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Tavakkol E, Kihira S, McArthur M, Polson J, Zhang H, Arnold CW, Yoo B, Linetsky M, Salehi B, Ledbetter L, Kim C, Jahan R, Duckwiler G, Saver JL, Liebeskind DS, Nael K. Automated Assessment of the DWI-FLAIR Mismatch in Patients with Acute Ischemic Stroke: Added Value to Routine Clinical Practice. AJNR Am J Neuroradiol 2024; 45:562-567. [PMID: 38290738 DOI: 10.3174/ajnr.a8170] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 09/14/2023] [Accepted: 01/12/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND AND PURPOSE The DWI-FLAIR mismatch is used to determine thrombolytic eligibility in patients with acute ischemic stroke when the time since stroke onset is unknown. Commercial software packages have been developed for automated DWI-FLAIR classification. We aimed to use e-Stroke software for automated classification of the DWI-FLAIR mismatch in a cohort of patients with acute ischemic stroke and in a comparative analysis with 2 expert neuroradiologists. MATERIALS AND METHODS In this retrospective study, patients with acute ischemic stroke who had MR imaging and known time since stroke onset were included. The DWI-FLAIR mismatch was evaluated by 2 neuroradiologists blinded to the time since stroke onset and automatically by the e-Stroke software. After 4 weeks, the neuroradiologists re-evaluated the MR images, this time equipped with automated predicted e-Stroke results as a computer-assisted tool. Diagnostic performances of e-Stroke software and the neuroradiologists were evaluated for prediction of DWI-FLAIR mismatch status. RESULTS A total of 157 patients met the inclusion criteria. A total of 82 patients (52%) had a time since stroke onset of ≤4.5 hours. By means of consensus reads, 81 patients (51.5%) had a DWI-FLAIR mismatch. The diagnostic accuracy (area under the curve/sensitivity/specificity) of e-Stroke software for the determination of the DWI-FLAIR mismatch was 0.72/90.0/53.9. The diagnostic accuracy (area under the curve/sensitivity/specificity) for neuroradiologists 1 and 2 was 0.76/69.1/84.2 and 0.82/91.4/73.7, respectively; both significantly (P < .05) improved to 0.83/79.0/86.8 and 0.89/92.6/85.5, respectively, following the use of e-Stroke predictions as a computer-assisted tool. The interrater agreement (κ) for determination of DWI-FLAIR status was improved from 0.49 to 0.57 following the use of the computer-assisted tool. CONCLUSIONS This automated quantitative approach for DWI-FLAIR mismatch provides results comparable with those of human experts and can improve the diagnostic accuracies of expert neuroradiologists in the determination of DWI-FLAIR status.
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Affiliation(s)
- E Tavakkol
- From the Department of Radiological Sciences (E.T., S.K., M.M. J.P., H.Z., C.W.A., B.Y., M.L., B.S., L.L., C.K., R.J., G.D., K.N.), University of California, Los Angeles, Los Angeles, California
| | - S Kihira
- From the Department of Radiological Sciences (E.T., S.K., M.M. J.P., H.Z., C.W.A., B.Y., M.L., B.S., L.L., C.K., R.J., G.D., K.N.), University of California, Los Angeles, Los Angeles, California
| | - M McArthur
- From the Department of Radiological Sciences (E.T., S.K., M.M. J.P., H.Z., C.W.A., B.Y., M.L., B.S., L.L., C.K., R.J., G.D., K.N.), University of California, Los Angeles, Los Angeles, California
| | - J Polson
- From the Department of Radiological Sciences (E.T., S.K., M.M. J.P., H.Z., C.W.A., B.Y., M.L., B.S., L.L., C.K., R.J., G.D., K.N.), University of California, Los Angeles, Los Angeles, California
| | - H Zhang
- From the Department of Radiological Sciences (E.T., S.K., M.M. J.P., H.Z., C.W.A., B.Y., M.L., B.S., L.L., C.K., R.J., G.D., K.N.), University of California, Los Angeles, Los Angeles, California
| | - C W Arnold
- From the Department of Radiological Sciences (E.T., S.K., M.M. J.P., H.Z., C.W.A., B.Y., M.L., B.S., L.L., C.K., R.J., G.D., K.N.), University of California, Los Angeles, Los Angeles, California
| | - B Yoo
- From the Department of Radiological Sciences (E.T., S.K., M.M. J.P., H.Z., C.W.A., B.Y., M.L., B.S., L.L., C.K., R.J., G.D., K.N.), University of California, Los Angeles, Los Angeles, California
| | - M Linetsky
- From the Department of Radiological Sciences (E.T., S.K., M.M. J.P., H.Z., C.W.A., B.Y., M.L., B.S., L.L., C.K., R.J., G.D., K.N.), University of California, Los Angeles, Los Angeles, California
| | - B Salehi
- From the Department of Radiological Sciences (E.T., S.K., M.M. J.P., H.Z., C.W.A., B.Y., M.L., B.S., L.L., C.K., R.J., G.D., K.N.), University of California, Los Angeles, Los Angeles, California
| | - L Ledbetter
- From the Department of Radiological Sciences (E.T., S.K., M.M. J.P., H.Z., C.W.A., B.Y., M.L., B.S., L.L., C.K., R.J., G.D., K.N.), University of California, Los Angeles, Los Angeles, California
| | - C Kim
- From the Department of Radiological Sciences (E.T., S.K., M.M. J.P., H.Z., C.W.A., B.Y., M.L., B.S., L.L., C.K., R.J., G.D., K.N.), University of California, Los Angeles, Los Angeles, California
| | - R Jahan
- From the Department of Radiological Sciences (E.T., S.K., M.M. J.P., H.Z., C.W.A., B.Y., M.L., B.S., L.L., C.K., R.J., G.D., K.N.), University of California, Los Angeles, Los Angeles, California
| | - G Duckwiler
- From the Department of Radiological Sciences (E.T., S.K., M.M. J.P., H.Z., C.W.A., B.Y., M.L., B.S., L.L., C.K., R.J., G.D., K.N.), University of California, Los Angeles, Los Angeles, California
| | - J L Saver
- Department of Neurology (J.L.S., D.S.L.), University of California, Los Angeles, Los Angeles, California
| | - D S Liebeskind
- Department of Neurology (J.L.S., D.S.L.), University of California, Los Angeles, Los Angeles, California
| | - K Nael
- From the Department of Radiological Sciences (E.T., S.K., M.M. J.P., H.Z., C.W.A., B.Y., M.L., B.S., L.L., C.K., R.J., G.D., K.N.), University of California, Los Angeles, Los Angeles, California
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McArthur MA, Tavakkol E, Bahr-Hosseini M, Jahan R, Duckwiler GR, Saver JL, Liebeskind DS, Nael K. Overestimation of ischemic core on baseline MRI in acute stroke. Interv Neuroradiol 2024:15910199231224500. [PMID: 38258456 DOI: 10.1177/15910199231224500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND AND PURPOSE In patients with acute ischemic stroke (AIS), overestimation of ischemic core on MRI-DWI has been described primarily in regions with milder reduced diffusion. We aimed to assess the possibility of ischemic core overestimation on pretreatment MRI despite using more restricted reduced diffusion (apparent diffusion coefficient (ADC) ≤620 × 10-6 mm2/s) in AIS patients with successful reperfusion. MATERIALS AND METHODS In this retrospective single institutional study, AIS patients who had pretreatment MRI underwent successful reperfusion and had follow-up MRI to determine the final infarct volume were reviewed. Pretreatment ischemic core and final infarction volumes were calculated. Ghost core was defined as overestimation of final infarct volume by baseline MRI of >10 mL. Baseline clinical, demographic, and treatment-related factors in this cohort were reviewed. RESULTS A total of 6/156 (3.8%) patients had overestimated ischemic core volume on baseline MRI, with mean overestimation of 65.6 mL. Three out of six patients had pretreatment ischemic core estimation of >70 mL, while the final infarct volume was <70 mL. All six patients had last known well-to-imaging <120 min, median (IQR): 65 (53-81) minutes. CONCLUSIONS Overestimation of ischemic core, known as ghost core, is rare using severe ADC threshold (≤620 × 10-6 mm2/s), but it does occur in nearly 1 of every 25 patients, confined to hyperacute patients imaged within 120 min of symptom onset. Awareness of this phenomenon carries implications for treatment and trial enrollment.
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Affiliation(s)
- M A McArthur
- Department of Radiological Sciences, University of California, Los Angeles, Los Angeles, USA
| | - E Tavakkol
- Department of Radiological Sciences, University of California, Los Angeles, Los Angeles, USA
| | - M Bahr-Hosseini
- Department of Neurology, University of California, Los Angeles, Los Angeles, USA
| | - R Jahan
- Department of Radiological Sciences, University of California, Los Angeles, Los Angeles, USA
| | - G R Duckwiler
- Department of Radiological Sciences, University of California, Los Angeles, Los Angeles, USA
| | - J L Saver
- Department of Neurology, University of California, Los Angeles, Los Angeles, USA
| | - D S Liebeskind
- Department of Neurology, University of California, Los Angeles, Los Angeles, USA
| | - K Nael
- Department of Radiological Sciences, University of California, Los Angeles, Los Angeles, USA
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Yedavalli V, Kihira S, Shahrouki P, Hamam O, Tavakkol E, McArthur M, Qiao J, Johanna F, Doshi A, Vagal A, Khatri P, Srinivasan A, Chaudhary N, Bahr-Hosseini M, Colby GP, Nour M, Jahan R, Duckwiler G, Arnold C, Saver JL, Mocco J, Liebeskind DS, Nael K. CTP-based estimated ischemic core: A comparative multicenter study between Olea and RAPID software. J Stroke Cerebrovasc Dis 2023; 32:107297. [PMID: 37738915 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107297] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND AND PURPOSE CTP is increasingly used to assess eligibility for endovascular therapy (EVT) in patients with large vessel occlusions (LVO). There remain variability and inconsistencies between software packages for estimation of ischemic core. We aimed to use heterogenous data from four stroke centers to perform a comparative analysis for CTP-estimated ischemic core between RAPID (iSchemaView) and Olea (Olea Medical). METHODS In this retrospective multicenter study, patients with anterior circulation LVO who underwent pretreatment CTP, successful EVT (defined TICI ≥ 2b), and follow-up MRI included. Automated CTP analysis was performed using Olea platform [rCBF < 25% and differential time-to-peak (dTTP)>5s] and RAPID (rCBF < 30%). The CTP estimated core volumes were compared against the final infarct volume (FIV) on post treatment MRI-DWI. RESULTS A total of 151 patients included. The CTP-estimated ischemic core volumes (mean ± SD) were 18.7 ± 18.9 mL on Olea and 10.5 ± 17.9 mL on RAPID significantly different (p < 0.01). The correlation between CTP estimated core and MRI final infarct volume was r = 0.38, p < 0.01 for RAPID and r = 0.39, p < 0.01 for Olea. Both software platforms demonstrated a strong correlation with each other (r = 0.864, p < 0.001). Both software overestimated the ischemic core volume above 70 mL in 4 patients (2.6%). CONCLUSIONS Substantial variation between Olea and RAPID CTP-estimated core volumes exists, though rates of overcalling of large core were low and identical. Both showed comparable core volume correlation to MRI infarct volume.
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Affiliation(s)
- V Yedavalli
- Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - S Kihira
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - P Shahrouki
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - O Hamam
- Massachussetts General Hospital, Boston, MA, United States
| | - E Tavakkol
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - M McArthur
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - J Qiao
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - Fifi Johanna
- Mount Sinai School of Medicine, New York, NY, United States
| | - A Doshi
- Mount Sinai School of Medicine, New York, NY, United States
| | - A Vagal
- University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - P Khatri
- University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - A Srinivasan
- University of Michigan School of Medicine, Ann Arbor, MI, United States
| | - N Chaudhary
- University of Michigan School of Medicine, Ann Arbor, MI, United States
| | - M Bahr-Hosseini
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - G P Colby
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - M Nour
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - R Jahan
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - G Duckwiler
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - C Arnold
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - J L Saver
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - J Mocco
- Mount Sinai School of Medicine, New York, NY, United States
| | - D S Liebeskind
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - K Nael
- David Geffen School of Medicine at the University of California - Los Angeles, United States
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