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Benjamin LA, Lim E, Sokolska M, Markus J, Zaletel T, Aggarwal V, Luder R, Sanchez E, Brown K, Sofat R, Singh A, Houlihan C, Nastouli E, Losseff N, Werring DJ, Brown MM, Mason JC, Simister RJ, Jäger HR. Vessel wall magnetic resonance and arterial spin labelling imaging in the management of presumed inflammatory intracranial arterial vasculopathy. Brain Commun 2022; 4:fcac157. [PMID: 35813881 PMCID: PMC9263889 DOI: 10.1093/braincomms/fcac157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 02/08/2022] [Accepted: 06/17/2022] [Indexed: 11/25/2022] Open
Abstract
Optimal criteria for diagnosing and monitoring response to treatment for infectious and inflammatory medium–large vessel intracranial vasculitis presenting with stroke are lacking. We integrated intracranial vessel wall MRI with arterial spin labelling into our routine clinical stroke pathway to detect presumed inflammatory intracranial arterial vasculopathy, and monitor disease activity, in patients with clinical stroke syndromes. We used predefined standardized radiological criteria to define vessel wall enhancement, and all imaging findings were rated blinded to clinical details. Between 2017 and 2018, stroke or transient ischaemic attack patients were first screened in our vascular radiology meeting and followed up in a dedicated specialist stroke clinic if a diagnosis of medium–large inflammatory intracranial arterial vasculopathy was radiologically confirmed. Treatment was determined and monitored by a multi-disciplinary team. In this case series, 11 patients were managed in this period from the cohort of young stroke presenters (<55 years). The median age was 36 years (interquartile range: 33,50), of which 8 of 11 (73%) were female. Two of 11 (18%) had herpes virus infection confirmed by viral nucleic acid in the cerebrospinal fluid. We showed improvement in cerebral perfusion at 1 year using an arterial spin labelling sequence in patients taking immunosuppressive therapy for >4 weeks compared with those not receiving therapy [6 (100%) versus 2 (40%) P = 0.026]. Our findings demonstrate the potential utility of vessel wall magnetic resonance with arterial spin labelling imaging in detecting and monitoring medium–large inflammatory intracranial arterial vasculopathy activity for patients presenting with stroke symptoms, limiting the need to progress to brain biopsy. Further systematic studies in unselected populations of stroke patients are needed to confirm our findings and establish the prevalence of medium–large artery wall inflammation.
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Affiliation(s)
- L A Benjamin
- Comprehensive Stroke Service, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square , Box 16, London WC1N 3BG , UK
- Laboratory of Molecular and Cell Biology, UCL, Gower St, Kings Cross , London WC1E 6BT , UK
- Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London , London WC1B 5EH , UK
- University of Liverpool, Brain Infections Group, Liverpool , Merseyside, L69 7BE , UK
| | - E Lim
- Department of Imaging, University College London Hospitals NHS foundation trust , London, NW1 2PG , UK
| | - M Sokolska
- Department of Medical Physics and Biomedical Engineering, University College London Hospitals NHS Foundation Trust , London, NW1 2PG , UK
| | - J Markus
- Department of Imaging, University College London Hospitals NHS foundation trust , London, NW1 2PG , UK
| | - T Zaletel
- Department of Medicine, University of Cambridge , Cambridge, CB2 1TN , UK
| | - V Aggarwal
- Comprehensive Stroke Service, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square , Box 16, London WC1N 3BG , UK
| | - R Luder
- Department of Medicine, North Middlesex University Hospital , London, N18 1QX , UK
| | - E Sanchez
- Department of clinical virology, University College London Hospitals NHS Foundation Trust , London, NW1 2PG , UK
| | - K Brown
- Department of Virology, UK Health Security Agency , London, NW9 5EQ , UK
| | - R Sofat
- Department of Pharmacology and Therapeutics, University of Liverpool , Liverpool L69 7BE , UK
- Health Data Research , London, NW1 2BE , UK
| | - A Singh
- Department of Medicine, Royal Free Hospital Foundation Trust , London, NW3 2QG , UK
| | - C Houlihan
- Department of clinical virology, University College London Hospitals NHS Foundation Trust , London, NW1 2PG , UK
| | - E Nastouli
- Department of clinical virology, University College London Hospitals NHS Foundation Trust , London, NW1 2PG , UK
- Crick Institute , London, NW1 1AT , UK
| | - N Losseff
- Comprehensive Stroke Service, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square , Box 16, London WC1N 3BG , UK
| | - D J Werring
- Comprehensive Stroke Service, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square , Box 16, London WC1N 3BG , UK
- Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London , London WC1B 5EH , UK
| | - M M Brown
- Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London , London WC1B 5EH , UK
| | - J C Mason
- Department of Medicine, Hammersmith Hospital , London, W12 0HS , UK
- National Heart and Lung Institute, Imperial College London , London, SW3 6LY , UK
| | - R J Simister
- Comprehensive Stroke Service, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square , Box 16, London WC1N 3BG , UK
- Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London , London WC1B 5EH , UK
| | - H R Jäger
- Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London , London WC1B 5EH , UK
- Department of Imaging, University College London Hospitals NHS foundation trust , London, NW1 2PG , UK
- Neuroradiological Academic Unit, UCL Queen Square Institute of Neurology, University College London , London, WC1N 3BG , UK
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Bala F, Siddiqui J, Sciacca S, Falzon AM, Benger M, Matloob SA, Miller FNAC, Simister RJ, Chatterjee I, Sztriha LK, Davagnanam I, Booth TC. Reply. AJNR Am J Neuroradiol 2021; 42:E54-E55. [PMID: 34016588 PMCID: PMC8367596 DOI: 10.3174/ajnr.a7161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- F Bala
- Department of NeuroradiologyKing's College Hospital, National Health Service Foundation TrustLondon, United Kingdom
| | - J Siddiqui
- Department of NeuroradiologyKing's College Hospital, National Health Service Foundation TrustLondon, United Kingdom
| | - S Sciacca
- Lysholm Department of Neuroradiology National Hospital for Neurology and NeurosurgeryUniversity College London Hospitals, National Health Service Foundation TrustLondon, United Kingdom
| | - A M Falzon
- Lysholm Department of Neuroradiology National Hospital for Neurology and NeurosurgeryUniversity College London Hospitals, National Health Service Foundation TrustLondon, United Kingdom
| | - M Benger
- Department of NeurologyKing's College Hospital, National Health Service Foundation TrustLondon, United Kingdom
| | - S A Matloob
- Department of Neurosurgery National Hospital for Neurology and NeurosurgeryUniversity College London Hospitals, National Health Service Foundation TrustLondon, United Kingdom
| | - F N A C Miller
- Department of RadiologyKing's College Hospital National Health Service Foundation TrustLondon, United Kingdom
| | - R J Simister
- Comprehensive Stroke ServiceUniversity College London Hospitals, National Health Service Foundation Trust, Stroke Research Centre, University College London Queen Square Institute of NeurologyLondon, United Kingdom
| | - I Chatterjee
- Comprehensive Stroke ServiceUniversity College London Hospitals, National Health Service Foundation TrustLondon, United Kingdom
| | - L K Sztriha
- Department of NeurologyKing's College Hospital National Health Service Foundation TrustLondon, United Kingdom
| | - I Davagnanam
- Lysholm Department of Neuroradiology National Hospital for Neurology and NeurosurgeryUniversity College London Hospitals, National Health Service Foundation TrustLondon, United KingdomBrain Repair & Rehabilitation Unit University College London Queen Square Institute of NeurologyLondon, United Kingdom
| | - T C Booth
- Department of NeuroradiologyKing's College Hospital, National Health Service Foundation TrustLondon, United KingdomSchool of Biomedical Engineering and Imaging SciencesKing's College LondonLondon, United Kingdom
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Siddiqui J, Bala F, Sciacca S, Falzon AM, Benger M, Matloob SA, Miller FNAC, Simister RJ, Chatterjee I, Sztriha LK, Davagnanam I, Booth TC. COVID-19 Stroke Apical Lung Examination Study: A Diagnostic and Prognostic Imaging Biomarker in Suspected Acute Stroke. AJNR Am J Neuroradiol 2021; 42:138-143. [PMID: 32943416 DOI: 10.3174/ajnr.a6832] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/17/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND PURPOSE Diagnosis of coronavirus disease 2019 (COVID-19) relies on clinical features and reverse-transcriptase polymerase chain reaction testing, but the sensitivity is limited. Carotid CTA is a routine acute stroke investigation and includes the lung apices. We evaluated CTA as a potential COVID-19 diagnostic imaging biomarker. MATERIALS AND METHODS This was a multicenter, retrospective study (n = 225) including CTAs of patients with suspected acute stroke from 3 hyperacute stroke units (March-April 2020). We evaluated the reliability and accuracy of candidate diagnostic imaging biomarkers. Demographics, clinical features, and risk factors for COVID-19 and stroke were analyzed using univariate and multivariate statistics. RESULTS Apical ground-glass opacification was present in 22.2% (50/225) of patients. Ground-glass opacification had high interrater reliability (Fleiss κ = 0.81; 95% CI, 0.68-0.95) and, compared with reverse-transcriptase polymerase chain reaction, had good diagnostic performance (sensitivity, 75% [95% CI, 56-87]; specificity, 81% [95% CI, 71-88]; OR = 11.65 [95% CI, 4.14-32.78]; P < .001) on multivariate analysis. In contrast, all other contemporaneous demographic, clinical, and imaging features available at CTA were not diagnostic for COVID-19. The presence of apical ground-glass opacification was an independent predictor of increased 30-day mortality (18.0% versus 5.7%, P = .017; hazard ratio = 3.51; 95% CI, 1.42-8.66; P = .006). CONCLUSIONS We identified a simple, reliable, and accurate COVID-19 diagnostic and prognostic imaging biomarker obtained from CTA lung apices: the presence or absence of ground-glass opacification. Our findings have important implications in the management of patients presenting with suspected stroke through early identification of COVID-19 and the subsequent limitation of disease transmission.
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Affiliation(s)
- J Siddiqui
- From the Departments of Neuroradiology (J.S., F.B., T.C.B.)
| | - F Bala
- From the Departments of Neuroradiology (J.S., F.B., T.C.B.)
| | - S Sciacca
- Lysholm Department of Neuroradiology (S.S., A.M.F., I.D.)
| | - A M Falzon
- Lysholm Department of Neuroradiology (S.S., A.M.F., I.D.)
| | | | - S A Matloob
- Department of Neurosurgery (S.A.M.), National Hospital for Neurology and Neurosurgery, University College London Hospitals, National Health Service Foundation Trust, London, UK
| | - F N A C Miller
- Radiology (F.N.A.C.M.), King's College Hospital, National Health Service Foundation Trust, London, UK
| | - R J Simister
- Comprehensive Stroke Service (R.J.S., I.C.), University College London Hospitals, National Health Service Foundation Trust, London, UK
- Stroke Research Centre (R.J.S.)
| | - I Chatterjee
- Comprehensive Stroke Service (R.J.S., I.C.), University College London Hospitals, National Health Service Foundation Trust, London, UK
| | | | - I Davagnanam
- Lysholm Department of Neuroradiology (S.S., A.M.F., I.D.)
- Brain Repair and Rehabilitation Unit (I.D.), University College London Queen Square Institute of Neurology, London, UK
| | - T C Booth
- From the Departments of Neuroradiology (J.S., F.B., T.C.B.)
- School of Biomedical Engineering and Imaging Sciences (T.C.B.), King's College London, Rayne Institute, St. Thomas' Hospital, London, UK
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Siddiqui J, Bala F, Sciacca S, Falzon AM, Benger M, Matloob SA, Miller FNAC, Simister RJ, Chatterjee I, Sztriha LK, Davagnanam I, Booth TC. A Comparison of Chest Radiograph and CTA Apical Pulmonary Findings in Patients Presenting with Suspected Acute Stroke during the COVID-19 Pandemic. AJNR Am J Neuroradiol 2020; 42:E13-E14. [PMID: 33272951 DOI: 10.3174/ajnr.a6940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- J Siddiqui
- Department of NeuroradiologyKing's College Hospital NHS Foundation TrustLondon, UK
| | | | - S Sciacca
- Lysholm Department of NeuroradiologyNational Hospital for Neurology and NeurosurgeryUniversity College London Hospitals NHS Foundation TrustLondon, UK
| | - A M Falzon
- Lysholm Department of NeuroradiologyNational Hospital for Neurology and NeurosurgeryUniversity College London Hospitals NHS Foundation TrustLondon, UK
| | - M Benger
- Department of NeurologyKing's College Hospital NHS Foundation TrustLondon, UK
| | - S A Matloob
- Department of NeurosurgeryNational Hospital for Neurology and NeurosurgeryUniversity College London Hospitals NHS Foundation TrustLondon, UK
| | - F N A C Miller
- Department of RadiologyKing's College Hospital NHS Foundation TrustLondon, UK
| | - R J Simister
- Comprehensive Stroke ServiceUniversity College London Hospitals NHS Foundation TrustLondon, UK.,Stroke Research CentreUniversity College London Queen Square Institute of NeurologyLondon, UK
| | - I Chatterjee
- Comprehensive Stroke ServiceUniversity College London Hospitals NHS Foundation TrustLondon, UK
| | - L K Sztriha
- Department of NeurologyKing's College Hospital NHS Foundation TrustLondon, UK
| | - I Davagnanam
- Lysholm Department of NeuroradiologyNational Hospital for Neurology and NeurosurgeryUniversity College London Hospitals NHS Foundation TrustLondon, UK.,Brain Repair & Rehabilitation UnitUniversity College London Queen Square Institute of NeurologyLondon, UK
| | - T C Booth
- Department of NeuroradiologyKing's College Hospital NHS Foundation TrustLondon, UK.,School of Biomedical Engineering and Imaging SciencesKing's College LondonLondon, UK
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Cheng SF, Brown MM, Simister RJ, Richards T. Contemporary prevalence of carotid stenosis in patients presenting with ischaemic stroke. Br J Surg 2019; 106:872-878. [PMID: 30938840 DOI: 10.1002/bjs.11136] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/02/2018] [Accepted: 01/21/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Carotid stenosis is a common cause of ischaemic stroke and transient ischaemic attack (TIA). Despite rising recognition and centralization of stroke services there has been a decline in interventions for carotid stenosis in recent years. The aim of this study was to determine the current prevalence and management of carotid stenosis in the UK. METHODS This was a 1-year prospective observational study of consecutive patients presenting with ischaemic stroke, TIA or ischaemic retinal artery occlusion to a central London hyperacute stroke unit. Patients with significant carotid stenosis, defined as atherosclerotic narrowing of 50 per cent or greater, underwent multidisciplinary team (MDT) discussion to determine the cause of stroke/TIA and classify carotid stenosis as symptomatic or incidental. RESULTS In total, 2707 patients were seen; half had an ischaemic event and the majority had carotid imaging (1252 of 1444). Carotid stenosis of at least 50 per cent was seen in 238 (prevalence 19·0 (95 per cent c.i. 16·6 to 21·4) per cent). Patients with significant carotid stenosis were more likely to have hypertension, hypercholesterolaemia, diabetes and ischaemic heart disease. Carotid stenosis was deemed symptomatic in 99 patients (7·9 (6·3 to 9·5) per cent); of these, 17 had carotid occlusion, 17 were unfit for surgery and 58 patients were referred for carotid intervention. Among 139 patients with asymptomatic stenosis, 75 had carotid stenosis ipsilateral to the stroke but, after MDT discussion, the cause was deemed to be atrial fibrillation (32), small-vessel disease (15), another determined cause (5), or not determined owing to atypical imaging or clinical presentation. CONCLUSION Carotid stenosis is common, affecting one in five patients presenting with stroke or TIA. Careful MDT discussion may avoid unnecessary intervention and should be the standard of care.
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Affiliation(s)
- S F Cheng
- Division of Surgery and Interventional Science, University College London, London, UK
| | - M M Brown
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, London, UK
| | - R J Simister
- University College London Hospitals NHS Foundation Trust, London, UK
| | - T Richards
- Division of Surgery and Interventional Science, University College London, London, UK
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McLean MA, Woermann FG, Simister RJ, Barker GJ, Duncan JS. In vivo short echo time 1H-magnetic resonance spectroscopic imaging (MRSI) of the temporal lobes. Neuroimage 2001; 14:501-9. [PMID: 11467922 DOI: 10.1006/nimg.2001.0827] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Two different methodologies for obtaining PRESS-localized magnetic resonance spectroscopic imaging (MRSI) data from the mesial and lateral temporal lobes were investigated. The study used short echo times (30 ms) and long repetition times (3000 ms) to minimize relaxation effects. Inhomogeneity and spectral distortions from the proximity of the temporal bones precluded the attainment of consistently good-quality data from both temporal lobes at once. Even when the right and left temporal lobes were studied separately, distortions often disturbed spectra from the anterior lateral temporal lobe. Quantitative analysis using LCModel was therefore performed only on the posterior lateral temporal lobe, and the posterior, middle, and anterior mesial temporal lobe. No significant left-right differences in metabolite content were found in a series of 10 controls. Significantly higher concentrations of myoinositol and choline were found in the anterior mesial temporal lobe, even when grey matter content was included as a covariate. The concentration of N-acetyl aspartate plus N-acetyl aspartyl glutamate (NAc) was not found to vary significantly along the length of the hippocampus. The previously observed lower anterior ratios of NAA to creatine plus choline (NAA/(Cr + Cho) may instead have been due to higher anterior choline. Large differences in metabolite concentrations were seen between posterior lateral temporal lobe (predominantly subcortical white matter) and the posterior mesial temporal lobe, most notably lower creatine, glutamate/glutamine, and myo-inositol, and higher NAA/(Cr + Cho) in the lateral than mesial temporal lobe. This pattern was similar to that previously seen for grey/white matter differences in the frontal, parietal and occipital regions.
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Affiliation(s)
- M A McLean
- The MRI Unit, University Department of Clinical Neurology, Institute of Neurology, London, Queen Square, United Kingdom
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