.001). Overall, 38 (39.4%) patients showed a disconnection of CE on 3D BB contrast-enhanced MR imaging, and 35 showed CE before and after the stenotic or thrombotic lesion. Symptomatic lesions on diffusion-weighted imaging in the TO group were significantly higher than that of the IAO group (97.0% vs, 70.5%, p = 0.003). CONCLUSION The long segment CE on 3D BB contrast-enhanced MR imaging was related to TO of MCA. CE before and after a stenotic or thrombotic lesion is a common finding on 3D BB contrast-enhanced MR imaging.
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Affiliation(s)
- Jooyeon Bhin
- Medical Student, Jeonbuk National University Medical School, Korea.
| | - Hyo Sung Kwak
- Department of Radiology and Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Korea.
| | - Seung Bae Hwang
- Department of Radiology and Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Korea.
| | - Gyung Ho Chung
- Department of Radiology and Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Korea.
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Acute Distal Vertebral Artery Occlusion in Patients with Asymmetrical Vertebral Artery Geometry: Role of Black-Blood-Enhanced MR Imaging. Diagnostics (Basel) 2022; 12:diagnostics12102391. [PMID: 36292080 PMCID: PMC9600196 DOI: 10.3390/diagnostics12102391] [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: 09/20/2022] [Revised: 09/25/2022] [Accepted: 09/27/2022] [Indexed: 11/17/2022] Open
Abstract
Background: The purpose of this study was to evaluate the diagnostic value of contrast enhancement in a unilateral distal vertebral artery (VA) using black blood (BB)-enhanced magnetic resonance (MR) imaging in patients with acute neurological symptoms and asymmetrical VA geometry. Methods: From January 2020 to August 2021, we retrospectively analyzed BB-contrast-enhanced MR imaging and MR angiography (MRA) findings in stroke patients visiting the emergency room for an evaluation of acute neurological symptoms. We classified four patterns according to asymmetrical VA geometry using MRA and contrast enhancement using BB-enhanced MR imaging: type 1 = enhanced VA + no visualization of VA, type 2 = enhanced VA + hypoplastic VA, type 3 = non-enhanced VA + hypoplastic VA, or type 4 = non-enhanced VA + no visualization of VA. Results: In total, 288 patients (type 1 = 65, type 2 = 17, type 3 = 130, type 4 = 76) were enrolled in this study. Of these patients, 82 (28.5%) showed contrast enhancement of a unilateral distal VA on BB-enhanced MR imaging, and 51 (17.8%) had positive findings on diffusion-weighted imaging (DWI) in the ipsilateral medulla, pons, or posterior inferior cerebellar artery (PICA) territory. The contrast enhancement of a unilateral distal VA using BB-enhanced MR imaging demonstrated a significantly higher prevalence in patients with acute infarction on DWI (50.0% vs. 4.9%, p < 0.001). Conclusions: The contrast enhancement of a unilateral distal VA on BB-enhanced MR imaging is associated with acute infarction of the medulla, pons, or PICA territory and suggests acute occlusion of a distal VA.
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6
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Li Z, Bai X, Gao P, Lin Y, Ju Y, Sui B. Changes of prominent vessel sign and susceptibility vessel sign in acute ischemic stroke patients with and without successful recanalization: a study based on susceptibility weighted images. Neurol Res 2022; 44:583-590. [PMID: 35001834 DOI: 10.1080/01616412.2021.2024729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To investigate the changes of prominent vessel sign (PVS) and susceptibility vessel sign (SVS) in acute ischemic stroke (AIS) patients with successful and non-successful vascular recanalization treatment, and to study the associations between the susceptibility-weighted imaging (SWI) findings and early clinical and imaging prognosis. METHODS Thirty-five patients with the acute MCA territory infarction were retrospectively included and classified into Groupre (n = 25) and Groupnon (n = 10) according to the success of vascular recanalization. NIHSS was used for clinical assessment. PVS and DWI were analyzed using ASPECT scores. Baseline, post-treatment, the changes of PVS and SVS, and SVS length were recorded and compared between two groups. Correlation analysis was performed between SWI factors and early post-treatment clinical and imaging factors. RESULTS The mean PVSpre value was 5.20 ± 1.76 and PVSpost was 8.20 ± 1.86. PVSpre and PVSpost showed statistical significance between Groupre and Groupnon (both p < 0.001). A significant difference wasfound in SVSpost(+) (p < 0.001), SVSpost-pre(+) (p = 0.001), SVSpost-pre length (p = 0.036) and SVSpost length (p = 0.001) between the two groups. A positive correlation was found between PVSpre and DWIpost (p < 0.001, r = 0.564). There were positive correlations between PVS-DWI mismatch and NIHSSpost in Groupre (p = 0.042, r = 0.410) and in Groupnon (p = 0.006, r = 0.789). CONCLUSIONS PVS and SVS changes are influenced by the success of vascular recanalization. However, the changes are unrelated to either early clinical or imaging outcomes in AIS patients. PVS-DWI mismatch can be taken as an imaging biomarker for early clinical outcomes, both for patients with or without successful vascular recanalization.
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Affiliation(s)
- Zhiye Li
- Tiantan Neuroimaging Center of Excellence, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing Neurosurgical Institute, Beijing, China
| | - Xiaoyan Bai
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing Neurosurgical Institute, Beijing, China
| | - Peiyi Gao
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing Neurosurgical Institute, Beijing, China
| | - Yan Lin
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing Neurosurgical Institute, Beijing, China
| | - Yi Ju
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Binbin Sui
- Tiantan Neuroimaging Center of Excellence, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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7
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Kovilapu UB, Jain N, Mishra A, Malik V. Selecting the Appropriate First-Line Strategy Based on Hyperdense Vessel Sign in Acute Ischemic Stroke Increases First Pass Recanalization: A Tertiary Center Experience. Indian J Radiol Imaging 2022; 31:830-836. [PMID: 35136493 PMCID: PMC8817827 DOI: 10.1055/s-0041-1741095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background:
The data pertaining to selecting an optimal first-line strategy (stent retriever [SR] vs. contact aspiration [CA]) based on noncontrast computed tomography (NCCT) in cases of acute ischemic stroke consequent to large vessel occlusion (LVO) is lacking.
Aims:
This article studies the influence of hyperdense vessel sign (HVS) in selecting optimal first-line strategy, with intention of increasing first-pass recanalization (FPR).
Methods:
Upfront approach at our center is SR technique with rescue therapy (CA) adoption consequent to three failed SR attempts to achieve successful recanalization. Data of patients with acute LVO who underwent mechanical thrombectomy from June 2017 to May 2020 was retrospectively analyzed. Patients were classified into HVS (+) and HVS (−) cohort. Rate of successful recanalization (first pass, early, and final) and efficacy of rescue therapy was assessed between the two cohorts.
Results:
Of 52 patients included, 28 and 24 were assigned to the HVS (+) and HVS (−) cohort, respectively. FPR was observed in 50% of HVS (+) and 20.9% of HVS (−) (
p
= 0.029). Early recanalization was documented in 64.2% of HVS (+) and 37.5% of HVS (−) (
p
= 0.054). Rescue therapy need was higher in patients not demonstrating HVS (
p
= 0.062). Successful recanalization was achieved with rescue therapy in 50% of HVS (−) group.
Conclusion:
A higher FPR is achievable following individualized first-pass strategy (based on NCCT appearance of clot), instead of a generalized SR first-pass approach. This CT imaging-based strategy is a step closer to achieving primary angiographic goal of FPR.
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Affiliation(s)
- Uday Bhanu Kovilapu
- Interventional Radiologist at Department of Radiodiagnosis and Interventional Radiology, Armed Forces Medical College, Pune, Maharashtra, India
| | - Narendra Jain
- Interventional Radiologist at Department of Radiodiagnosis and Interventional Radiology, Command Hospital, Chandi Mandir, Haryana, India
| | - Atul Mishra
- Interventional Radiologist at Department of Radiodiagnosis and Interventional Radiology, Army Hospital (R&R), New Delhi, India
| | - Virender Malik
- Interventional Radiologist at Department of Radiodiagnosis and Interventional Radiology, Army Institute of Cardiothoracic sciences (AICTS), affiliated to Armed Forces Medical College, Pune, Maharashtra, India
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8
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Guenego A, Fahed R, Sussman ES, Leipzig M, Albers GW, Martin BW, Marcellus DG, Kuraitis G, Marks MP, Lansberg MG, Wintermark M, Heit JJ. Impact of Clot Shape on Successful M1 Endovascular Reperfusion. Front Neurol 2021; 12:642877. [PMID: 33597919 PMCID: PMC7882685 DOI: 10.3389/fneur.2021.642877] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 01/08/2021] [Indexed: 11/15/2022] Open
Abstract
Objectives: The susceptibility-vessel-sign (SVS) allows thrombus visualization, length estimation and composition, and it may impact reperfusion during mechanical thrombectomy (MT). SVS can also describe thrombus shape in the occluded artery: in the straight M1-segment (S-shaped), or in an angulated/traversing a bifurcation segment (A-shaped). We determined whether SVS clot shape influenced reperfusion and outcomes after MT for proximal middle-cerebral-artery (M1) occlusions. Methods: Between May 2015 and March 2018, consecutive patients who underwent MT at one comprehensive stroke center and who had a baseline MRI with a T2* sequence were included. Clinical, procedural and radiographic data, including clot shape on SVS [angulated/bifurcation (A-SVS) vs. straight (S-SVS)] and length were assessed. Primary outcome was successful reperfusion (TICI 2b-3). Secondary outcome were MT complication rates, MT reperfusion time, and clinical outcome at 90-days. Predictors of outcome were assessed with univariate and multivariate analyses. Results: A total of 62 patients were included. 56% (35/62) had an A-SVS. Clots were significantly longer in the A-SVS group (19 mm vs. 8 mm p = 0.0002). Groups were otherwise well-matched with regard to baseline characteristics. There was a significantly lower rate of successful reperfusion in the A-SVS cohort (83%) compared to the S-SVS cohort (96%) in multivariable analysis [OR 0.04 (95% CI, 0.002–0.58), p = 0.02]. There was no significant difference in long term clinical outcome between groups. Conclusion: Clot shape as determined on T2* imaging, in patients presenting with M1 occlusion appears to be a predictor of successful reperfusion after MT. Angulated and bifurcating clots are associated with poorer rates of successful reperfusion.
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Affiliation(s)
- Adrien Guenego
- Interventional and Diagnostic Neuroradiology, Stanford Medical Center, Stanford, CA, United States
| | - Robert Fahed
- Division of Neurology, Department of Medicine, Ottawa Hospital Research Institute, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Eric S Sussman
- Interventional and Diagnostic Neuroradiology, Stanford Medical Center, Stanford, CA, United States
| | - Matthew Leipzig
- Interventional and Diagnostic Neuroradiology, Stanford Medical Center, Stanford, CA, United States
| | - Gregory W Albers
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, United States
| | - Blake W Martin
- Interventional and Diagnostic Neuroradiology, Stanford Medical Center, Stanford, CA, United States
| | - David G Marcellus
- Interventional and Diagnostic Neuroradiology, Stanford Medical Center, Stanford, CA, United States
| | - Gabriella Kuraitis
- Interventional and Diagnostic Neuroradiology, Stanford Medical Center, Stanford, CA, United States
| | - Michael P Marks
- Interventional and Diagnostic Neuroradiology, Stanford Medical Center, Stanford, CA, United States
| | - Maarten G Lansberg
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, United States
| | - Max Wintermark
- Interventional and Diagnostic Neuroradiology, Stanford Medical Center, Stanford, CA, United States
| | - Jeremy J Heit
- Interventional and Diagnostic Neuroradiology, Stanford Medical Center, Stanford, CA, United States
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Ha SH, Chang JY, Lee SH, Lee KM, Heo SH, Chang DI, Kim BJ. Mechanism of Stroke According to the Severity and Location of Atherosclerotic Middle Cerebral Artery Disease. J Stroke Cerebrovasc Dis 2020; 30:105503. [PMID: 33271485 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105503] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/12/2020] [Accepted: 11/22/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND PURPOSE Strategy for secondary prevention of ischemic stroke depends on the mechanism of stroke. The aim of this study was to compare the stroke mechanism according to the location and severity of middle cerebral artery (MCA) disease. METHODS We analyzed acute ischemic stroke patients within 7 days of onset with symptomatic MCA disease. The location of MCA disease was classified into proximal MCA M1 (pMCA) and distal MCA M1/proximal M2 (dMCA). The mechanism of stroke was categorized according to the pattern of ischemic lesion: local branch occlusion, artery-to-artery embolism/hemodynamic infarction, in situ-thrombosis, or a combined mechanism. The mechanism and imaging characteristics of stroke were compared according to the location and severity. The factors associated with the stroke mechanism were also investigated. RESULTS A symptomatic MCA disease was observed in 126 patients (74 pMCA and 52 dMCA). The mechanism of stroke differed according to the location (p < 0.001); the combined mechanism was most common in pMCA disease (54.1%), especially in those who presented with MCA occlusion and with a susceptible vessel sign. Artery-to-artery embolism/hemodynamic infarction was most common in dMCA disease (46.2%). A longer length of stenosis was observed in local branch occlusion than in other mechanisms (p = 0.04) and was an independent factor associated with local branch occlusion (OR=1.631, 95% CI=1.161-2.292; p = 0.005). CONCLUSIONS The mechanism of stroke differed according to the location of MCA disease: occlusion caused by plaque rupture with combined mechanism of stroke type was predominant in pMCA. Longer length of stenosis was associated with local branch occlusion.
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Affiliation(s)
- Sang Hee Ha
- Department of Neurology, Kyung Hee University Hospital, Seoul, Korea
| | | | - Sang Hun Lee
- Department of Neurology, Korea University Ansan Hospital, Ansan, Korea
| | - Kyung Mi Lee
- Department of Neurology and Radiology, Kyung Hee University Hospital, Seoul, Korea
| | - Sung Hyuk Heo
- Department of Neurology, Kyung Hee University Hospital, Seoul, Korea
| | - Dae-Il Chang
- Department of Neurology, Kyung Hee University Hospital, Seoul, Korea
| | - Bum Joon Kim
- Department of Neurology, Asan Medical Center, Seoul, Korea.
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10
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Rudilosso S, Olivera M, Esteller D, Laredo C, Amaro S, Llull L, Renú A, Obach V, Vera V, Rodríguez A, Blasco J, López-Rueda A, Urra X, Chamorro Á. Susceptibility Vessel Sign in Deep Perforating Arteries in Patients with Recent Small Subcortical Infarcts. J Stroke Cerebrovasc Dis 2020; 30:105415. [PMID: 33142246 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105415] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/05/2020] [Accepted: 10/15/2020] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Recent small subcortical infarcts (RSSI) are considered an acute manifestation of cerebral small vessel disease. Paramagnetic signals in perforating arteries supplying RSSI may be detected on T2*-relaxation derived sequences on MRI and is defined as susceptibility vessel sign (SVS). We aimed to study the prevalence of SVS in patients with RSSI, and explore whether its identification is related to cerebral small vessel disease markers. MATERIALS AND METHODS We selected patients with RSSI identified on MRI during admission from a single-center stroke registry. The main demographic and clinical features, including vascular risk factors, were collected. Radiological features of RSSI and cerebral small vessel disease [white matter hyperintensities in deep and periventricular regions, enlarged perivascular spaces, lacunae, microbleeds, and brain atrophy] were described using validated qualitative scores. The presence of SVS was assessed on T2*gradient-echo or other susceptibility-weighted imaging. We compared the clinical and radiological features of patients with or without SVS in uni- and multivariate models. RESULTS Out of 210 patients with an RSSI on an MRI, 35 (17%) showed SVS. The proportion of SVS+ patients was similar in different susceptibility imaging modalities (p=.64). Risk factor profiles and clinical course were similar in SVS+ and SVS- patients. SVS+ patients had a higher grade of deep white matter hyperintensities and brain atrophy, more lacunae (p=.001, p=.034, p=.022, respectively), and a similar degree of the rest of radiological variables, compared to SVS- patients. In the multivariate analysis, the grade of deep white matter hyperintensities was the only independent factor associated with SVS [OR 3.1 (95% CI, 1.5-6.4)]. CONCLUSIONS SVS in patients with RSSI is uncommon and related to a higher grade of deep white matter hyperintensities. Pathophysiological mechanisms underlying the deposition of hemosiderin in the path of occluded perforating arteries are uncertain and might include endothelial dysfunction or embolic mechanisms.
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Affiliation(s)
- Salvatore Rudilosso
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain; August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.
| | - Marta Olivera
- Department of Neurology, Hospital Clínic of Barcelona, Spain
| | - Diana Esteller
- Department of Neurology, Hospital Clínic of Barcelona, Spain
| | - Carlos Laredo
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain; August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Sergio Amaro
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain; August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Laura Llull
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain; August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Arturo Renú
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain; August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Víctor Obach
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain; August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Víctor Vera
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Alejandro Rodríguez
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Jordi Blasco
- Department of Radiology, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Antonio López-Rueda
- Department of Radiology, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Xabier Urra
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain; August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.
| | - Ángel Chamorro
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain; August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
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11
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Simultaneous feedback control for joint field and motion correction in brain MRI. Neuroimage 2020; 226:117286. [PMID: 32992003 DOI: 10.1016/j.neuroimage.2020.117286] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/21/2020] [Accepted: 08/14/2020] [Indexed: 11/23/2022] Open
Abstract
T2*-weighted gradient-echo sequences count among the most widely used techniques in neuroimaging and offer rich magnitude and phase contrast. The susceptibility effects underlying this contrast scale with B0, making T2*-weighted imaging particularly interesting at high field. High field also benefits baseline sensitivity and thus facilitates high-resolution studies. However, enhanced susceptibility effects and high target resolution come with inherent challenges. Relying on long echo times, T2*-weighted imaging not only benefits from enhanced local susceptibility effects but also suffers from increased field fluctuations due to moving body parts and breathing. High resolution, in turn, renders neuroimaging particularly vulnerable to motion of the head. This work reports the implementation and characterization of a system that aims to jointly address these issues. It is based on the simultaneous operation of two control loops, one for field stabilization and one for motion correction. The key challenge with this approach is that the two loops both operate on the magnetic field in the imaging volume and are thus prone to mutual interference and potential instability. This issue is addressed at the levels of sensing, timing, and control parameters. Performance assessment shows the resulting system to be stable and exhibit adequate loop decoupling, precision, and bandwidth. Simultaneous field and motion control is then demonstrated in examples of T2*-weighted in vivo imaging at 7T.
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12
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Saver JL, Chapot R, Agid R, Hassan A, Jadhav AP, Liebeskind DS, Lobotesis K, Meila D, Meyer L, Raphaeli G, Gupta R. Thrombectomy for Distal, Medium Vessel Occlusions: A Consensus Statement on Present Knowledge and Promising Directions. Stroke 2020; 51:2872-2884. [PMID: 32757757 DOI: 10.1161/strokeaha.120.028956] [Citation(s) in RCA: 187] [Impact Index Per Article: 46.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Endovascular thrombectomy (EVT) is well established as a highly effective treatment for acute ischemic stroke (AIS) due to proximal, large vessel occlusions (PLVOs). With iterative further advances in catheter technology, distal, medium vessel occlusions (DMVOs) are now emerging as a promising next potential EVT frontier. This consensus statement integrates recent epidemiological, anatomic, clinical, imaging, and therapeutic research on DMVO-AIS and provides a framework for further studies. DMVOs cause 25% to 40% of AISs, arising as primary thromboemboli and as unintended consequences of EVT performed for PLVOs, including emboli to new territories (ENTs) and emboli to distal territories (EDTs) within the initially compromised arterial field. The 6 distal medium arterial arbors (anterior cerebral artery [ACA], M2–M4 middle cerebral artery [MCA], posterior cerebral artery [PCA], posterior inferior cerebellar artery [PICA], anterior inferior cerebellar artery [AICA], and superior cerebellar artery [SCA]) typically have 25 anatomic segments and give rise to 34 distinct arterial branches nourishing highly differentiated, largely superficial cerebral neuroanatomical regions. DMVOs produce clinical syndromes that are highly heterogenous but frequently disabling. While intravenous fibrinolytics are more effective for distal than proximal occlusions, they fail to recanalize one-half to two-thirds of DMVOs. Early clinical series using recently available, smaller, more navigable stent retriever and thromboaspiration devices suggest EVT for DMVOs is safe, technically efficacious, and potentially clinically beneficial. Collaborative investigations are desirable to enhance imaging recognition of DMVOs; advance device design and technical efficacy; conduct large registry studies using harmonized, common data elements; and complete formal randomized trials, improving treatment of this frequent mechanism of stroke.
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Affiliation(s)
- Jeffrey L Saver
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA (J.L.S., D.S.L.)
| | - Rene Chapot
- Department of Neuroradiology and Intracranial Endovascular Therapy, Alfried Krupp Krankenhaus, Essen, Germany (R.C.)
| | - Ronit Agid
- Division of Neuroradiology, Toronto Western Hospital, JDMI, UHN, Canada (R.A.)
| | - Ameer Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Valley Baptist Medical Center, Harlingen (A.H.)
| | - Ashutosh P Jadhav
- Departments of Neurology and Neurosurgery, University of Pittsburgh Medical Center, PA (A.P.J.)
| | - David S Liebeskind
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA (J.L.S., D.S.L.)
| | - Kyriakos Lobotesis
- Department of Neuroradiology, Imperial College Healthcare NHS Trust, London, United Kingdom (K.L.)
| | - Dan Meila
- Department of Interventional Neuroradiology, Johanna-Étienne-Hospital, Neuss, Germany (D.M.)
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (L.M.)
| | - Guy Raphaeli
- Departments of Neurology (G.R.), Rabin Medical Center, Tel Aviv, Israel.,Interventional Neuroradiology (G.R.), Rabin Medical Center, Tel Aviv, Israel
| | - Rishi Gupta
- Departments of Neurology (R.G.), WellStar Health System, Atlanta, GA.,Neuroradiology (R.G.), WellStar Health System, Atlanta, GA
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13
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Chen Q, Wang W, Chen YC, Chen G, Ni L, Zhang D, Zhou J, Yin XD. Peri-thrombus vascular hyperintensity sign: detection of intracranial thrombus location and length in acute ischemic stroke. Jpn J Radiol 2020; 38:516-523. [DOI: 10.1007/s11604-020-00937-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 02/18/2020] [Indexed: 01/03/2023]
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14
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Chung GH, Hwang SB, Kwak HS. Use of 3-Dimensional, Black-Blood, Contrast-Enhanced, T1-Weighted Magnetic Resonance Imaging to Identify Vascular Occlusion in the Posterior Circulation After Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2019; 28:104373. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104373] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 07/21/2019] [Accepted: 08/26/2019] [Indexed: 11/30/2022] Open
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15
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Zheng MZ, Yang QY, Lu XD, Hu SL, Chai C, Shen W, Chang BG, Wang ZY, Xia S. Middle cerebral artery thrombus susceptibility-weighted imaging mapping predicts prognosis. Quant Imaging Med Surg 2019; 9:1556-1565. [PMID: 31667141 DOI: 10.21037/qims.2019.08.17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Susceptibility weighted imaging and mapping (SWIM) of magnetic resonance imaging (MRI) is used to evaluate cerebral arterial thrombosis. The aim of this research was to assess susceptibility, length, and clot burden score (CBS) of thrombus in the middle cerebral artery (MCA) and their relationship with cerebral infarction and early clinical prognosis in patients with acute or subacute cerebral infarction. Methods In total, 56 patients with acute or subacute cerebral infarction (with the time from onset to admission less than 72 h) and only unilateral MCA occlusion were included in the current study. All the patients had the corresponding susceptibility vessel sign (SVS) on susceptibility-weighted imaging (SWI). Parameters including susceptibility, length, and CBS of thrombus were obtained from SWI and SWIM. The differences in susceptibility of different portions of the thrombus were compared with each other by one-way ANOVA test. The relationship between susceptibility and stroke onset time was further analyzed by Spearman correlation analysis, in addition to the relationships between susceptibility, length, CBS, diffusion-weighted imaging-Alberta stroke program early CT score (DWI-ASPECTS), and admission and discharge National Institutes of Health Stroke Scale (NIHSS). Results The susceptibility among different portions and different segments of thrombus showed no statistical difference. The susceptibility and length were weakly yet negatively correlated with DWI-ASPECTS (rs=-0.382, -0.457; P=0.004, 0.000). The susceptibility was weakly yet positively correlated with admission NIHSS and discharged NIHSS (rs=0.403, 0.430; P=0.002, 0.001). CBS was weakly yet positively correlated with DWI-ASPECTS (rs=0.349; P=0.008) and weakly yet negatively correlated with admission and discharged NIHSS (rs=-0.375, -0.335; P=0.004, 0.012). Conclusions The susceptibility remained consistent regardless of location, length, and onset time, which indicates that the thrombus composition was similar when detected on SWI less than 72 h from the onset. Susceptibility and CBS may help to predict clinical severity and short-term clinical prognosis to some extent.
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Affiliation(s)
- Mei-Zhu Zheng
- Radiological Department, Third Central Hospital of Tianjin, Tianjin Key Laboratory of Artificial Cell, Artificial Cell Engineering Technology Research Center of Public Health Ministry, Tianjin 300170, China
| | - Qing-Yuan Yang
- Radiological Department, Tianjin Haihe Hospital, Tianjin 300222, China
| | - Xiu-Di Lu
- Radiological Department, First Central Clinical College, Tianjin Medical University, Tianjin 300381, China.,Radiological Department, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300192, China
| | - Si-Le Hu
- Intervention Division Department, Inner Mongolia Autonomous Region People's Hospital, Hohhot 010020, China
| | - Chao Chai
- Radiological Department, Tianjin First Central Hospital, Tianjin 300192, China
| | - Wen Shen
- Radiological Department, Tianjin First Central Hospital, Tianjin 300192, China
| | - Bin-Ge Chang
- Neurosurgery Department, Tianjin First Central Hospital, Tianjin 300192, China
| | - Zhi-Yun Wang
- Neurological Department, Tianjin First Central Hospital, Tianjin 300192, China
| | - Shuang Xia
- Radiological Department, Tianjin First Central Hospital, Tianjin 300192, China
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16
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Chung JW, Kim YC, Cha J, Choi EH, Kim BM, Seo WK, Kim GM, Bang OY. Characterization of clot composition in acute cerebral infarct using machine learning techniques. Ann Clin Transl Neurol 2019; 6:739-747. [PMID: 31019998 PMCID: PMC6469248 DOI: 10.1002/acn3.751] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 01/31/2019] [Accepted: 02/11/2019] [Indexed: 01/01/2023] Open
Abstract
Objective Clot characteristics can provide information on the cause of cerebral artery occlusion and may guide acute revascularization and secondary prevention strategies. We developed a rapid automated clot analysis system using machine learning (ML) and validated its accuracy in patients undergoing endovascular treatment. Methods Pre‐endovascular treatment gradient echo (GRE) images from consecutive patients with middle cerebral artery occlusion were utilized to develop and validate an ML system to predict whether atrial fibrillation (AF) was the underlying cause of ischemic stroke. The accuracy of the ML algorithm was compared with that of visual inspection by neuroimaging specialists for the presence of blooming artifact. Endovascular procedures and outcomes were compared in patients with and without AF. Results Of 67 patients, 29 (43.3%) had AF. Of these, 13 had known AF and 16 were newly diagnosed with cardiac monitoring. By visual inspection, interrater correlation for blooming artifact was 0.73 and sensitivity and specificity for AF were 0.79 and 0.63, respectively. For AF classification, the ML algorithms yielded an average accuracy of > 75.4% in fivefold cross‐validation with clot signal profiles obtained from 52 patients and an area under the curve >0.87 for the average AF probability from five signal profiles in external validation (n = 15). Analysis with an in‐house interface took approximately 3 min per patient. Absence of AF was associated with increased number of passes by stentriever, high reocclusion frequency, and additional use of rescue stenting and/or glycogen IIb/IIIa blocker for recanalization. Interpretation ML‐based rapid clot analysis is feasible and can identify AF with high accuracy, enabling selection of endovascular treatment strategy.
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Affiliation(s)
- Jong-Won Chung
- Department of Neurology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Yoon-Chul Kim
- Clinical Research Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Jihoon Cha
- Department of Radiology Yonsei University Medical Center Yonsei University College of Medicine Seoul Republic of Korea
| | - Eun-Hyeok Choi
- Department of Neurology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Byung Moon Kim
- Department of Radiology Yonsei University Medical Center Yonsei University College of Medicine Seoul Republic of Korea
| | - Woo-Keun Seo
- Department of Neurology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Gyeong-Moon Kim
- Department of Neurology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Oh Young Bang
- Department of Neurology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
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17
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Bourcier R, Legrand L, Soize S, Labreuche J, Beaumont M, Desal H, Derraz I, Bracard S, Oppenheim C, Naggara O. Validation of overestimation ratio and TL-SVS as imaging biomarker of cardioembolic stroke and time from onset to MRI. Eur Radiol 2018; 29:2624-2631. [PMID: 30421018 DOI: 10.1007/s00330-018-5835-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 09/17/2018] [Accepted: 10/02/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE We aimed to determine in the "THRACE" trial, the clinical and MRI technical parameters associated with the two-layered susceptibility vessel sign (TL-SVS) and the overestimation ratio (overR). MATERIALS AND METHODS Patients with pre-treatment brain gradient echo (GRE) sequence and an etiological work-up were identified. Two readers reviewed TL-SVS, i.e., a SVS with a linear low-intense signal core surrounded by a higher intensity and measured the overR as the width of SVS divided by the width of the artery. Binomial and ordinal logistic regression respectively tested the association between TL-SVS and quartiles of overR with patient characteristics, cardioembolic stroke (CES), time from onset to imaging, and GRE sequence parameters (inter slice gap, slice thickness, echo time, flip angle, voxel size, and field strength). RESULTS Among 258 included patients, 102 patients were examined by 3 Tesla MRI and 156 by 1.5 Tesla MRI. Intra- and inter-reader agreements for quartiles of overR and TL-SVS were good to excellent. The median overR was 1.59 (IQR, 1.30 to 1.86). TL-SVS was present in 101 patients (39.2%, 95%CI, 33.1 to 45.1%). In multivariate analysis, only CES was associated with overR quartiles (OR, 1.83; 95%CI, 1.11 to 2.99), and every 60 min increase from onset to MRI time was associated with TL-SVS (OR, 1.72; 95%CI, 1.10 to 2.67). MRI technical parameters were statistically associated with neither overR nor TL-SVS. CONCLUSION Independent of GRE sequence parameters, an increased overR was associated to CES, while the TL-SVS is independently related to a longer time from onset to MRI. KEY POINTS • An imaging biomarker would be useful to predict the etiology of stroke in order to adapt secondary prevention of stroke. • The two-layered susceptibility vessel sign and the overestimation ratio are paramagnetic effect derived markers that vary according to the MRI machines and sequence parameters. • Independent of sequence parameters, an increased overestimation ratio was associated to cardioembolic stroke, while the two-layered susceptibility vessel sign is independently related to a longer time from onset to MRI.
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Affiliation(s)
- Romain Bourcier
- Department of Diagnostic and Interventional Neuroradiology, Guillaume et René Laennec University Hospital, Nantes, France.
| | - Laurence Legrand
- Department of Neuroradiology, Université Paris-Descartes. INSERM U894, Sainte-Anne Hospital, Paris, France
| | - Sébastien Soize
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Reims, Reims, France.,INSERM UMR-S 1237 Physiopathology and imaging of neurological disorders, Université Caen Normandie, Caen, France
| | - Julien Labreuche
- Centre Hospitalier Regional Universitaire de Lille, Biostatistics, Lille, Hauts-de-France, France
| | - Marine Beaumont
- CIC1433, INSERM, IADI, U1254, Université de Lorraine, INSERM, CHRU de Nancy CIC-IT Nancy, Nancy, France
| | - Hubert Desal
- Department of Diagnostic and Interventional Neuroradiology, Guillaume et René Laennec University Hospital, Nantes, France
| | - Imad Derraz
- Department of Diagnostic and Interventional Neuroradiology, Hopital Gui de Chauillac, Montpellier, France
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, Nancy, France
| | - Catherine Oppenheim
- Department of Neuroradiology, Université Paris-Descartes. INSERM U894, Sainte-Anne Hospital, Paris, France
| | - Olivier Naggara
- Department of Neuroradiology, Université Paris-Descartes. INSERM U894, Sainte-Anne Hospital, Paris, France.,Pediatric Radiology Department, Necker Enfants Malades, Paris, France
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18
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Abstract
BACKGROUND Pediatric stroke is a distinct clinical entity as compared with that in adults due to its unique and diverse set of etiologies. Furthermore, the role and application of diagnostic imaging has specific constraints and considerations. The intention of this article is to review these concepts in a thorough manner to offer a pediatric stroke imaging framework that providers can employ when taking care of these patients. METHODS A comprehensive primary and secondary literature review was performed with specific attention to the common causes of pediatric stroke, appropriate use of neuroimaging, specific imaging findings, and developing techniques which may improve our ability to accurately diagnose these patients. RESULTS Findings from this literature review were synthesized and summarized in order to thoroughly review the aforementioned concepts and outline the current consensus-based approach to diagnostic imaging in pediatric stroke. Furthermore, imaging findings drawn from patients seen in our institution are demonstrated to familiarize readers with pediatric stroke neuroimaging. CONCLUSIONS The challenges posed by pediatric stroke can be mitigated, in part, by the thoughtful application of diagnostic imaging, with the ultimate hope of improving outcomes for these vulnerable patients.
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Affiliation(s)
- Alexander Khalaf
- Stanford University and Medical Center, Department of Radiology, Neuroradiology Section
| | - Iv Michael
- Stanford University and Medical Center, Department of Radiology, Neuroradiology Section
| | - Heather Fullerton
- University of California, San Francisco, Department of Neurology, Pediatric Neurology Section
| | - Max Wintermark
- Stanford University and Medical Center, Department of Radiology, Neuroradiology Section, Stanford, CA.
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19
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Bourcier R, Derraz I, Delasalle B, Beaumont M, Soize S, Legrand L, Desal H, Bracard S, Naggara O, Oppenheim C. Susceptibility Vessel Sign and Cardioembolic Etiology in the THRACE Trial. Clin Neuroradiol 2018; 29:685-692. [PMID: 29947813 DOI: 10.1007/s00062-018-0699-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 05/28/2018] [Indexed: 01/24/2023]
Abstract
PURPOSE The susceptibility vessel sign (SVS) has been described on gradient echo (GRE) magnetic resonance imaging (MRI) in acute ischemic stroke patients by large vessel occlusion. The presence of SVS (SVS+) was associated with treatment outcome and stroke etiology with conflicting results. Based on multicenter data from the THRombectomie des Artères CErebrales (THRACE) study, we aimed to determine if the association between SVS and cardioembolic etiology (CE) was independent of GRE sequence parameters. MATERIAL AND METHODS Patients with a pretreatment brain GRE sequence were identified. Logistic regression tested the association between SVS+, CE, time from onset to imaging and GRE sequence parameters (e.g. echo time, voxel size, field strength). We calculated the sensitivity, specificity, positive and negative predictive values (PPV and NPV) for the SVS to predict a stroke from a CE. RESULTS An SVS+ was observed in 237 out of 287 (83%) patients. In the univariate analysis, there was a significant association between SVS+ and a CE with an odds ratio (OR) and 95% confidence interval (95% CI) of 2.10 (1.02-4.29), respectively (p = 0.04) but not with GRE sequence parameters. In multivariate analysis, there was an independent relationship between SVS+ and CE (OR [95% CI]: 2.14 [1.02-4.45], p = 0.04). Sensitivity and specificity of SVS+ to predict CE were 0.89 and 0.21, respectively. The PPV and NPV of SVS+ were 0.44 and 0.78, respectively. CONCLUSION The presence of SVS is associated to CE, independent of GRE sequence parameters. While the specificity and the PPV of the sign were low, CE seems less likely in the absence of an SVS.
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Affiliation(s)
- Romain Bourcier
- Department of Diagnostic and Interventional Neuroradiology, Guillaume et René Laennec University Hospital, Nantes, France.
| | - Imad Derraz
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Montpellier, Montpellier, France
| | - Béatrice Delasalle
- L'institut du thorax, Centre Hospitalier Universitaire Nantes, Nantes, France.,UMR1087, Institut National de la Santé et de la Recherche Médicale, Nantes, France
| | - Marine Beaumont
- CIC1433, INSERM, Université de Lorraine, Nancy, France.,IADI, U1254, Université de Lorraine, Nancy, France.,CHRU de Nancy CIC-IT, INSERM, Nancy, France
| | - Sebastien Soize
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Reims, Reims, France.,INSERM UMR-S 1237 Physiopathology and imaging of neurological disorders, Université Caen Normandie, Caen, France
| | - Laurence Legrand
- Department of Neuroradiology, Université Paris-Descartes, Paris, France.,INSERM U894, Sainte-Anne Hospital, Paris, France
| | - Hubert Desal
- Department of Diagnostic and Interventional Neuroradiology, Guillaume et René Laennec University Hospital, Nantes, France
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Montpellier, Montpellier, France
| | - Olivier Naggara
- Department of Neuroradiology, Université Paris-Descartes, Paris, France.,Pediatric Radiology Department, Necker Enfants Malades, Paris, France.,INSERM U894, Sainte-Anne Hospital, Paris, France
| | - Catherine Oppenheim
- Department of Neuroradiology, Université Paris-Descartes, Paris, France.,INSERM U894, Sainte-Anne Hospital, Paris, France
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20
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Bourcier R, Mazighi M, Labreuche J, Fahed R, Blanc R, Gory B, Duhamel A, Marnat G, Saleme S, Costalat V, Bracard S, Desal H, Consoli A, Piotin M, Lapergue B. Susceptibility Vessel Sign in the ASTER Trial: Higher Recanalization Rate and More Favourable Clinical Outcome after First Line Stent Retriever Compared to Contact Aspiration. J Stroke 2018; 20:268-276. [PMID: 29886714 PMCID: PMC6007297 DOI: 10.5853/jos.2018.00192] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 04/04/2018] [Accepted: 05/07/2018] [Indexed: 12/20/2022] Open
Abstract
Background and Purpose In the Aspiration vs. Stent Retriever for Successful Revascularization (ASTER) trial, which evaluated contact aspiration (CA) versus stent retriever (SR) use as first-line technique, the impact of the susceptibility vessel sign (SVS) on magnetic resonance imaging (MRI) was studied to determine its influence on trial results.
Methods We included patients having undergone CA or SR for M1 or M2 occlusions, who were screened by MRI with T2* gradient recalled echo. Occlusions were classified as SVS (+) or SVS (–) in each randomization arm. Modified thrombolysis in cerebral infarction (mTICI) 2b, 2c, or 3 revascularization rates were recorded and clinical outcomes assessed by the overall distribution of modified Rankin scale (mRS) at 90 days.
Results Among the 202 patients included, 143 patients were SVS (+) (70.8%; 95% confidence interval [CI], 64.5% to 77.1%). Overall, there was no difference in angiographic and clinical outcomes according to SVS status. However, compared to SR, CA achieved a lower mTICI 2c/3 rate in SVS (+) patients (risk ratio [RR] for CA vs. SR, 0.60; 95% CI, 0.51 to 0.71) but not in SVS (–) (RR, 1.11; 95% CI, 0.69 to 1.77; P for interaction=0.018). A significant heterogeneity in favor of superiority of first-line SR strategy in SVS (+) patients was also found regarding the overall mRS distribution (common odds ratio for CA vs. SR, 0.40 vs. 1.32; 95% CI, 0.21 to 0.74 in SVS (+) vs. 95% CI, 0.51 to 3.35 in SVS (–); P for interaction=0.038).
Conclusions As a first line strategy, SR achieved higher recanalization rates and a more favourable clinical outcome at 3 months compared to CA when MRI shows SVS within the thrombus.
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Affiliation(s)
- Romain Bourcier
- Department of Diagnostic and Interventional Neuroradiology, Guillaume et René Laennec University Hospital, Nantes, France
| | - Mickael Mazighi
- Department of Diagnostic and Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Julien Labreuche
- Department of Biostatistics, University Lille, CHRU Lille, Lille, France
| | - Robert Fahed
- Department of Diagnostic and Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Raphael Blanc
- Department of Diagnostic and Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, Nancy, France
| | - Alain Duhamel
- Department of Biostatistics, University Lille, CHRU Lille, Lille, France
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Suzana Saleme
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Limoges, Limoges, France
| | - Vincent Costalat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Montpellier, Montpellier, France
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, Nancy, France
| | - Hubert Desal
- Department of Diagnostic and Interventional Neuroradiology, Guillaume et René Laennec University Hospital, Nantes, France
| | - Arturo Consoli
- Department of Stroke Center and Diagnostic and Interventional Neuroradiology, University of Versailles and Saint Quentin en Yvelines, Foch Hospital, Suresnes, France
| | - Michel Piotin
- Department of Diagnostic and Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Bertrand Lapergue
- Department of Stroke Center and Diagnostic and Interventional Neuroradiology, University of Versailles and Saint Quentin en Yvelines, Foch Hospital, Suresnes, France
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21
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Jang W, Kwak HS, Chung GH, Hwang SB. Three-dimensional black-blood contrast-enhanced MRI improves detection of intraluminal thrombi in patients with acute ischaemic stroke. Eur Radiol 2018; 28:3840-3847. [DOI: 10.1007/s00330-018-5323-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 01/02/2018] [Accepted: 01/10/2018] [Indexed: 10/17/2022]
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Lee S, Byun JS, Jung MS, Kim JM, Nam TK. Usefulness of multiphase computed tomography angiography in a patient with transient ischemic attack in the hyperacute phase: A case report. Medicine (Baltimore) 2017; 96:e9502. [PMID: 29384950 PMCID: PMC6392663 DOI: 10.1097/md.0000000000009502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
RATIONALE Patients with transient ischemic attack (TIA) have the possibility of developing stroke in the future. To prevent recurrent TIA or future stroke, identifying the cause of TIA is important. However, about two-third of patients with TIA have negative findings on diffusion-weighted imaging (DWI).We present a case of TIA, the cause of which was identified using multiphase computed tomography angiography (MCTA) in the hyperacute phase of the disease. PATIENT CONCERNS The patient was a 57-year-old man who was admitted to the emergency department for right-side weakness persisting for 1 hour. DIAGNOSES Occlusion of the proximal M3 segment of the left middle cerebral artery territory was found on the initial MCTA. OUTCOMES The weakness completely resolved at 2 hours after symptom onset, and there was no acute infarction on the initial diffusion-weighted magnetic resonance imaging (MRI) on the same day. Follow-up MCTA on the next day showed recanalization of the left M3 segment. Follow-up diffusion-weighted MRI showed focal acute infarction in the left middle cerebral artery territory. LESSONS MCTA could identify distal occlusion of the anterior circulation in patients with cardioembolic TIA in the hyperacute phase with negative DWI findings.
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Affiliation(s)
| | | | | | | | - Taek-Kyun Nam
- Departments of Neurosurgery, Chung-Ang University Hospital, Seoul, Republic of Korea
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Lin CH, Tsai YH, Lee JD, Weng HH, Yang JT, Lin LC, Lin YH, Wu CY, Huang YC, Hsu HL, Lee M, Hsu CY, Pan YT, Huang YC. Magnetic Resonance Perfusion Imaging Provides a Significant Tool for the Identification of Cardioembolic Stroke. Curr Neurovasc Res 2017; 13:271-276. [PMID: 27586679 PMCID: PMC5068491 DOI: 10.2174/1567202613666160901143040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 07/15/2016] [Accepted: 07/18/2016] [Indexed: 11/24/2022]
Abstract
Despite advances in imaging techniques and detailed examinations to determine the etiology of a stroke, the cause still remains undetermined in about one fourth of all ischemic strokes. The aim of this prospective study was to determine whether perfusion magnetic resonance imaging (MRI) can differentiate cardioembolic stroke from large artery atherosclerosis (LAA). We recruited 17 cardioembolic stroke and 22 LAA stroke patients, who were classified according to the Trial of Org 10172 in Acute Stroke Treatment and underwent perfusion MRI within 24 hours after the onset of stroke. The patients with cardioembolic stroke had more severe initial stroke severity and larger volumes of initial and final infarct compared to those with LAA stroke. Receiver operating characteristic curve analysis showed that the ratio of time to maximum of the residual curve (Tmax) volume for a 2-, 3-, 4- or 5-s lag over Tmax volume for a 8s lag all had excellent area under the curve values (> 0.9) to predict cardioembolic stroke. After adjusting for initial National Institute of Health Stroke Scale scores, a threshold of 3.73 for (Tmax > 4s volume)/(Tmax > 8s volume) had the highest odds ratio to predict cardioembolic stroke (p=0.012; odds ratio: 58.5; 95% confident interval: 2.5-1391.1), with 87.5% sensitivity and 94.4% specificity. In conclusion, perfusion MRI could be a reliable tool to identify cardioembolic stroke with its lower collateral. This is important as it could be used to reveal the exact mechanism and provide supportive evidence to classify a stroke.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Yen-Chu Huang
- Department of Neurology, Chang Gung Memorial Hospital, 6 West Chia-Pu Road, Putz City, Chiayi County, Taiwan.
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Lee SJ, Lee DG. Distribution of atherosclerotic stenosis determining early neurologic deterioration in acute ischemic stroke. PLoS One 2017; 12:e0185314. [PMID: 28945817 PMCID: PMC5612689 DOI: 10.1371/journal.pone.0185314] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 09/11/2017] [Indexed: 12/19/2022] Open
Abstract
Background and purpose Early neurologic deterioration (END) during the acute stage of stroke is clinically important because of its association with poor outcomes. The purpose of this study was (1) to investigate variables associated with END, (2) to determine the distribution of atherosclerotic stenosis associated with END, and (3) to clarify the relationship between END and clinical outcomes. Methods 516 patients with acute ischemic stroke were included. The median follow-up period was 31.7 months. END was defined as a ≥2 point increase in the National Institutes of Health Stroke Scale (NIHSS), ≥1 point increase in level of consciousness or motor item of the NIHSS, or the development of any new neurological deficits during the first 72 hours of hospitalization. A signal loss on 1.5-T magnetic resonance angiography exceeding 50% was considered to be significant for the categorization of stenosis pattern. Results The prevalence of END was 19.0%. END was associated with intracranial atherosclerotic stenosis (IAS) together with large artery atherosclerosis (LAA) subtype. In particular, stenosis of basilar artery or posterior cerebral artery was independently associated with END. Lesion growth or hypoperfusion was more accountable for END in patients with IAS, whereas intracerebral hemorrhage or edema/herniation was more frequently observed in END patients without IAS. Patients with END had a higher rate of mortality, but a similar rate of further vascular events compared to patients without END. Conclusion Pre-stroke IAS and LAA subtype could determine the development of END during the acute stage of ischemic stroke.
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Affiliation(s)
- Seung-Jae Lee
- Department of Neurology, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea
- * E-mail:
| | - Dong-Geun Lee
- Department of Neurology, Sejong General Hospital, Bucheon, South Korea
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Tian C, Cao X, Wang J. Recanalisation therapy in patients with acute ischaemic stroke caused by large artery occlusion: choice of therapeutic strategy according to underlying aetiological mechanism? Stroke Vasc Neurol 2017; 2:244-250. [PMID: 29507785 PMCID: PMC5829917 DOI: 10.1136/svn-2017-000090] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 06/08/2017] [Accepted: 07/07/2017] [Indexed: 01/20/2023] Open
Abstract
Various mechanisms underlie causative large artery occlusion (LAO) in patients with acute ischaemic stroke. Cardioembolic and atherosclerotic occlusions are the two most common types. The pathophysiological changes and responses to mechanical thrombectomy (MT) and antithrombotic treatments including thrombolysis, antiplatelet and anticoagulation therapy may vary among patients with different aetiological mechanisms of occlusion. Atherosclerotic occlusion is inclined to have relatively abundant collaterals and larger area of penumbra, hence a relatively wider time window for reperfusion therapy, while poor response to medical thrombolysis and MT. Severe residual stenosis and reocclusion occurred frequently after MT in atherosclerotic LAO. Angioplasty and stenting as rescue or the first-line therapy and more intensified antiplatelet therapy beyond related recommendations in the current guidelines are sometimes used in managing acute causative LAO because of poor recanalisation after recommended standard thrombolysis or MT therapy, which are usually based on individual experience. Standard protocol to establish emergent aetiological diagnosis of causative LAO and individualised aetiology-specific treatment strategy is needed.
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Affiliation(s)
- Chenglin Tian
- Department of Neurology, The Chinese PLA General Hospital, Beijing, China
| | - Xiangyu Cao
- Department of Neurology, The Chinese PLA General Hospital, Beijing, China
| | - Jun Wang
- Department of Neurology, The Chinese PLA General Hospital, Beijing, China
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Vanaerde O, Budzik JF, Mackowiak A, Norberciak L, Uettwiller M, Leclerc X, Verclytte S. Comparison between enhanced susceptibility-weighted angiography and time of flight sequences in the detection of arterial occlusion in acute ischemic stroke. J Neuroradiol 2017; 44:210-216. [PMID: 28258760 DOI: 10.1016/j.neurad.2017.01.125] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 12/14/2016] [Accepted: 01/02/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE Optimizing the MRI protocol in acute ischemic stroke remains a challenging issue. In this field, susceptibility-weighted sequences have proved their superiority over T2*. Besides the strengthened susceptibility effect, enhanced susceptibility-weighted angiography (eSWAN) sequence provides also a time-of-flight (TOF) effect, allowing the exploration of the intracranial arterial circulation. The objective of our study was to compare eSWAN and 3D TOF, considered as the reference, in the detection of arterial occlusion in acute stroke. METHODS Patients who underwent MRI between March and July 2014 for suspected acute stroke with an acute ischemic lesion on diffusion-weighted imaging (DWI) were prospectively included in this study. eSWAN and TOF images were analyzed under double-blind conditions by a junior radiologist and a senior neuroradiologist for the detection of arterial occlusion. eSWAN images were assessed in order to estimate the inter-observer agreement. After a consensus, eSWAN and TOF data were compared to calculate inter-modality agreement. RESULTS Thirty-four patients were included. Inter-observer agreement was excellent (kappa: 0.96) for eSWAN detection of occlusion. After consensus, comparison between TOF and eSWAN showed substantial agreement (kappa: 0.71). eSWAN provided better detection of distal occlusions, but poorer performance for detection of siphon occlusions. CONCLUSIONS Shortest echoes eSWAN images enabled detection of arterial occlusion with substantial agreement with TOF images. The susceptibility vessel sign associated with the TOF effect improved the identification of distal occlusions. In acute stroke protocol, eSWAN may represent a valuable alternative to T2* and TOF sequences.
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Affiliation(s)
- O Vanaerde
- Department of radiology, Catholic university hospitals, 115, rue du Grand-But-Lomme, 59160 Lille, France.
| | - J-F Budzik
- Department of radiology, Catholic university hospitals, 115, rue du Grand-But-Lomme, 59160 Lille, France
| | - A Mackowiak
- Department of neurology, Stroke unit, Catholic university hospitals, 59160 Lille, France
| | - L Norberciak
- Clinical research department, Catholic university hospitals, 59160 Lille, France
| | | | - X Leclerc
- Neuroimaging department, CHU de Lille, 59000 Lille, France
| | - S Verclytte
- Department of radiology, Catholic university hospitals, 115, rue du Grand-But-Lomme, 59160 Lille, France
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Evaluation of the role of susceptibility-weighted imaging in thrombolytic therapy for acute ischemic stroke. J Clin Neurosci 2017; 40:175-179. [PMID: 28228323 DOI: 10.1016/j.jocn.2017.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 01/22/2017] [Indexed: 11/20/2022]
Abstract
We inspected low-intensity venous signals and microbleeds in patients with acute ischemic stroke (AIS) using susceptibility-weighted imaging (SWI) before and after administration of within-thrombolytic-time-window thrombolytic therapies, and observed their prognosis and safety, in order to guide individualized thrombolytic therapies. Patients with AIS were divided into groups A or B according to the presence of symmetric or asymmetric veins on SWI, and were re-inspected by SWI after intravenous thrombolysis using recombinant tissue plasminogen activator (rt-PA). The National Institutes of Health stroke scale (NIHSS) score before treatment and at 1-h and 24-h posttreatment in the two groups were 11.9, 7.3, and 7.1 in group A, 12.4, 8.2, and 7.9 in group B, significant difference was detected between the two groups after treatment. The 90-day mortality rate was 0, and the incidences of cerebral microbleeds (CMBs) and symptomatic cerebral hemorrhage (SCH) were 17.6%, and 0% in group A, 25.6% and 0% in group B, respectively. The incidences of CMBs and SCH in group A were lower than those in group B, but the intergroup differences were not statistically significant (P>0.05). The 90-day neurological improvement rates in the two groups were 70.2% and 58.1%, respectively, and group A showed a significantly better prognosis than group B (P<0.05). Thus, low-intensity venous signals in SWI can be used to evaluate a low level of perfusion, post-thrombolytic prognosis, and bleeding indexes, and can therefore be used to guide individualized thrombolytic therapies.
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ASL and susceptibility-weighted imaging contribution to the management of acute ischaemic stroke. Insights Imaging 2016; 8:91-100. [PMID: 27822669 PMCID: PMC5265193 DOI: 10.1007/s13244-016-0529-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 09/19/2016] [Accepted: 10/03/2016] [Indexed: 12/04/2022] Open
Abstract
Abstract Magnetic resonance imaging (MRI) plays a central role in the early diagnosis of cerebral vascular events. Today, MRI is used not only for the detection of acute ischaemic lesions, but also to fine tune the diagnosis and improve patient selection for early therapeutic decision-making. In this perspective, new tools such as arterial spin labelling (ASL) and susceptibility-weighted imaging (SWI) sequences have been developed. These MRI sequences enable noninvasive assessment of brain damage, providing important diagnostic and prognostic information: evaluation of cerebral parenchymal perfusion; detection and aetiological assessment of thrombi; ruling out differential diagnoses. After a brief recall of the fundamental basis of these sequences, this article proposes an update on their current contribution to the early management of stroke victims. Teaching Points • These noninvasive sequences provide essential information for early management of acute stroke. • They can detect zones of parenchymal hypoperfusion. • Susceptibility-weighted sequences provide information on thrombus localisation and composition. • ASL can identify certain aetiologies of stroke mimics. • Post-therapeutic ASL perfusion status predicts outcome.
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