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Lange KS, Mourand I, Coget A, Menjot de Champfleur N, Ayrignac X, Arquizan C, Scheel M, Bohner G, Villringer K, Zagroun C, Siebert E, Danyel LA. Diffusion-weighted magnetic resonance imaging in early central retinal artery occlusion. Eur Stroke J 2023; 8:974-981. [PMID: 37997381 PMCID: PMC10683725 DOI: 10.1177/23969873231190716] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/12/2023] [Indexed: 11/25/2023] Open
Abstract
INTRODUCTION Restricted retinal diffusion (RDR) has recently been recognized as a frequent finding on standard diffusion-weighted imaging (DWI) in central retinal artery occlusion (CRAO). However, data on early DWI signal evolution are missing. PATIENTS AND METHODS Consecutive CRAO patients with DWI performed within 24 h after onset of visual impairment were included in a bicentric, retrospective cross-sectional study. Two blinded neuroradiologists assessed randomized DWI scans for the presence of retinal ischemia. RDR detection rates, false positive ratings, and interrater agreement were evaluated for predefined time groups. RESULTS Sixty eight CRAO patients (68.4 ± 16.8 years; 25 female) with 72 DWI scans (76.4% 3 T, 23.6% 1.5 T) were included. Mean time-delay between onset of CRAO and DWI acquisition was 13.4 ± 7.0 h. Overall RDR detection rates ranged from 52.8% to 62.5% with false positive ratings in 4.2%-8.3% of cases. RDR detection rates were higher in DWI performed 12-24 h after onset, when compared with DWI acquired within the first 12 h (79.5%vs 39.3%, p < 0.001). The share of false positive ratings was highest for DWI performed within the first 6 h of symptom onset (up to 14.3%). Interrater reliability was "moderate" for DWI performed within the first 18 h (κ = 0.57-0.58), but improved for DWI acquired between 18 and 24 h (κ = 0.94). CONCLUSION DWI-based detection of retinal ischemia in early CRAO is likely to be time-dependent with superior diagnostic accuracy for DWI performed 12-24 h after onset of visual impairment.
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Affiliation(s)
- Kristin Sophie Lange
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France
| | - Isabelle Mourand
- Department of Neurology, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France
| | - Arthur Coget
- Department of Neuroradiology, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France
| | - Nicolas Menjot de Champfleur
- Department of Neuroradiology, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France
- I2FH, Institut d’Imagerie Fonctionnelle Humaine, Hôpital Gui de Chauliac, CHRU de Montpellier, Montpellier, France
| | - Xavier Ayrignac
- Department of Neurology, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France
| | - Caroline Arquizan
- Department of Neurology, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France
| | - Michael Scheel
- Institute for Neuroradiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Georg Bohner
- Institute for Neuroradiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Charlie Zagroun
- Department of Ophthalmology, Montpellier University Hospital Center, Gui de Chauliac Hospital, Montpellier, France
| | - Eberhard Siebert
- Institute for Neuroradiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Gerken A, Walluscheck S, Kohlmann P, Galinovic I, Villringer K, Fiebach JB, Klein J, Heldmann S. Deep learning-based segmentation of brain parenchyma and ventricular system in CT scans in the presence of anomalies. Front Neuroimaging 2023; 2:1228255. [PMID: 37554647 PMCID: PMC10406198 DOI: 10.3389/fnimg.2023.1228255] [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] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/18/2023] [Indexed: 08/10/2023]
Abstract
INTRODUCTION The automatic segmentation of brain parenchyma and cerebrospinal fluid-filled spaces such as the ventricular system is the first step for quantitative and qualitative analysis of brain CT data. For clinical practice and especially for diagnostics, it is crucial that such a method is robust to anatomical variability and pathological changes such as (hemorrhagic or neoplastic) lesions and chronic defects. This study investigates the increase in overall robustness of a deep learning algorithm that is gained by adding hemorrhage training data to an otherwise normal training cohort. METHODS A 2D U-Net is trained on subjects with normal appearing brain anatomy. In a second experiment the training data includes additional subjects with brain hemorrhage on image data of the RSNA Brain CT Hemorrhage Challenge with custom reference segmentations. The resulting networks are evaluated on normal and hemorrhage test casesseparately, and on an independent test set of patients with brain tumors of the publicly available GLIS-RT dataset. RESULTS Adding data with hemorrhage to the training set significantly improves the segmentation performance over an algorithm trained exclusively on normally appearing data, not only in the hemorrhage test set but also in the tumor test set. The performance on normally appearing data is stable. Overall, the improved algorithm achieves median Dice scores of 0.98 (parenchyma), 0.91 (left ventricle), 0.90 (right ventricle), 0.81 (third ventricle), and 0.80 (fourth ventricle) on the hemorrhage test set. On the tumor test set, the median Dice scores are 0.96 (parenchyma), 0.90 (left ventricle), 0.90 (right ventricle), 0.75 (third ventricle), and 0.73 (fourth ventricle). CONCLUSION Training on an extended data set that includes pathologies is crucial and significantly increases the overall robustness of a segmentation algorithm for brain parenchyma and ventricular system in CT data, also for anomalies completely unseen during training. Extension of the training set to include other diseases may further improve the generalizability of the algorithm.
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Affiliation(s)
- Annika Gerken
- Fraunhofer Institute for Digital Medicine MEVIS, Bremen, Germany
| | - Sina Walluscheck
- Fraunhofer Institute for Digital Medicine MEVIS, Lübeck, Germany
| | - Peter Kohlmann
- Fraunhofer Institute for Digital Medicine MEVIS, Berlin, Germany
| | - Ivana Galinovic
- Center for Stroke Research Berlin (CSB) Charité, Universitätsmedizin, Berlin, Berlin, Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin (CSB) Charité, Universitätsmedizin, Berlin, Berlin, Germany
| | - Jochen B. Fiebach
- Center for Stroke Research Berlin (CSB) Charité, Universitätsmedizin, Berlin, Berlin, Germany
| | - Jan Klein
- Fraunhofer Institute for Digital Medicine MEVIS, Bremen, Germany
| | - Stefan Heldmann
- Fraunhofer Institute for Digital Medicine MEVIS, Lübeck, Germany
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Gosch V, Villringer K, Galinovic I, Ganeshan R, Piper SK, Fiebach JB, Khalil A. Automated acute ischemic stroke lesion delineation based on apparent diffusion coefficient thresholds. Front Neurol 2023; 14:1203241. [PMID: 37576010 PMCID: PMC10415099 DOI: 10.3389/fneur.2023.1203241] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/13/2023] [Indexed: 08/15/2023] Open
Abstract
Purpose Automated lesion segmentation is increasingly used in acute ischemic stroke magnetic resonance imaging (MRI). We explored in detail the performance of apparent diffusion coefficient (ADC) thresholding for delineating baseline diffusion-weighted imaging (DWI) lesions. Methods Retrospective, exploratory analysis of the prospective observational single-center 1000Plus study from September 2008 to June 2013 (clinicaltrials.org; NCT00715533). We built a fully automated lesion segmentation algorithm using a fixed ADC threshold (≤620 × 10-6 mm2/s) to delineate the baseline DWI lesion and analyzed its performance compared to manual assessments. Diagnostic capabilities of best possible ADC thresholds were investigated using receiver operating characteristic curves. Influential patient factors on ADC thresholding techniques' performance were studied by conducting multiple linear regression. Results 108 acute ischemic stroke patients were selected for analysis. The median Dice coefficient for the algorithm was 0.43 (IQR 0.20-0.64). Mean ADC values in the DWI lesion (β = -0.68, p < 0.001) and DWI lesion volumes (β = 0.29, p < 0.001) predicted performance. Optimal individual ADC thresholds differed between subjects with a median of ≤691 × 10-6 mm2/s (IQR ≤660-750 × 10-6 mm2/s). Mean ADC values in the DWI lesion (β = -0.96, p < 0.001) and mean ADC values in the brain parenchyma (β = 0.24, p < 0.001) were associated with the performance of individual thresholds. Conclusion The performance of ADC thresholds for delineating acute stroke lesions varies substantially between patients. It is influenced by factors such as lesion size as well as lesion and parenchymal ADC values. Considering the inherent noisiness of ADC maps, ADC threshold-based automated delineation of very small lesions is not reliable.
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Affiliation(s)
- Vitus Gosch
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ivana Galinovic
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ramanan Ganeshan
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Sophie K. Piper
- Institute of Medical Informatics, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jochen B. Fiebach
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ahmed Khalil
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Heinzinger N, Maass A, Berron D, Yakupov R, Peters O, Fiebach J, Villringer K, Preis L, Priller J, Spruth EJ, Altenstein S, Schneider A, Fliessbach K, Wiltfang J, Bartels C, Jessen F, Maier F, Glanz W, Buerger K, Janowitz D, Perneczky R, Rauchmann BS, Teipel S, Killimann I, Göerß D, Laske C, Munk MH, Spottke A, Roy N, Heneka MT, Brosseron F, Dobisch L, Ewers M, Dechent P, Haynes JD, Scheffler K, Wolfsgruber S, Kleineidam L, Schmid M, Berger M, Düzel E, Ziegler G. Exploring the ATN classification system using brain morphology. Alzheimers Res Ther 2023; 15:50. [PMID: 36915139 PMCID: PMC10009950 DOI: 10.1186/s13195-023-01185-x] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 02/08/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND The NIA-AA proposed amyloid-tau-neurodegeneration (ATN) as a classification system for AD biomarkers. The amyloid cascade hypothesis (ACH) implies a sequence across ATN groups that patients might undergo during transition from healthy towards AD: A-T-N-➔A+T-N-➔A+T+N-➔A+T+N+. Here we assess the evidence for monotonic brain volume decline for this particular (amyloid-conversion first, tau-conversion second, N-conversion last) and alternative progressions using voxel-based morphometry (VBM) in a large cross-sectional MRI cohort. METHODS We used baseline data of the DELCODE cohort of 437 subjects (127 controls, 168 SCD, 87 MCI, 55 AD patients) which underwent lumbar puncture, MRI scanning, and neuropsychological assessment. ATN classification was performed using CSF-Aβ42/Aβ40 (A+/-), CSF phospho-tau (T+/-), and adjusted hippocampal volume or CSF total-tau (N+/-). We compared voxel-wise model evidence for monotonic decline of gray matter volume across various sequences over ATN groups using the Bayesian Information Criterion (including also ROIs of Braak stages). First, face validity of the ACH transition sequence A-T-N-➔A+T-N-➔A+T+N-➔A+T+N+ was compared against biologically less plausible (permuted) sequences among AD continuum ATN groups. Second, we evaluated evidence for 6 monotonic brain volume progressions from A-T-N- towards A+T+N+ including also non-AD continuum ATN groups. RESULTS The ACH-based progression A-T-N-➔A+T-N-➔A+T+N-➔A+T+N+ was consistent with cognitive decline and clinical diagnosis. Using hippocampal volume for operationalization of neurodegeneration (N), ACH was most evident in 9% of gray matter predominantly in the medial temporal lobe. Many cortical regions suggested alternative non-monotonic volume progressions over ACH progression groups, which is compatible with an early amyloid-related tissue expansion or sampling effects, e.g., due to brain reserve. Volume decline in 65% of gray matter was consistent with a progression where A status converts before T or N status (i.e., ACH/ANT) when compared to alternative sequences (TAN/TNA/NAT/NTA). Brain regions earlier affected by tau tangle deposition (Braak stage I-IV, MTL, limbic system) present stronger evidence for volume decline than late Braak stage ROIs (V/VI, cortical regions). Similar findings were observed when using CSF total-tau for N instead. CONCLUSION Using the ATN classification system, early amyloid status conversion (before tau and neurodegeneration) is associated with brain volume loss observed during AD progression. The ATN system and the ACH are compatible with monotonic progression of MTL atrophy. TRIAL REGISTRATION DRKS00007966, 04/05/2015, retrospectively registered.
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Affiliation(s)
- Nils Heinzinger
- German Center for Neurodegenerative Diseases (DZNE), Magdeburg, Germany. .,Institute of Cognitive Neurology and Dementia Research (IKND), University Hospital Magdeburg, Otto-von-Guericke University, Leipziger Str. 44, 39120, Magdeburg, Germany.
| | - Anne Maass
- German Center for Neurodegenerative Diseases (DZNE), Magdeburg, Germany.,Institute of Cognitive Neurology and Dementia Research (IKND), University Hospital Magdeburg, Otto-von-Guericke University, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - David Berron
- German Center for Neurodegenerative Diseases (DZNE), Magdeburg, Germany.,Institute of Cognitive Neurology and Dementia Research (IKND), University Hospital Magdeburg, Otto-von-Guericke University, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Renat Yakupov
- German Center for Neurodegenerative Diseases (DZNE), Magdeburg, Germany.,Institute of Cognitive Neurology and Dementia Research (IKND), University Hospital Magdeburg, Otto-von-Guericke University, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Oliver Peters
- German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany.,Department of Psychiatry, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Jochen Fiebach
- Center for Stroke Research Berlin, Charité-Universitätsmedizin, Berlin, Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin, Charité-Universitätsmedizin, Berlin, Germany
| | - Lukas Preis
- Department of Psychiatry, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Josef Priller
- German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany.,Department of Psychiatry and Psychotherapy, Charité, Berlin, Germany.,Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany.,University of Edinburgh and UK DRI, Edinburgh, UK
| | - Eike Jacob Spruth
- German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany.,Department of Psychiatry and Psychotherapy, Charité, Berlin, Germany
| | - Slawek Altenstein
- German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany.,Department of Psychiatry and Psychotherapy, Charité, Berlin, Germany
| | - Anja Schneider
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany.,Department of Neurodegenerative Diseases and Geriatric Psychiatry/Psychiatry, University of Bonn Medical Center, Bonn, Germany
| | - Klaus Fliessbach
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany.,Department of Neurodegenerative Diseases and Geriatric Psychiatry/Psychiatry, University of Bonn Medical Center, Bonn, Germany
| | - Jens Wiltfang
- German Center for Neurodegenerative Diseases (DZNE), Göttingen, Germany.,Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, University of Göttingen, Göttingen, Germany.,Department of Medical Sciences, Neurosciences and Signaling Group, Institute of Biomedicine (iBiMED), University of Aveiro, Aveiro, Portugal
| | - Claudia Bartels
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, University of Göttingen, Göttingen, Germany
| | - Frank Jessen
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany.,Department of Psychiatry, Medical Faculty, University of Cologne, Cologne, Germany.,Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
| | - Franziska Maier
- Department of Psychiatry, Medical Faculty, University of Cologne, Cologne, Germany
| | - Wenzel Glanz
- German Center for Neurodegenerative Diseases (DZNE), Magdeburg, Germany
| | - Katharina Buerger
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany.,Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | - Daniel Janowitz
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | - Robert Perneczky
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany.,Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany.,Ageing Epidemiology Research Unit (AGE), School of Public Health, Imperial College London, London, UK
| | - Boris-Stephan Rauchmann
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Stefan Teipel
- German Center for Neurodegenerative Diseases (DZNE), Rostock, Germany.,Department of Psychosomatic Medicine, Rostock University Medical Center, Rostock, Germany
| | - Ingo Killimann
- German Center for Neurodegenerative Diseases (DZNE), Rostock, Germany.,Department of Psychosomatic Medicine, Rostock University Medical Center, Rostock, Germany
| | - Doreen Göerß
- Department of Psychosomatic Medicine, Rostock University Medical Center, Rostock, Germany
| | - Christoph Laske
- German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany.,Section for Dementia Research, Hertie Institute for Clinical Brain Research and Department of Psychiatry and Psychotherapy, University of Tübingen, Tübingen, Germany
| | - Matthias H Munk
- German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany.,Section for Dementia Research, Hertie Institute for Clinical Brain Research and Department of Psychiatry and Psychotherapy, University of Tübingen, Tübingen, Germany
| | - Annika Spottke
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany.,Department of Neurology, University of Bonn, Bonn, Germany
| | - Nina Roy
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Michael T Heneka
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany.,Department of Neurodegenerative Diseases and Geriatric Psychiatry/Psychiatry, University of Bonn Medical Center, Bonn, Germany
| | - Frederic Brosseron
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany.,Department of Neurodegenerative Diseases and Geriatric Psychiatry/Psychiatry, University of Bonn Medical Center, Bonn, Germany
| | - Laura Dobisch
- German Center for Neurodegenerative Diseases (DZNE), Magdeburg, Germany
| | - Michael Ewers
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Peter Dechent
- MR-Research in Neurosciences, Department of Cognitive Neurology, Georg-August-University Göttingen, Göttingen, Germany
| | - John Dylan Haynes
- Bernstein Center for Computational Neuroscience, Charité-Universitätsmedizin, Berlin, Germany
| | - Klaus Scheffler
- Department for Biomedical Magnetic Resonance, University of Tübingen, Tübingen, Germany
| | - Steffen Wolfsgruber
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany.,Department of Neurodegenerative Diseases and Geriatric Psychiatry/Psychiatry, University of Bonn Medical Center, Bonn, Germany
| | - Luca Kleineidam
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Matthias Schmid
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany.,Institute for Medical Biometry, University Hospital Bonn, Bonn, Germany
| | - Moritz Berger
- Institute for Medical Biometry, University Hospital Bonn, Bonn, Germany
| | - Emrah Düzel
- German Center for Neurodegenerative Diseases (DZNE), Magdeburg, Germany.,Institute of Cognitive Neurology and Dementia Research (IKND), University Hospital Magdeburg, Otto-von-Guericke University, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Gabriel Ziegler
- German Center for Neurodegenerative Diseases (DZNE), Magdeburg, Germany.,Institute of Cognitive Neurology and Dementia Research (IKND), University Hospital Magdeburg, Otto-von-Guericke University, Leipziger Str. 44, 39120, Magdeburg, Germany
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Braemswig TB, Kusserow M, Bellmann B, Beckhoff F, Reinthaler M, von Rennenberg R, Erdur H, Scheitz JF, Galinovic I, Villringer K, Leistner DM, Audebert HJ, Endres M, Landmesser U, Haeusler KG, Fiebach JB, Lauten A, Rillig A, Nolte CH. New Cerebral Microbleeds After Catheter-Based Structural Heart Interventions: An Exploratory Analysis. J Am Heart Assoc 2023; 12:e8189. [PMID: 36734351 PMCID: PMC9973666 DOI: 10.1161/jaha.122.027284] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Cerebral microbleeds (CMBs) are increasingly recognized as "covert" brain lesions indicating increased risk of future neurological events. However, data on CMBs in patients undergoing catheter-based structural heart interventions are scarce. Therefore, we assessed occurrence and predictors of new CMBs in patients undergoing catheter-based left atrial appendage closure and percutaneous mitral valve repair using the MitraClip System. Methods and Results We conducted an exploratory analysis using data derived from 2 prospective, observational studies. Eligible patients underwent cerebral magnetic resonance imaging (3 Tesla) examinations and cognitive tests (using the Montreal Cognitive Assessment) before and after catheter-based left atrial appendage closure and percutaneous mitral valve repair. Forty-seven patients (53% men; median age, 77 years) were included. New CMBs occurred in 17 of 47 patients (36%) following catheter-based structural heart interventions. Occurrences of new CMBs did not differ significantly between patients undergoing catheter-based left atrial appendage closure and percutaneous mitral valve repair (7/25 versus 10/22; P=0.348). In univariable analysis, longer procedure time was significantly associated with new CMBs. Adjustment for heparin attenuated this association (adjusted odds ratio [per 30 minutes]: 1.77 [95% CI, 0.92-3.83]; P=0.090). Conclusions New CMBs occur in approximately one-third of patients after catheter-based left atrial appendage closure and percutaneous mitral valve repair using the MitraClip System. Our data suggest that longer duration of the procedure may be a risk factor for new CMBs. Future studies in larger populations are needed to further investigate their clinical relevance. Clinical Trial Registration German Clinical Trials Register: DRKS00010300 (https://drks.de/search/en/trial/DRKS00010300); ClinicalTrials.gov : NCT03104556 (https://clinicaltrials.gov/ct2/show/NCT03104556?term=NCT03104556&draw=2&rank=1).
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Affiliation(s)
- Tim Bastian Braemswig
- Klinik und Hochschulambulanz für NeurologieCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- German Centre for Cardiovascular Research (DZHK), partner site BerlinBerlinGermany
| | - Madeleine Kusserow
- Klinik für Innere MedizinBundeswehrkrankenhaus BerlinBerlinGermany
- Charité – Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Barbara Bellmann
- MEDIAN Klinik AGZ DüsseldorfDüsseldorfGermany
- Department of CardiologyCampus Benjamin FranklinCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Frederik Beckhoff
- Department of CardiologyCampus Benjamin FranklinCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Markus Reinthaler
- Department of CardiologyCampus Benjamin FranklinCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Institute of Active Polymers and Berlin‐Brandenburg Center for Regenerative TherapiesHelmholtz‐Zentrum HereonTeltowGermany
- Deutsches Herzzentrum der Charité, Klinik für KardiologieAngiologie und IntensivmedizinBerlinGermany
| | - Regina von Rennenberg
- Klinik und Hochschulambulanz für NeurologieCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- German Center for Neurodegenerative Diseases (DZNE), partner site BerlinBerlinGermany
| | - Hebun Erdur
- Klinik und Hochschulambulanz für NeurologieCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Jan F. Scheitz
- Klinik und Hochschulambulanz für NeurologieCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- German Centre for Cardiovascular Research (DZHK), partner site BerlinBerlinGermany
| | - Ivana Galinovic
- Center for Stroke Research Berlin (CSB)Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Kersten Villringer
- Center for Stroke Research Berlin (CSB)Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - David M. Leistner
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin BerlinBerlinGermany
- German Centre for Cardiovascular Research (DZHK), partner site BerlinBerlinGermany
- Department of CardiologyCampus Benjamin FranklinCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Department of Medicine III, CardiologyGoethe UniversityFrankfurt am MainGermany
- German Centre for Cardiovascular Research (DZHK), partner site Rhine‐MainFrankfurtGermany
| | - Heinrich J. Audebert
- Klinik und Hochschulambulanz für NeurologieCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Matthias Endres
- Klinik und Hochschulambulanz für NeurologieCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- German Centre for Cardiovascular Research (DZHK), partner site BerlinBerlinGermany
- German Center for Neurodegenerative Diseases (DZNE), partner site BerlinBerlinGermany
- ExcellenceCluster NeuroCureBerlinGermany
| | - Ulf Landmesser
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin BerlinBerlinGermany
- German Centre for Cardiovascular Research (DZHK), partner site BerlinBerlinGermany
- Department of CardiologyCampus Benjamin FranklinCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Deutsches Herzzentrum der Charité, Klinik für KardiologieAngiologie und IntensivmedizinBerlinGermany
| | | | - Jochen B. Fiebach
- Center for Stroke Research Berlin (CSB)Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
| | - Alexander Lauten
- Department of CardiologyCampus Benjamin FranklinCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Department of General and Interventional CardiologyHelios Klinikum ErfurtErfurtGermany
| | - Andreas Rillig
- Department of CardiologyCampus Benjamin FranklinCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Universitäres Herz‐ und Gefässzentrum Hamburg‐EppendorfHamburgGermany
| | - Christian H. Nolte
- Klinik und Hochschulambulanz für NeurologieCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- German Centre for Cardiovascular Research (DZHK), partner site BerlinBerlinGermany
- German Center for Neurodegenerative Diseases (DZNE), partner site BerlinBerlinGermany
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6
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Ali HF, Fast L, Khalil A, Siebert E, Liman T, Endres M, Villringer K, Kufner A. White matter hyperintensities are an independent predictor of cognitive decline 3 years following first-ever stroke-results from the PROSCIS-B study. J Neurol 2023; 270:1637-1646. [PMID: 36471099 PMCID: PMC9971076 DOI: 10.1007/s00415-022-11481-5] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/05/2022] [Accepted: 11/06/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND White matter hyperintensities (WMH) are the result of cerebral small vessel disease and may increase the risk of cognitive impairment (CI), recurrent stroke, and depression. We aimed to explore the association between selected cerebrovascular risk factors (CVRF) and WMH load as well as the effect of increased WMH burden on recurrent vascular events, CI, and depression in first-ever ischemic stroke patients. METHODS 431 from the PROSpective Cohort with Incident Stroke (PROSCIS) were included; Age-Related White Matter Changes (ARWMC) score was used to assess WMH burden on FLAIR. The presence of CVRF (defined via blood pressure, body-mass-index, and serological markers of kidney dysfunction, diabetes mellitus, and hyperlipoproteinemia) was categorized into normal, borderline, and pathological profiles based on commonly used clinical definitions. The primary outcomes included recurrent vascular events (combined endpoint of recurrent stroke, myocardial infarction and/or death), CI 3 years post-stroke, and depression 1-year post-stroke. RESULTS There was no clear association between CVRF profiles and WMH burden. High WMH lesion load (ARWMC score ≥ 10) was found to be associated with CI (adjusted OR 1.05 [95% CI 1.00-1.11]; p < 0.02) in a mixed-model analysis. Kaplan-Meier survival analysis showed a visible increase in the risk of recurrent vascular events following stroke; however, after adjustment, the risk was non-significant (HR 1.5 [95% CI 0.76-3]; p = 0.18). WMH burden was not associated with depression 1-year post stroke (adjusted OR 0.72 [95% CI 0.31-1.64]; p = 0.44). CONCLUSION Higher WMH burden was associated with a significant decline in cognition 3 years post-stroke in this cohort of first-ever stroke patients.
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Affiliation(s)
- Huma Fatima Ali
- Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lea Fast
- Klinik für Psychiatrie and Psychotherapie, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Ahmed Khalil
- Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany ,Center for Stroke Research Berlin (CSB), Klinik Für Neurologie, Charité, Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany ,Berlin Institute of Health (BIH), Berlin, Germany ,Max Planck Institute for Human Cognitive and Brain Sciences, Berlin, Germany
| | - Eberhard Siebert
- Department of Neuroradiology, University Hospital of Berlin (Charité), Berlin, Germany
| | - Thomas Liman
- Center for Stroke Research Berlin (CSB), Klinik Für Neurologie, Charité, Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany ,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin (CSB), Klinik Für Neurologie, Charité, Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany ,Klinik und Hochschulambulanz für Neurologie mit Experimenteller Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany ,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany ,German Center for Neurodegerenative Diseases (DZNE), Partner Site Berlin, Berlin, Germany ,ExcellenceCluster NeuroCure, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin (CSB), Klinik Für Neurologie, Charité, Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Anna Kufner
- Center for Stroke Research Berlin (CSB), Klinik Für Neurologie, Charité, Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. .,Berlin Institute of Health (BIH), Berlin, Germany. .,Klinik und Hochschulambulanz für Neurologie mit Experimenteller Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany. .,ExcellenceCluster NeuroCure, Charité-Universitätsmedizin Berlin, Berlin, Germany.
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7
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Fast L, Temuulen U, Villringer K, Kufner A, Ali HF, Siebert E, Huo S, Piper SK, Sperber PS, Liman T, Endres M, Ritter K. Machine learning-based prediction of clinical outcomes after first-ever ischemic stroke. Front Neurol 2023; 14:1114360. [PMID: 36895902 PMCID: PMC9990416 DOI: 10.3389/fneur.2023.1114360] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 12/02/2022] [Accepted: 01/31/2023] [Indexed: 02/23/2023] Open
Abstract
Background Accurate prediction of clinical outcomes in individual patients following acute stroke is vital for healthcare providers to optimize treatment strategies and plan further patient care. Here, we use advanced machine learning (ML) techniques to systematically compare the prediction of functional recovery, cognitive function, depression, and mortality of first-ever ischemic stroke patients and to identify the leading prognostic factors. Methods We predicted clinical outcomes for 307 patients (151 females, 156 males; 68 ± 14 years) from the PROSpective Cohort with Incident Stroke Berlin study using 43 baseline features. Outcomes included modified Rankin Scale (mRS), Barthel Index (BI), Mini-Mental State Examination (MMSE), Modified Telephone Interview for Cognitive Status (TICS-M), Center for Epidemiologic Studies Depression Scale (CES-D) and survival. The ML models included a Support Vector Machine with a linear kernel and a radial basis function kernel as well as a Gradient Boosting Classifier based on repeated 5-fold nested cross-validation. The leading prognostic features were identified using Shapley additive explanations. Results The ML models achieved significant prediction performance for mRS at patient discharge and after 1 year, BI and MMSE at patient discharge, TICS-M after 1 and 3 years and CES-D after 1 year. Additionally, we showed that National Institutes of Health Stroke Scale (NIHSS) was the top predictor for most functional recovery outcomes as well as education for cognitive function and depression. Conclusion Our machine learning analysis successfully demonstrated the ability to predict clinical outcomes after first-ever ischemic stroke and identified the leading prognostic factors that contribute to this prediction.
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Affiliation(s)
- Lea Fast
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Psychiatry and Psychotherapy, Berlin, Germany
| | - Uchralt Temuulen
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin (CSB), Berlin, Germany
| | - Kersten Villringer
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin (CSB), Berlin, Germany
| | - Anna Kufner
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin (CSB), Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.,Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
| | - Huma Fatima Ali
- Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Eberhard Siebert
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neuroradiology, Berlin, Germany
| | - Shufan Huo
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin (CSB), Berlin, Germany.,Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany.,German Center for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislauferkrankungen, DZHK), Partner Site Berlin, Berlin, Germany
| | - Sophie K Piper
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.,Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany.,Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Informatics, Berlin, Germany
| | - Pia Sophie Sperber
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin (CSB), Berlin, Germany.,Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, NeuroCure Cluster of Excellence, NeuroCure Clinical Research Center (NCRC), Berlin, Germany.,Experimental and Clinical Research Center, A Cooperation Between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité - Universitätsmedizin Berlin, Berlin, Germany.,Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| | - Thomas Liman
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin (CSB), Berlin, Germany.,German Center for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislauferkrankungen, DZHK), Partner Site Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen, DZNE), Partner Site Berlin, Berlin, Germany.,Department of Neurology, Evangelical Hospital Oldenburg, Carl von Ossietzky-University, Oldenburg, Germany
| | - Matthias Endres
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Stroke Research Berlin (CSB), Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.,Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany.,German Center for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislauferkrankungen, DZHK), Partner Site Berlin, Berlin, Germany.,Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, NeuroCure Cluster of Excellence, NeuroCure Clinical Research Center (NCRC), Berlin, Germany.,German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen, DZNE), Partner Site Berlin, Berlin, Germany
| | - Kerstin Ritter
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Psychiatry and Psychotherapy, Berlin, Germany.,Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Bernstein Center for Computational Neuroscience (BCCN), Berlin, Germany
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8
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Braemswig TB, Kusserow MM, Kruppa J, Reinthaler M, Erdur H, Fritsch M, Curio J, Alushi B, Villringer K, Galinovic I, Berger C, Leistner DM, Audebert HJ, Endres M, Landmesser U, Fiebach JB, Nolte CH, Beckhoff F, Lauten A. Cerebral embolisation during transcatheter edge-to-edge repair of the mitral valve with the MitraClip system: a prospective, observational study. EUROINTERVENTION 2022; 18:e160-e168. [PMID: 34916177 PMCID: PMC9904372 DOI: 10.4244/eij-d-21-00646] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND New ischaemic brain lesions on magnetic resonance imaging (MRI) are reported in up to 86% of patients after transcatheter edge-to-edge repair of the mitral valve (TEER-MV). Knowledge of the exact procedural step(s) that carry the highest risk for cerebral embolisation may help to further improve the procedure. AIMS The aim of this study was to identify the procedural step(s) that are associated with an increased risk of cerebral embolisation during TEER-MV with the MitraClip system. Furthermore, the risk of overt stroke and silent brain ischaemia after TEER-MV was assessed. METHODS In this prospective, pre-specified observational study, all patients underwent continuous transcranial Doppler examination during TEER-MV to detect microembolic signals (MES). MES were assigned to specific procedural steps: (1) transseptal puncture and placement of the guide, (2) advancing and adjustment of the clip in the left atrium, (3) device interaction with the MV, and (4) removal of the clip delivery system and the guide. Neurological examination using the National Institutes of Health Stroke Scale (NIHSS) and cerebral MRI were performed before and after TEER-MV. RESULTS Fifty-four patients were included. The number of MES differed significantly between the procedural steps with the highest numbers observed during device interaction with the MV. Mild neurological deterioration (NIHSS ≤3) occurred in 9/54 patients. New ischaemic lesions were detected in 21/24 patients who underwent MRI. Larger infarct volume was significantly associated with neurological deterioration. CONCLUSIONS Cerebral embolisation is immanent to TEER-MV and predominantly occurs during device interaction with the MV. Improvements to the procedure may focus on this procedural step.
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Affiliation(s)
- Tim Bastian Braemswig
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany,Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany,Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Madeleine M.D. Kusserow
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,Klinik für Innere Medizin, Bundeswehrkrankenhaus Berlin, Germany
| | - Jochen Kruppa
- Institute of Medical Informatics, Charité – Universitätsmedizin Berlin, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Markus Reinthaler
- Department of Cardiology, Campus Benjamin Franklin, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Hebun Erdur
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany,Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Merve Fritsch
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany,Department of Psychiatry, Campus Mitte, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jonathan Curio
- Department of Cardiology, Campus Benjamin Franklin, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Brunilda Alushi
- Department of Cardiology, Campus Benjamin Franklin, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany,Department of General and Interventional Cardiology, Helios Klinikum Erfurt, Erfurt, Germany,Department of Interventional Cardiology, Klinik Vincentinum Augsburg, Augsberg, Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ivana Galinovic
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Christian Berger
- Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - David M. Leistner
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany,Department of Cardiology, Campus Benjamin Franklin, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - Heinrich J. Audebert
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany,Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Matthias Endres
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany,Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany,ExcellenceCluster NeuroCure, Berlin, Germany,German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Berlin, Germany
| | - Ulf Landmesser
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany,Department of Cardiology, Campus Benjamin Franklin, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - Jochen B. Fiebach
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Christian H. Nolte
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany,Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany,Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany,German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Berlin, Germany
| | - Frederik Beckhoff
- Department of Cardiology, Campus Benjamin Franklin, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Alexander Lauten
- Department of Cardiology, Campus Benjamin Franklin, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,Department of General and Interventional Cardiology, Helios Klinikum Erfurt, Erfurt, Germany
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9
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Müller S, Kufner A, Dell'Orco A, Rackoll T, Mekle R, Piper SK, Fiebach JB, Villringer K, Flöel A, Endres M, Ebinger M, Nave AH. Evolution of Blood-Brain Barrier Permeability in Subacute Ischemic Stroke and Associations With Serum Biomarkers and Functional Outcome. Front Neurol 2021; 12:730923. [PMID: 34744972 PMCID: PMC8567961 DOI: 10.3389/fneur.2021.730923] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 09/07/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: In the setting of acute ischemic stroke, increased blood-brain barrier permeability (BBBP) as a sign of injury is believed to be associated with increased risk of poor outcome. Pre-clinical studies show that selected serum biomarkers including C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNFα), matrix metallopeptidases (MMP), and vascular endothelial growth factors (VEGFs) may play a role in BBBP post-stroke. In the subacute phase of stroke, increased BBBP may also be caused by regenerative mechanisms such as vascular remodeling and therefore may improve functional recovery. Our aim was to investigate the evolution of BBBP in ischemic stroke using contrast-enhanced (CE) magnetic resonance imaging (MRI) and to analyze potential associations with blood-derived biomarkers as well as functional recovery in subacute ischemic stroke patients. Methods: This is an exploratory analysis of subacute ischemic stroke patients enrolled in the BAPTISe study nested within the randomized controlled PHYS-STROKE trial (interventions: 4 weeks of aerobic fitness training vs. relaxation). Patients with at least one CE-MRI before (v1) or after (v2) the intervention were eligible for this analysis. The prevalence of increased BBBP was visually assessed on T1-weighted MR-images based on extent of contrast-agent enhancement within the ischemic lesion. The intensity of increased BBBP was assessed semi-quantitatively by normalizing the mean voxel intensity within the region of interest (ROI) to the contralateral hemisphere (“normalized CE-ROI”). Selected serum biomarkers (high-sensitive CRP, IL-6, TNF-α, MMP-9, and VEGF) at v1 (before intervention) were analyzed as continuous and dichotomized variables defined by laboratory cut-off levels. Functional outcome was assessed at 6 months after stroke using the modified Rankin Scale (mRS). Results: Ninety-three patients with a median baseline NIHSS of 9 [IQR 6–12] were included into the analysis. The median time to v1 MRI was 30 days [IQR 18–37], and the median lesion volume on v1 MRI was 4 ml [IQR 1.2–23.4]. Seventy patients (80%) had increased BBBP visible on v1 MRI. After the trial intervention, increased BBBP was still detectable in 52 patients (74%) on v2 MRI. The median time to v2 MRI was 56 days [IQR 46–67]. The presence of increased BBBP on v1 MRI was associated with larger lesion volumes and more severe strokes. Aerobic fitness training did not influence the increase of BBBP evaluated at v2. In linear mixed models, the time from stroke onset to MRI was inversely associated with normalized CE-ROI (coefficient −0.002, Standard Error 0.007, p < 0.01). Selected serum biomarkers were not associated with the presence or evolution of increased BBBP. Multivariable regression analysis did not identify the occurrence or evolution of increased BBBP as an independent predictor of favorable functional outcome post-stroke. Conclusion: In patients with moderate-to-severe subacute stroke, three out of four patients demonstrated increased BBB permeability, which decreased over time. The presence of increased BBBP was associated with larger lesion volumes and more severe strokes. We could not detect an association between selected serum biomarkers of inflammation and an increased BBBP in this cohort. No clear association with favorable functional outcome was observed. Trial registration: NCT01954797.
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Affiliation(s)
- Sarah Müller
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Anna Kufner
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie - Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Andrea Dell'Orco
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Torsten Rackoll
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,BIH QUEST - Center for Transforming Biomedical Research, Berlin Institute of Health (BIH), Berlin, Germany.,ExcellenceCluster NeuroCure, Charite-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Ralf Mekle
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Sophie K Piper
- Berlin Institute of Health (BIH), Berlin, Germany.,Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Agnes Flöel
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany.,German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie - Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,ExcellenceCluster NeuroCure, Charite-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany
| | - Martin Ebinger
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Alexander H Nave
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie - Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Berlin, Germany
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10
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Rangus I, S Milles L, Galinovic I, Villringer K, J Audebert H, B Fiebach J, H Nolte C, Hebun Erdur. Reclassifications of ischemic stroke patterns due to variants of the Circle of Willis. Int J Stroke 2021; 17:770-776. [PMID: 34569879 PMCID: PMC9358303 DOI: 10.1177/17474930211048381] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Variants of the Circle of Willis (vCoW) may impede correct identification of ischemic lesion patterns and stroke etiology. We assessed reclassifications of ischemic lesion patterns due to vCoW. METHODS We analyzed vCoW in patients with acute ischemic stroke from the 1000+ study using time-of-flight magnetic resonance angiography (TOF MRA) of intracranial arteries. We assessed A1 segment agenesis or hypoplasia in the anterior circulation and fetal posterior cerebral artery in the posterior circulation. Stroke patterns were classified as one or more-than-one territory stroke pattern. We examined associations between vCoW and stroke patterns and the frequency of reclassifications of stroke patterns due to vCoW. RESULTS Of 1000 patients, 991 had evaluable magnetic resonance angiography. At least one vCoW was present in 37.1%. VCoW were more common in the posterior than in the anterior circulation (33.3% vs. 6.7%). Of 238 patients initially thought to have a more-than-one territory stroke pattern, 20 (8.4%) had to be reclassified to a one territory stroke pattern after considering vCoW. All these patients had fetal posterior cerebral artery and six (30%) additionally had carotid artery disease. Of 753 patients initially presumed to have a one-territory stroke pattern, four (0.5%) were reclassified as having more-than-one territory pattern. CONCLUSIONS VCoW are present in about one in three stroke patients and more common in the posterior circulation. Reclassifications of stroke lesion patterns due to vCoW occurred predominantly in the posterior circulation with fetal posterior cerebral artery mimicking multiple territory stroke pattern. Considering vCoW in these cases may uncover symptomatic carotid disease.
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Affiliation(s)
- Ida Rangus
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Lennart S Milles
- Department of Neurology, Universitätsklinikum Essen, Essen, Germany
| | | | | | - Heinrich J Audebert
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Berlin, Germany
| | | | - Christian H Nolte
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Hebun Erdur
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
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11
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Danyel LA, Miszczuk M, Connolly F, Villringer K, Bohner G, Rossel-Zemkouo M, Siebert E. Time Course and Clinical Correlates of Retinal Diffusion Restrictions in Acute Central Retinal Artery Occlusion. AJNR Am J Neuroradiol 2021; 42:1661-1666. [PMID: 34266868 DOI: 10.3174/ajnr.a7201] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 10/27/2020] [Accepted: 04/04/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Retinal diffusion restrictions were recently identified as a regular finding in acute central retinal artery occlusion. We sought to investigate the influence of technical MR imaging and clinical parameters on the detection rate of retinal diffusion restrictions on standard brain DWI. MATERIALS AND METHODS In this retrospective cohort study, MR imaging scans of patients with central retinal artery occlusion were assessed by 2 readers for retinal diffusion restrictions on DWI performed within 2 weeks after vision loss. The influence of clinical and technical MR imaging parameters and the time interval between symptom onset and DWI on the presence of retinal diffusion restrictions were evaluated. RESULTS One hundred twenty-seven patients (mean age, 69.6 [SD 13.9] years; 59 women) and 131 DWI scans were included. Overall, the MR imaging sensitivity of retinal diffusion restrictions in acute central retinal artery occlusion was 62.6%-67.2%. Interrater and intrarater agreement for retinal diffusion restrictions was "substantial" with κinter = 0.70 (95% CI, 0.57-0.83) and κintra = 0.75 (95% CI, 0.63-0.88). Detection of retinal diffusion restrictions did not differ with differences in field strengths (1.5 versus 3T, P = .35) or sequence type (P = .22). Retinal diffusion restrictions were consistently identified within the first week with a peak sensitivity of 79% in DWI performed within 24 hours after symptom onset. Sensitivity of retinal diffusion restrictions declined in the second week (10.0%, P < .001). Absence of retinal diffusion restrictions was more prevalent in patients without fundoscopic retinal edema (60% versus 27.1%, P = .004) and with restitution of visual acuity at discharge (75% versus 28.4%, P = .006). CONCLUSIONS Retinal diffusion restrictions in acute central retinal artery occlusion can be reliably identified on DWI performed within 24 hours and 1 week after onset of visual impairment. Detectability of retinal diffusion restrictions is dependent on the clinical course of the disease.
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Affiliation(s)
- L A Danyel
- From the Department of Neurology (L.A.D., F.C.)
| | - M Miszczuk
- Institute for Neuroradiology (M.M., G.B., E.S.)
| | - F Connolly
- From the Department of Neurology (L.A.D., F.C.)
| | | | - G Bohner
- Institute for Neuroradiology (M.M., G.B., E.S.)
| | - M Rossel-Zemkouo
- Department of Ophthalmology (M.R.-Z.), Charité-Universitätsmedizin, Berlin, Germany
| | - E Siebert
- Institute for Neuroradiology (M.M., G.B., E.S.)
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12
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Hu JY, Kirilina E, Nierhaus T, Ovadia-Caro S, Livne M, Villringer K, Margulies D, Fiebach JB, Villringer A, Khalil AA. A novel approach for assessing hypoperfusion in stroke using spatial independent component analysis of resting-state fMRI. Hum Brain Mapp 2021; 42:5204-5216. [PMID: 34323339 PMCID: PMC8519861 DOI: 10.1002/hbm.25610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/09/2021] [Accepted: 07/20/2021] [Indexed: 01/03/2023] Open
Abstract
Individualized treatment of acute stroke depends on the timely detection of ischemia and potentially salvageable tissue in the brain. Using functional MRI (fMRI), it is possible to characterize cerebral blood flow from blood‐oxygen‐level‐dependent (BOLD) signals without the administration of exogenous contrast agents. In this study, we applied spatial independent component analysis to resting‐state fMRI data of 37 stroke patients scanned within 24 hr of symptom onset, 17 of whom received follow‐up scans the next day. Our analysis revealed “Hypoperfusion spatially‐Independent Components” (HICs) whose spatial patterns of BOLD signal resembled regions of delayed perfusion depicted by dynamic susceptibility contrast MRI. These HICs were detected even in the presence of excessive patient motion, and disappeared following successful tissue reperfusion. The unique spatial and temporal features of HICs allowed them to be distinguished with high accuracy from other components in a user‐independent manner (area under the curve = 0.93, balanced accuracy = 0.90, sensitivity = 1.00, and specificity = 0.85). Our study therefore presents a new, noninvasive method for assessing blood flow in acute stroke that minimizes interpretative subjectivity and is robust to severe patient motion.
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Affiliation(s)
- Jiun-Yiing Hu
- Department of Internal Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Evgeniya Kirilina
- Department of Neurophysics, Max-Planck-Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.,Neurocomputation and Neuroimaging Unit, Center for Cognitive Neuroscience Berlin (CCNB), Department of Education and Psychology, Freie Universität Berlin, Berlin, Germany
| | - Till Nierhaus
- Neurocomputation and Neuroimaging Unit, Center for Cognitive Neuroscience Berlin (CCNB), Department of Education and Psychology, Freie Universität Berlin, Berlin, Germany.,Department of Neurology, Max-Planck-Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | | | - Michelle Livne
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Daniel Margulies
- Centre National de la Recherche Scientifique (CNRS) UMR 7225, Frontlab, Institut du Cerveau et de la Moelle Épinière, Paris, France
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Arno Villringer
- Department of Neurology, Max-Planck-Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.,Berlin School of Mind and Brain, Humboldt Universität zu Berlin, Berlin, Germany
| | - Ahmed A Khalil
- Department of Neurology, Max-Planck-Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin School of Mind and Brain, Humboldt Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
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13
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Schindlbeck KA, Vo A, Mattis PJ, Villringer K, Marzinzik F, Fiebach JB, Eidelberg D. Cognition-Related Functional Topographies in Parkinson's Disease: Localized Loss of the Ventral Default Mode Network. Cereb Cortex 2021; 31:5139-5150. [PMID: 34148072 DOI: 10.1093/cercor/bhab148] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 03/05/2021] [Revised: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 02/07/2023] Open
Abstract
Cognitive dysfunction in Parkinson's disease (PD) is associated with increased expression of the PD cognition-related pattern (PDCP), which overlaps with the normal default mode network (DMN). Here, we sought to determine the degree to which the former network represents loss of the latter as a manifestation of the disease process. To address this, we first analyzed metabolic images (fluorodeoxyglucose positron emission tomography [PET]) from a large PD sample with varying cognitive performance. Cognitive impairment in these patients correlated with increased PDCP expression as well as DMN loss. We next determined the spatial relationship of the 2 topographies at the subnetwork level. To this end, we analyzed resting-state functional magnetic resonance imaging (rs-fMRI) data from an independent population. This approach uncovered a significant PD cognition-related network that resembled previously identified PET- and rs-fMRI-based PDCP topographies. Further analysis revealed selective loss of the ventral DMN subnetwork (precuneus and posterior cingulate cortex) in PD, whereas the anterior and posterior components were not affected by the disease. Importantly, the PDCP also included a number of non-DMN regions such as the dorsolateral prefrontal and medial temporal cortex. The findings show that the PDCP is a reproducible cognition-related network that is topographically distinct from the normal DMN.
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Affiliation(s)
- Katharina A Schindlbeck
- Center for Neurosciences, The Feinstein Institutes for Medical Research, Manhasset, NY 11030, USA
| | - An Vo
- Center for Neurosciences, The Feinstein Institutes for Medical Research, Manhasset, NY 11030, USA
| | - Paul J Mattis
- Center for Neurosciences, The Feinstein Institutes for Medical Research, Manhasset, NY 11030, USA.,Department of Neurology, Northwell Health, Manhasset, NY 11030, USA
| | - Kersten Villringer
- Center for Stroke Research, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, Berlin 12200, Germany
| | - Frank Marzinzik
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, Berlin 12200, Germany
| | - Jochen B Fiebach
- Center for Stroke Research, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, Berlin 12200, Germany
| | - David Eidelberg
- Center for Neurosciences, The Feinstein Institutes for Medical Research, Manhasset, NY 11030, USA
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14
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Fritsch M, Villringer K, Ganeshan R, Rangus I, Nolte CH. Frequency, clinical presentation and outcome of vigilance impairment in patients with uni- and bilateral ischemic infarction of the paramedian thalamus. J Neurol 2021; 268:4340-4348. [PMID: 33881597 PMCID: PMC8505279 DOI: 10.1007/s00415-021-10565-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 12/02/2022]
Abstract
Ischemic stroke of the paramedian thalamus is a rare differential diagnosis in sudden altered vigilance states. While efforts to describe clinical symptomatology exist, data on the frequency of paramedian thalamic stroke as a cause of sudden impaired vigilance and on accompanying clinical signs and outcome are scarce. We retrospectively analyzed consecutive patients admitted to a tertiary stroke center between 2010 and 2019 diagnosed with paramedian thalamic stroke. We evaluated frequency of vigilance impairment (VI) due to paramedian thalamic stroke, accompanying clinical signs and short-term outcome in uni- versus bilateral paramedian lesion location. Of 3896 ischemic stroke patients, 53 showed a paramedian thalamic stroke location (1.4%). VI was seen in 29/53 patients with paramedian thalamic stroke and in 414/3896 with any stroke (10.6%). Paramedian thalamic stroke was identified as causal to VI in 3.4% of all patients with initial VI in the emergency department and in 0.7% of all ischemic stroke patients treated in our center. Accompanying clinical signs were detected in 21 of these 29 patients (72.4%) and facilitated a timely diagnosis. VI was significantly more common after bilateral than unilateral lesions (92.0% vs. 21.4%; p < 0.001). Patients with bilateral paramedian lesions were more severely affected, had longer hospital stays and more frequently required in-patient rehabilitation. Paramedian thalamic lesions account for about 1 in 15 stroke patients presenting with impaired vigilance. Bilateral paramedian lesion location is associated with worse stroke severity and short-term outcome. Paying attention to accompanying clinical signs is of importance as they may facilitate a timely diagnosis.
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Affiliation(s)
- Merve Fritsch
- Department of Neurology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany. .,Department of Psychiatry and Psychotherapy, CCM, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.
| | - Kersten Villringer
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Ramanan Ganeshan
- Department of Neurology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.,Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Ida Rangus
- Department of Neurology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.,Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.,Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
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15
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Preis L, Cetindag AC, Villringer K, Fiebach JB, Peters O. Blood–brain barrier permeability measured by contrast‐enhanced MRI in early Alzheimer’s disease. Alzheimers Dement 2020. [DOI: 10.1002/alz.045909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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)
- Lukas Preis
- Charité ‐ Universitätsmedizin Berlin Berlin Germany
| | | | | | | | - Oliver Peters
- Charité ‐ Universitätsmedizin Berlin Berlin Germany
- German Center for Neurodegenerative Diseases (DZNE) Berlin Germany
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16
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Tanrıtanır AC, Villringer K, Galinovic I, Grittner U, Kirilina E, Fiebach JB, Villringer A, Khalil AA. The Effect of Scan Length on the Assessment of BOLD Delay in Ischemic Stroke. Front Neurol 2020; 11:381. [PMID: 32431665 PMCID: PMC7214917 DOI: 10.3389/fneur.2020.00381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 04/15/2020] [Indexed: 01/21/2023] Open
Abstract
Objectives: To evaluate the impact of resting-state functional MRI scan length on the diagnostic accuracy, image quality and lesion volume estimation of BOLD delay maps used for brain perfusion assessment in acute ischemic stroke. Methods: Sixty-three acute ischemic stroke patients received a 340 s resting-state functional MRI within 24 h of stroke symptom onset. BOLD delay maps were calculated from the full scan and four shortened versions (68 s, 136 s, 204 s, 272 s). The BOLD delay lesions on these maps were compared in terms of spatial overlap and volumetric agreement with the lesions derived from the full scans and with time-to-maximum (Tmax) lesions derived from DSC-MRI in a subset of patients (n = 10). In addition, the interpretability and quality of these maps were compared across different scan lengths using mixed models. Results: Shortened BOLD delay scans showed a small volumetric bias (ranging from 0.05 to 5.3 mL; between a 0.13% volumetric underestimation and a 7.7% overestimation relative to the mean of the volumes, depending on scan length) compared to the full scan. Decreased scan length was associated with decreased spatial overlap with both the BOLD delay lesions derived from the full scans and with Tmax lesions. Only the two shortest scan lengths (68 and 136 s) were associated with substantially decreased interpretability, decreased structure clarity, and increased noisiness of BOLD delay maps. Conclusions: BOLD delay maps derived from resting-state fMRI scans lasting 272 and 204 s provide sufficient diagnostic quality and adequate assessment of perfusion lesion volumes. Such shortened scans may be helpful in situations where quick clinical decisions need to be made.
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Affiliation(s)
| | - Kersten Villringer
- Center for Stroke Research, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ivana Galinovic
- Center for Stroke Research, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Evgeniya Kirilina
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.,Center for Cognitive Neuroscience Berlin, Free University, Berlin, Germany
| | - Jochen B Fiebach
- Center for Stroke Research, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Arno Villringer
- Berlin School of Mind and Brain, Humboldt Universität zu Berlin, Berlin, Germany.,Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Ahmed A Khalil
- Center for Stroke Research, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,Berlin School of Mind and Brain, Humboldt Universität zu Berlin, Berlin, Germany.,Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
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17
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Fan AP, Khalil AA, Fiebach JB, Zaharchuk G, Villringer A, Villringer K, Gauthier CJ. Elevated brain oxygen extraction fraction measured by MRI susceptibility relates to perfusion status in acute ischemic stroke. J Cereb Blood Flow Metab 2020; 40:539-551. [PMID: 30732551 PMCID: PMC7026852 DOI: 10.1177/0271678x19827944] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Recent clinical trials of new revascularization therapies in acute ischemic stroke have highlighted the importance of physiological imaging to identify optimal treatments for patients. Oxygen extraction fraction (OEF) is a hallmark of at-risk tissue in stroke, and can be quantified from the susceptibility effect of deoxyhemoglobin molecules in venous blood on MRI phase scans. We measured OEF within cerebral veins using advanced quantitative susceptibility mapping (QSM) MRI reconstructions in 20 acute stroke patients. Absolute OEF was elevated in the affected (29.3 ± 3.4%) versus the contralateral hemisphere (25.5 ± 3.1%) of patients with large diffusion-perfusion lesion mismatch (P = 0.032). In these patients, OEF negatively correlated with relative CBF measured by dynamic susceptibility contrast MRI (P = 0.004), suggesting compensation for reduced flow. Patients with perfusion-diffusion match or no hypo-perfusion showed less OEF difference between hemispheres. Nine patients received longitudinal assessment and showed OEF ratio (affected to contralateral) of 1.2 ± 0.1 at baseline that normalized (decreased) to 1.0 ± 0.1 at follow-up three days later (P = 0.03). Our feasibility study demonstrates that QSM MRI can non-invasively quantify OEF in stroke patients, relates to perfusion status, and is sensitive to OEF changes over time. Clinical trial registration: Longitudinal MRI examinations of patients with brain ischemia and blood brain barrier permeability; clinicaltrials.org :NCT02077582.
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Affiliation(s)
- Audrey P Fan
- Department of Radiology, Stanford University, Stanford, CA, USA
| | - Ahmed A Khalil
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany.,Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.,Berlin School of Mind and Brain, Humboldt-Universitaet zu Berlin, Berlin, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Greg Zaharchuk
- Department of Radiology, Stanford University, Stanford, CA, USA
| | - Arno Villringer
- Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.,Berlin School of Mind and Brain, Humboldt-Universitaet zu Berlin, Berlin, Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Claudine J Gauthier
- Department of Physics, Concordia University, Montreal, Canada.,Montreal Heart Institute, Montreal, Canada
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18
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Khalil AA, Villringer K, Filleböck V, Hu JY, Rocco A, Fiebach JB, Villringer A. Non-invasive monitoring of longitudinal changes in cerebral hemodynamics in acute ischemic stroke using BOLD signal delay. J Cereb Blood Flow Metab 2020; 40:23-34. [PMID: 30334657 PMCID: PMC6928563 DOI: 10.1177/0271678x18803951] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Relative delays in blood-oxygen-level-dependent (BOLD) signal oscillations can be used to assess cerebral perfusion without using contrast agents. However, little is currently known about the utility of this method in detecting clinically relevant perfusion changes over time. We investigated the relationship between longitudinal BOLD delay changes, vessel recanalization, and reperfusion in 15 acute stroke patients with vessel occlusion examined within 24 h of symptom onset (D0) and one day later (D1). We created BOLD delay maps using time shift analysis of resting-state functional MRI data and quantified perfusion lesion volume changes (using the D1/D0 volume ratio) and severity changes (using a linear mixed model) over time. Between baseline and follow-up, BOLD delay lesions shrank (median D1/D0 ratio = 0.2, IQR = 0.03-0.7) and BOLD delay severity decreased (b = -4.4 s) in patients with recanalization, whereas they grew (median D1/D0 ratio = 1.47, IQR = 1.1-1.7) and became more severe (b = 4.3 s) in patients with persistent vessel occlusion. Clinically relevant changes in cerebral perfusion in early stroke can be detected using BOLD delay, making this non-invasive method a promising option for detecting tissue at risk of infarction and monitoring stroke patients following recanalization therapy.
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Affiliation(s)
- Ahmed A Khalil
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.,Mind, Brain, Body Institute, Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Vivien Filleböck
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jiun-Yiing Hu
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Andrea Rocco
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Arno Villringer
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.,Mind, Brain, Body Institute, Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
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19
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Villringer K, Zimny S, Galinovic I, Nolte CH, Fiebach JB, Khalil AA. The Association Between Recanalization, Collateral Flow, and Reperfusion in Acute Stroke Patients: A Dynamic Susceptibility Contrast MRI Study. Front Neurol 2019; 10:1147. [PMID: 31708866 PMCID: PMC6823193 DOI: 10.3389/fneur.2019.01147] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/14/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Collateral circulation in ischemic stroke patients plays an important role in infarct evolution und assessing patients' eligibility for endovascular treatment. By means of dynamic susceptibility contrast MRI, we aimed to investigate the effects of reperfusion, recanalization, and collateral flow on clinical and imaging outcomes after stroke. Methods: Retrospective analysis of 184 patients enrolled into the prospective observational 1000Plus study (clinicaltrials.org NCT00715533). Inclusion criteria were vessel occlusion on baseline MR-angiography, imaging within 24 h after stroke onset and follow-up perfusion imaging. Baseline Higashida score using subtracted dynamic MR perfusion source images was used to quantify collateral flow. The influence of these variables, and their interaction with vessel recanalization, on clinical and imaging outcomes was assessed using robust linear regression. Results: Ninety-eight patients (53.3%) showed vessel recanalization. Higashida score (p = 0.002), and recanalization (p = 0.0004) were independently associated with reperfusion. However, we found no evidence that the association between Higashida score and reperfusion relied on recanalization status (p = 0.2). NIHSS on admission (p < 0.0001) and recanalization (p = 0.001) were independently associated with long-term outcome at 3 months, however, Higashida score (p = 0.228) was not. Conclusion: Higashida score and recanalization were independently associated with reperfusion, but the association between recanalization and reperfusion was similar regardless of collateral flow quality. Recanalization was associated with long-term outcome. DSC-based measures of collateral flow were not associated with long-term outcome, possibly due to the complex dynamic nature of collateral recruitment, timing of imaging and the employed post-processing.
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Affiliation(s)
- Kersten Villringer
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sascha Zimny
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Ev.-Luth. Diakonissenanstalt zu Flensburg, Flensburg, Germany
| | - Ivana Galinovic
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ahmed A Khalil
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.,Mind, Brain, Body Institute, Berlin School of Mind and Brain, Humboldt-Universität Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
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20
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Galinovic I, Boutitie F, Fiebach JB, Villringer K, Cheng B, Ebinger M, Endres M, Fiehler J, Ford I, Thijs V, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Simonsen CZ, Roy P, Gerloff C, Thomalla G. Post-hoc Analysis of Outcome of Intravenous Thrombolysis in Infarcts of Infratentorial Localization in the WAKE-UP Trial. Front Neurol 2019; 10:983. [PMID: 31572293 PMCID: PMC6749039 DOI: 10.3389/fneur.2019.00983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 08/28/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction: In WAKE-UP (Efficacy and Safety of MRI-based Thrombolysis in Wake-Up Stroke), patients with an acute stroke of unknown onset time were randomized to treatment with intravenous alteplase or placebo, guided by MRI. Methods: In this exploratory post-hoc secondary analysis we compared clinical and imaging data, as well as treatment effects and safety of intravenous thrombolysis between patients with infra- vs. supratentorial stroke. Results: Forty-eight out of 503 randomized patients (9.5%) presented with a stroke involving the cerebellum or brainstem. Patients with infratentorial stroke were younger compared to patients with supratentorial stroke (mean age 60 vs. 66 years), more frequently male (85 vs. 62%), and less severely affected (median NIHSS 4.5 vs. 6.0). There was no heterogeneity for treatment effect between supratentorial (OR 1.67 95% CI 1.11-2.51) and infratentorial (OR 1.31 95% CI 0.41-4.22) sub-groups (test for interaction p = 0.70). In patients with infratentorial stroke, favorable outcome [a score of 0-1 on the modified Rankin scale (mRS) at 90 days] was observed in 12/22 patients (54.5%) in the alteplase group and in 13/25 patients (52.0%) in the placebo group (p = 0.59). The primary safety endpoint (death or mRS 4-6 at day 90) occurred in three patients of the alteplase group (13.6%) and three patients in the placebo group (12.0%); p = 0.74. Discussion: WAKE-UP was underpowered for demonstrating treatment effect in subgroup analyses however, based on our current results, there is no evidence to recommend withholding MRI-guided thrombolysis in patients with unknown onset stroke of infratentorial localization.
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Affiliation(s)
- Ivana Galinovic
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, Lyon, France.,Université Lyon 1, Villeurbanne, France.,Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - Jochen B Fiebach
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Ebinger
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany.,Neurologie der Rehaklinik Medical Park Humboldtmühle, Berlin, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases Within the Helmholtz Association, Partner Site Berlin, Bonn, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, United Kingdom
| | - Vincent Thijs
- Stroke Theme, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia.,Austin Health, Department of Neurology, Heidelberg, VIC, Australia
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium.,Department of Neurosciences, Experimental Neurology, KU Leuven-University of Leuven, Leuven, Belgium.,VIB, Laboratory of Neurobiology, Center for Brain and Disease Research, Leuven, Belgium
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, United Kingdom
| | | | - Salvador Pedraza
- Department of Radiology, Hospital Dr. Josep Trueta, Institut de Diagnostic per la Image (IDI), Institut d'Investigació Biomèdica de Girona (IDIBGI), Girona, Spain
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Pascal Roy
- Hospices Civils de Lyon, Service de Biostatistique, Lyon, France.,Université Lyon 1, Villeurbanne, France.,Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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21
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Fritsch M, Krause T, Klostermann F, Villringer K, Ihrke M, Nolte CH. “Thalamic aphasia” after stroke is associated with left anterior lesion location. J Neurol 2019; 267:106-112. [DOI: 10.1007/s00415-019-09560-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/22/2019] [Accepted: 09/24/2019] [Indexed: 11/24/2022]
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22
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Bornstein NM, Saver JL, Diener HC, Gorelick PB, Shuaib A, Solberg Y, Devlin T, Leung T, Molina CA, Skoloudik D, Fiksa J, Krieger D, Andersen G, Berrouschot J, Hobohm C, Schneider D, Griewing B, Endres M, Hausler KG, Kimmig H, Ringleb P, Weimar C, Schilling M, Kohrmann M, Hetzel A, Kaps M, Cheung R, Sobolewski P, Nyke W, Czlonkowska A, Stepien A, Waldemar B, Słowik A, Zbigniewem S, Lubiński I, Portela P, Segure T, Marti-Fabregas J, Alonso M, Nunez A, Miguel MB, Campello A, Arenillas J, Marshall N, Chiu D, Shownkeen H, Rymer M, Sen S, Roubec M, Kuliha M, Lakomý C, Tyl D, Kemlink D, Doležal O, Rekova P, Krejčí V, Christensen A, Belhage B, Maschmann C, Kruse Larsen C, Pott F, Christensen H, Marstrand J, Nielsen JK, Meden P, Prytz S, Rosenbaum S, Hedemann Sorensen JC, Stenhoj Meier K, Schmift Ettrup K, Dupont Hougaard K, Von Wietzel P, Stoll A, Schwetlick H, Pradel H, Hemprich A, Schulz A, Frerich B, Hobohm C, Weise C, Michalski D, Schaller F, Schiefke F, Helmrich J, Pelz J, Schnieder M, Schneider M, Matzen P, Langos R, Müller-Duerwald S, Lukhaup S, Bauer U, Kloppig W, Hiermann E, Mucha G, Soda H, Weinhardt R, Mucha T, Ziegler V, Abbushi A, Hotter B, Winter B, Anthofer B, Noack C, Laubisch D, Heldge Schneider G, Jan Jungehulsing G, Mueller H, Dreier J, Fiebach J, Flechsenhar J, Villringer K, Ebinger M, Rozanski M, Vajkoczy P, Klingebiel R, Steinicke R, Pittl S, Hoffmann S, Maul S, Krause T, Liman T, Plath T, Nowe T, Schmidt W, Fritzsch C, Haas C, Will HG, Haußmann-Betz K, Bayat M, Pordzik T, Hug A, Staff CJ, Lichy C, Eggers G, Kloss M, Bendszus M, Herrmann O, Seeberger R, Schwarting S, Rhode S, Rizos T, Hacke W, Frank B, Bozkurt B, Holle D, Mueller D, Koch D, Shanib H, Sudendey J, Brenck J, Busch K, Gartzen K, Gasser T, Hagenacker T, Buerke B, Prigge G, Minnerup J, Albers J, Wermker K, Schwindt W, Kallmünzer RB, Hauer E, Breuer L, Schellinger P, Kollmar R, Sauer R, Schwab S, Struffert T, Funfack A, Stechmann A, Schlaeger A, Laeppchen C, Schuchardt F, Klingler JH, Reis J, Lambeck J, Friedrich M, Laible M, Wellermeyer P, Beck S, Rutsch S, Niesen WD, Tanislav C, Schaaf H, Kerkmann H, Schirotzek I, Allendörfer J, Wolff S, Yuk-Lun Lau A, Yin Yan Chan A, Siu D, Wong EHC, Chu Wong GK, Leung H, Wong LK, Zhu XL, Yan Soo YO, Ting Tse AC, Kit Leung GK, Leung KM, Ngai Hung K, Wai Mei Kwan M, Man Yu Tse M, Tse P, Hon Chan P, Lee R, Shek Kwan Chang R, Yin Yu Pang S, Fong Kwong Hon S, Cheng TS, Lui WM, Wo Mak WW, Sobota A, Wiater B, Loch B, Wolak G, Łabudzka I, Dabal J, Grzesik M, Sledzinska M, Hatalska-Żerebiec R, Szczuchniak W, Gójska A, Nałęcz D, Gasecki D, Kozera G, Dylewicz Ł, Niekra M, Kwarciany M, Chomik P, Skowron P, Kobayashi A, Chabik G, Makowicz G, Bembenek J, Jędrzejewska J, Karlinski M, Czepiel W, Brodacki B, Staszewski J, Kosek J, Jadczak M, Durka-Kęsy M, Kaluzny K, Ziomek M, Fudala M, Sosnowski Z, Ferens A, Szczygieł E, Banaszkiewicz K, Ziomek M, Wnuk M, Szczepańska-Szerej A, Jach E, Maslanko GE, Wojczal J, Luchowski P, Kowalczyk A, Jakubiak J, Kopcewicz J, Gajda M, Wichlinska-Lubinska M, Rodriguez D, Santamarin E, Pagola J, Lorente Guerrero J, Ribo M, Rubiera M, Maisterra O, Pinero S, Catalina Iglesias V, Plans G, Quesada H, Aparicio Caballero MA, Portela PC, De Diego AB, Garay DS, García Rodriguez MR, Martin OA, Braña SC, Garcia J, Hernandez FM, Catala I, Marti-Vilalta JL, Delgado Mederos R, de Quintana SC, Martinez-Ramirez S, Valcarcel Gonzalez J, Masjuan Vallejo J, Diamantopoulus J, Del Alamo M, Poveda PD, Pastor AG, Carballal CF, Diaz F, Garcia Leal R, Juretschke R, Echabe EA, Sanchez JC, Yanez MR, Garcia RS, Muino RL, Rivas SA, Lopez Gonzalez DM, Cuadrado E, Giralt E, Villalba G, Roquer J, Angel O, Jimenez M, Cedeño RR, Salinas R, Lejarreta S, Silva Y, Fraile A, Calleja A, Cepeda Landínez GA, Tellez N, Garcia Bermejo P, Santos PJ, Herranz RF, Hunt P, Browning D, Violette M, Hoddeson R, Rose J, Zhang J, Mazumdar A, Echiverri H, Chow J, Lovick D, Coleman M, Akhtar N, Sugg R, Zanation A, Germanwala A, Senior B, Huang D, Aucutt-Walter N, Kasner S, LeRoux P, von Kummer R, Palesch Y. Sphenopalatine Ganglion Stimulation to Augment Cerebral Blood Flow. Stroke 2019; 50:2108-2117. [DOI: 10.1161/strokeaha.118.024582] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Many patients with acute ischemic stroke are not eligible for thrombolysis or mechanical reperfusion therapies due to contraindications, inaccessible vascular occlusions, late presentation, or large infarct core. Sphenopalatine ganglion (SPG) stimulation to enhance collateral flow and stabilize the blood-brain barrier offers an alternative, potentially more widely deliverable, therapy.
Methods—
In a randomized, sham-controlled, double-masked trial at 41 centers in 7 countries, patients with anterior circulation ischemic stroke not treated with reperfusion therapies within 24 hours of onset were randomly allocated to active SPG stimulation or sham control. The primary efficacy outcome was improvement beyond expectations on the modified Rankin Scale of global disability at 90 days (sliding dichotomy), assessed in the modified intention-to-treat population. The initial planned sample size was 660 patients, but the trial was stopped early when technical improvements in device placement occurred, so that analysis of accumulated experience could be conducted to inform a successor trial.
Results—
Among 303 enrolled patients, 253 received at least one active SPG or sham stimulation, constituting the modified intention-to-treat population (153 SPG stimulation and 100 sham control). Age was median 73 years (interquartile range, 64–79), 52.6% were female, deficit severity on the National Institutes of Health Stroke Scale was median 11 (interquartile range, 9–15), and time from last known well median 18.6 hours (interquartile range, 14.5–22.5). For the primary outcome, improved 3-month disability beyond expectations, rates in the SPG versus sham treatment groups were 49.7% versus 40.0%; odds ratio, 1.48 (95% CI, 0.89–2.47);
P
=0.13. A significant treatment interaction with stroke location (cortical versus noncortical) was noted,
P
=0.04. In the 87 patients with confirmed cortical involvement, rates of improvement beyond expectations were 50.0% versus 27.0%; odds ratio, 2.70 (95% CI, 1.08–6.73);
P
=0.03. Similar response patterns were observed for all prespecified secondary efficacy outcomes. No differences in mortality or serious adverse event safety end points were observed.
Conclusions—
SPG stimulation within 24 hours of onset is safe in acute ischemic stroke. SPG stimulation was not shown to statistically significantly improve 3-month disability above expectations, though favorable outcomes were nominally higher with SPG stimulation. Beneficial effects may distinctively be conferred in patients with confirmed cortical involvement. The results of this study need to be confirmed in a larger pivotal study.
Clinical Trial Registration—
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT03767192.
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Affiliation(s)
- Natan M. Bornstein
- From the Brain Division, Shaarei Zedek Medical Center, Jerusalem and Tel Aviv Sourasky Medical School, Tel Aviv University (N.M.B.)
| | - Jeffrey L. Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at UCLA, Los Angeles CA (J.L.S.)
| | | | - Philip B. Gorelick
- Davee Department of Neurology, Northwestern University, Chicago, IL (P.B.G.)
| | - Ashfaq Shuaib
- Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.)
| | | | - Thomas Devlin
- Department of Neurology, University of Tennessee College of Medicine, Chattanooga (T.D.)
| | - Thomas Leung
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong (T.L.)
| | - Carlos A. Molina
- and Stroke Unit, Department of Neurology, Vall d’Hebron University Hospital, Barcelona (C.A.M.)
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23
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Hotter B, Galinovic I, Kunze C, Brunecker P, Jungehulsing GJ, Villringer A, Endres M, Villringer K, Fiebach JB. High‐resolution diffusion‐weighted imaging identifies ischemic lesions in a majority of transient ischemic attack patients. Ann Neurol 2019; 86:452-457. [DOI: 10.1002/ana.25551] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 07/10/2019] [Accepted: 07/10/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Benjamin Hotter
- Center for Stroke Research BerlinCharité Universitätsmedizin Berlin Berlin Germany
- Klinik und Hochschulambulanz für NeurologieCharité Universitätsmedizin Berlin Berlin Germany
| | - Ivana Galinovic
- Center for Stroke Research BerlinCharité Universitätsmedizin Berlin Berlin Germany
| | - Claudia Kunze
- Center for Stroke Research BerlinCharité Universitätsmedizin Berlin Berlin Germany
| | - Peter Brunecker
- Center for Stroke Research BerlinCharité Universitätsmedizin Berlin Berlin Germany
- Berlin Institute of Health Berlin Germany
| | - Gerhard J. Jungehulsing
- Center for Stroke Research BerlinCharité Universitätsmedizin Berlin Berlin Germany
- Department of NeurologyJewish Hospital Berlin Germany
| | - Arno Villringer
- Center for Stroke Research BerlinCharité Universitätsmedizin Berlin Berlin Germany
- Max Planck Institute for Human Cognitive and Brain Sciences Leipzig Germany
| | - Matthias Endres
- Center for Stroke Research BerlinCharité Universitätsmedizin Berlin Berlin Germany
- Klinik und Hochschulambulanz für NeurologieCharité Universitätsmedizin Berlin Berlin Germany
- Berlin Institute of Health Berlin Germany
- Max Planck Institute for Human Cognitive and Brain Sciences Leipzig Germany
- German Centre for Cardiovascular Research (DZHK) Berlin Germany
| | - Kersten Villringer
- Center for Stroke Research BerlinCharité Universitätsmedizin Berlin Berlin Germany
- Klinik und Hochschulambulanz für NeurologieCharité Universitätsmedizin Berlin Berlin Germany
| | - Jochen B. Fiebach
- Center for Stroke Research BerlinCharité Universitätsmedizin Berlin Berlin Germany
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24
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Bayrak Ş, Khalil AA, Villringer K, Fiebach JB, Villringer A, Margulies DS, Ovadia-Caro S. The impact of ischemic stroke on connectivity gradients. Neuroimage Clin 2019; 24:101947. [PMID: 31376644 PMCID: PMC6676042 DOI: 10.1016/j.nicl.2019.101947] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/08/2019] [Accepted: 07/17/2019] [Indexed: 11/19/2022]
Abstract
The functional organization of the brain can be represented as a low-dimensional space that reflects its macroscale hierarchy. The dimensions of this space, described as connectivity gradients, capture the similarity of areas' connections along a continuous space. Studying how pathological perturbations with known effects on functional connectivity affect these connectivity gradients provides support for their biological relevance. Previous work has shown that localized lesions cause widespread functional connectivity alterations in structurally intact areas, affecting a network of interconnected regions. By using acute stroke as a model of the effects of focal lesions on the connectome, we apply the connectivity gradient framework to depict how functional reorganization occurs throughout the brain, unrestricted by traditional definitions of functional network boundaries. We define a three-dimensional connectivity space template based on functional connectivity data from healthy controls. By projecting lesion locations into this space, we demonstrate that ischemic strokes result in dimension-specific alterations in functional connectivity over the first week after symptom onset. Specifically, changes in functional connectivity were captured along connectivity Gradients 1 and 3. The degree of functional connectivity change was associated with the distance from the lesion along these connectivity gradients (a measure of functional similarity) regardless of the anatomical distance from the lesion. Together, these results provide support for the biological validity of connectivity gradients and suggest a novel framework to characterize connectivity alterations after stroke.
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Affiliation(s)
- Şeyma Bayrak
- Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany; Department of Cognitive Neurology, University Hospital Leipzig and Faculty of Medicine, University of Leipzig, Leipzig, Germany
| | - Ahmed A Khalil
- Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany; Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Arno Villringer
- Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany; Department of Cognitive Neurology, University Hospital Leipzig and Faculty of Medicine, University of Leipzig, Leipzig, Germany; Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Daniel S Margulies
- Centre National de la Recherche Scientifique (CNRS) UMR 7225, Frontlab, Institut du Cerveau et de la Moelle épinière, Paris, France.
| | - Smadar Ovadia-Caro
- Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany; Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany; Department of Neurology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany.
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25
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Braemswig TB, Villringer K, Turc G, Erdur H, Fiebach JB, Audebert HJ, Endres M, Nolte CH, Scheitz JF. Predictors of new remote cerebral microbleeds after IV thrombolysis for ischemic stroke. Neurology 2019; 92:e630-e638. [PMID: 30674591 DOI: 10.1212/wnl.0000000000006915] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 10/01/2018] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To assess the frequency, associated factors, and underlying vasculopathy of new remote cerebral microbleeds (CMB), as well as the risk of concomitant hemorrhagic complications related to new CMBs, after IV thrombolysis (IVT) in acute stroke patients. METHODS We conducted an observational study using data from our local thrombolysis registry. We included consecutive stroke patients with MRI (3T)-based IVT and a follow-up MRI the next day between 2008 and 2017 (n = 396). Only CMBs located outside of the ischemic lesions were considered. We also performed a meta-analysis on new CMBs after IVT that included 2 additional studies. RESULTS In our cohort, new remote CMBs occurred in 16/396 patients (4.0%) after IVT and the distribution was strictly lobar in 13/16 patients (81%). Patients with preexisting CMBs with a strictly lobar distribution were significantly more likely to have new CMBs after IVT (p = 0.014). In the random-effects meta-analysis (n = 741), the pooled cumulative frequency of new CMBs after IVT was 4.4%. A higher preexisting CMB burden (>2) was associated with a higher likelihood of new CMBs (odds ratio [OR] 3.6, 95% confidence interval [CI] 1.3-10.3) and new CMBs were associated with the occurrence of remote parenchymal hemorrhage (OR 28.8, 95% CI 8.6-96.4). CONCLUSIONS New remote CMBs after IVT occurred in 4% of stroke patients, mainly had a strictly lobar distribution, and were associated with IVT-related hemorrhagic complications. Preexisting CMBs with a strictly lobar distribution and a higher CMB burden were associated with new CMBs after IVT, which may indicate an underlying cerebral amyloid angiopathy.
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Affiliation(s)
- Tim Bastian Braemswig
- From the Klinik und Hochschulambulanz für Neurologie (T.B.B., H.E., H.J.A., M.E., C.H.N., J.F.S.), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (T.B.B., H.E., M.E., C.H.N., J.F.S.); Center for Stroke Research Berlin (T.B.B., K.V., G.T., J.B.F., H.J.A., M.E., C.H.N., J.F.S.), Charité-Universitätsmedizin Berlin, Germany; Department of Neurology (G.T.), Hôpital Sainte-Anne, Université Paris Descartes; INSERM U894 (G.T.), Paris, France; German Center for Cardiovascular Diseases (M.E., C.H.N., J.F.S.), partner site Berlin; German Center for Neurodegenerative Diseases (M.E.), partner site Berlin, Germany.
| | - Kersten Villringer
- From the Klinik und Hochschulambulanz für Neurologie (T.B.B., H.E., H.J.A., M.E., C.H.N., J.F.S.), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (T.B.B., H.E., M.E., C.H.N., J.F.S.); Center for Stroke Research Berlin (T.B.B., K.V., G.T., J.B.F., H.J.A., M.E., C.H.N., J.F.S.), Charité-Universitätsmedizin Berlin, Germany; Department of Neurology (G.T.), Hôpital Sainte-Anne, Université Paris Descartes; INSERM U894 (G.T.), Paris, France; German Center for Cardiovascular Diseases (M.E., C.H.N., J.F.S.), partner site Berlin; German Center for Neurodegenerative Diseases (M.E.), partner site Berlin, Germany
| | - Guillaume Turc
- From the Klinik und Hochschulambulanz für Neurologie (T.B.B., H.E., H.J.A., M.E., C.H.N., J.F.S.), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (T.B.B., H.E., M.E., C.H.N., J.F.S.); Center for Stroke Research Berlin (T.B.B., K.V., G.T., J.B.F., H.J.A., M.E., C.H.N., J.F.S.), Charité-Universitätsmedizin Berlin, Germany; Department of Neurology (G.T.), Hôpital Sainte-Anne, Université Paris Descartes; INSERM U894 (G.T.), Paris, France; German Center for Cardiovascular Diseases (M.E., C.H.N., J.F.S.), partner site Berlin; German Center for Neurodegenerative Diseases (M.E.), partner site Berlin, Germany
| | - Hebun Erdur
- From the Klinik und Hochschulambulanz für Neurologie (T.B.B., H.E., H.J.A., M.E., C.H.N., J.F.S.), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (T.B.B., H.E., M.E., C.H.N., J.F.S.); Center for Stroke Research Berlin (T.B.B., K.V., G.T., J.B.F., H.J.A., M.E., C.H.N., J.F.S.), Charité-Universitätsmedizin Berlin, Germany; Department of Neurology (G.T.), Hôpital Sainte-Anne, Université Paris Descartes; INSERM U894 (G.T.), Paris, France; German Center for Cardiovascular Diseases (M.E., C.H.N., J.F.S.), partner site Berlin; German Center for Neurodegenerative Diseases (M.E.), partner site Berlin, Germany
| | - Jochen B Fiebach
- From the Klinik und Hochschulambulanz für Neurologie (T.B.B., H.E., H.J.A., M.E., C.H.N., J.F.S.), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (T.B.B., H.E., M.E., C.H.N., J.F.S.); Center for Stroke Research Berlin (T.B.B., K.V., G.T., J.B.F., H.J.A., M.E., C.H.N., J.F.S.), Charité-Universitätsmedizin Berlin, Germany; Department of Neurology (G.T.), Hôpital Sainte-Anne, Université Paris Descartes; INSERM U894 (G.T.), Paris, France; German Center for Cardiovascular Diseases (M.E., C.H.N., J.F.S.), partner site Berlin; German Center for Neurodegenerative Diseases (M.E.), partner site Berlin, Germany
| | - Heinrich J Audebert
- From the Klinik und Hochschulambulanz für Neurologie (T.B.B., H.E., H.J.A., M.E., C.H.N., J.F.S.), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (T.B.B., H.E., M.E., C.H.N., J.F.S.); Center for Stroke Research Berlin (T.B.B., K.V., G.T., J.B.F., H.J.A., M.E., C.H.N., J.F.S.), Charité-Universitätsmedizin Berlin, Germany; Department of Neurology (G.T.), Hôpital Sainte-Anne, Université Paris Descartes; INSERM U894 (G.T.), Paris, France; German Center for Cardiovascular Diseases (M.E., C.H.N., J.F.S.), partner site Berlin; German Center for Neurodegenerative Diseases (M.E.), partner site Berlin, Germany
| | - Matthias Endres
- From the Klinik und Hochschulambulanz für Neurologie (T.B.B., H.E., H.J.A., M.E., C.H.N., J.F.S.), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (T.B.B., H.E., M.E., C.H.N., J.F.S.); Center for Stroke Research Berlin (T.B.B., K.V., G.T., J.B.F., H.J.A., M.E., C.H.N., J.F.S.), Charité-Universitätsmedizin Berlin, Germany; Department of Neurology (G.T.), Hôpital Sainte-Anne, Université Paris Descartes; INSERM U894 (G.T.), Paris, France; German Center for Cardiovascular Diseases (M.E., C.H.N., J.F.S.), partner site Berlin; German Center for Neurodegenerative Diseases (M.E.), partner site Berlin, Germany
| | - Christian H Nolte
- From the Klinik und Hochschulambulanz für Neurologie (T.B.B., H.E., H.J.A., M.E., C.H.N., J.F.S.), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (T.B.B., H.E., M.E., C.H.N., J.F.S.); Center for Stroke Research Berlin (T.B.B., K.V., G.T., J.B.F., H.J.A., M.E., C.H.N., J.F.S.), Charité-Universitätsmedizin Berlin, Germany; Department of Neurology (G.T.), Hôpital Sainte-Anne, Université Paris Descartes; INSERM U894 (G.T.), Paris, France; German Center for Cardiovascular Diseases (M.E., C.H.N., J.F.S.), partner site Berlin; German Center for Neurodegenerative Diseases (M.E.), partner site Berlin, Germany
| | - Jan F Scheitz
- From the Klinik und Hochschulambulanz für Neurologie (T.B.B., H.E., H.J.A., M.E., C.H.N., J.F.S.), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (T.B.B., H.E., M.E., C.H.N., J.F.S.); Center for Stroke Research Berlin (T.B.B., K.V., G.T., J.B.F., H.J.A., M.E., C.H.N., J.F.S.), Charité-Universitätsmedizin Berlin, Germany; Department of Neurology (G.T.), Hôpital Sainte-Anne, Université Paris Descartes; INSERM U894 (G.T.), Paris, France; German Center for Cardiovascular Diseases (M.E., C.H.N., J.F.S.), partner site Berlin; German Center for Neurodegenerative Diseases (M.E.), partner site Berlin, Germany
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26
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Nasel C, Klickovic U, Kührer HM, Villringer K, Fiebach JB, Villringer A, Moser E. A Quantitative Comparison of Clinically Employed Parameters in the Assessment of Acute Cerebral Ischemia Using Dynamic Susceptibility Contrast Magnetic Resonance Imaging. Front Physiol 2019; 9:1945. [PMID: 30697166 PMCID: PMC6341064 DOI: 10.3389/fphys.2018.01945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 12/22/2018] [Indexed: 11/13/2022] Open
Abstract
Purpose: Perfusion magnetic resonance imaging (P-MRI) is part of the mismatch concept employed for therapy decisions in acute ischemic stroke. Using dynamic susceptibility contrast (DSC) MRI the time-to-maximum (Tmax) parameter is quite popular, but its inconsistently defined computation, arterial input function (AIF) selection, and the applied deconvolution method may introduce bias into the assessment. Alternatively, parameter free methods, namely, standardized time-to-peak (stdTTP), zf-score, and standardized-zf (stdZ) are also available, offering consistent calculation procedures without the need of an AIF or deconvolution. Methods: Tmax was compared to stdTTP, zf-, and stdZ to evaluate robustness of infarct volume estimation in 66 patients, using data from two different sites and MR systems (i.e., 1.5T vs. 3T; short TR (= 689 ms) vs. medium TR (= 1,390 ms); bolus dose 0.1 or 0.2 ml/kgBW, respectively). Results: Quality factors (QF) for Tmax were 0.54 ± 0.18 (sensitivity), 0.90 ± 0.06 (specificity), and 0.87 ± 0.05 (accuracy). Though not significantly different, best specificity (0.93 ± 0.05) and accuracy (0.90 ± 0.04) were found for stdTTP with a sensitivity of 0.56 ± 0.17. Other tested parameters performed not significantly worse than Tmax and stdTTP, but absolute values of QFs were slightly lower, except for zf showing the highest sensitivity (0.72 ± 0.16). Accordingly, in ROC-analysis testing the parameter performance to predict the final infarct volume, stdTTP and zf showed the best performance. The odds for stdTTP to obtain the best prediction of the final infarct size, was 6.42 times higher compared to all other parameters (odds-ratio test; p = 2.2*10–16). Conclusion: Based on our results, we suggest to reanalyze data from large cohort studies using the parameters presented here, particularly stdTTP and zf-score, to further increase consistency of perfusion assessment in acute ischemic stroke.
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Affiliation(s)
- Christian Nasel
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,Department of Radiology, University Hospital Tulln, Tulln, Austria.,MR Center of Excellence, Medical University of Vienna, Vienna, Austria
| | - Uros Klickovic
- Department of Radiology, University Hospital Tulln, Tulln, Austria.,Sobell Department of Motor Neuroscience and Movement Disorders, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | | | - Kersten Villringer
- Center for Stroke Research Berlin, Neuroradiology, Charité-Universitätsmedizin, Berlin, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Neuroradiology, Charité-Universitätsmedizin, Berlin, Germany
| | - Arno Villringer
- Department of Cognitive Neurology, University Hospital Leipzig, Leipzig, Germany.,Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Ewald Moser
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,MR Center of Excellence, Medical University of Vienna, Vienna, Austria
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27
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Kunz A, Nolte CH, Erdur H, Fiebach JB, Geisler F, Rozanski M, Scheitz JF, Villringer K, Waldschmidt C, Weber JE, Wendt M, Winter B, Zieschang K, Grittner U, Kaczmarek S, Endres M, Ebinger M, Audebert HJ. Effects of Ultraearly Intravenous Thrombolysis on Outcomes in Ischemic Stroke: The STEMO (Stroke Emergency Mobile) Group. Circulation 2019; 135:1765-1767. [PMID: 28461420 DOI: 10.1161/circulationaha.117.027693] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alexander Kunz
- From Klinik und Hochschulambulanz für Neurologie (A.K., C.H.N., H.E., J.B.F., F.G., M.R., J.F.S., K.V., C.W., J.E.W., M.W., B.W., K.Z., M. Endres, M. Ebinger, H.J.A.), Center for Stroke Research Berlin (A.K., C.H.N., J.B.F., M.R., K.V., U.G., M. Endres, M. Ebinger, H.J.A.), German Center for Cardiovascular Research (DZHK), Berlin Partner Site (M. Endres), and German Center for Neurodegenerative Diseases (DZNE), Berlin Partner Site (M. Endres), Charité-Universitätsmedizin Berlin, Germany; Berliner Feuerwehr, Germany (S.K.); and Berlin Institute of Health, Germany (M. Endres)
| | - Christian H Nolte
- From Klinik und Hochschulambulanz für Neurologie (A.K., C.H.N., H.E., J.B.F., F.G., M.R., J.F.S., K.V., C.W., J.E.W., M.W., B.W., K.Z., M. Endres, M. Ebinger, H.J.A.), Center for Stroke Research Berlin (A.K., C.H.N., J.B.F., M.R., K.V., U.G., M. Endres, M. Ebinger, H.J.A.), German Center for Cardiovascular Research (DZHK), Berlin Partner Site (M. Endres), and German Center for Neurodegenerative Diseases (DZNE), Berlin Partner Site (M. Endres), Charité-Universitätsmedizin Berlin, Germany; Berliner Feuerwehr, Germany (S.K.); and Berlin Institute of Health, Germany (M. Endres)
| | - Hebun Erdur
- From Klinik und Hochschulambulanz für Neurologie (A.K., C.H.N., H.E., J.B.F., F.G., M.R., J.F.S., K.V., C.W., J.E.W., M.W., B.W., K.Z., M. Endres, M. Ebinger, H.J.A.), Center for Stroke Research Berlin (A.K., C.H.N., J.B.F., M.R., K.V., U.G., M. Endres, M. Ebinger, H.J.A.), German Center for Cardiovascular Research (DZHK), Berlin Partner Site (M. Endres), and German Center for Neurodegenerative Diseases (DZNE), Berlin Partner Site (M. Endres), Charité-Universitätsmedizin Berlin, Germany; Berliner Feuerwehr, Germany (S.K.); and Berlin Institute of Health, Germany (M. Endres)
| | - Jochen B Fiebach
- From Klinik und Hochschulambulanz für Neurologie (A.K., C.H.N., H.E., J.B.F., F.G., M.R., J.F.S., K.V., C.W., J.E.W., M.W., B.W., K.Z., M. Endres, M. Ebinger, H.J.A.), Center for Stroke Research Berlin (A.K., C.H.N., J.B.F., M.R., K.V., U.G., M. Endres, M. Ebinger, H.J.A.), German Center for Cardiovascular Research (DZHK), Berlin Partner Site (M. Endres), and German Center for Neurodegenerative Diseases (DZNE), Berlin Partner Site (M. Endres), Charité-Universitätsmedizin Berlin, Germany; Berliner Feuerwehr, Germany (S.K.); and Berlin Institute of Health, Germany (M. Endres)
| | - Frederik Geisler
- From Klinik und Hochschulambulanz für Neurologie (A.K., C.H.N., H.E., J.B.F., F.G., M.R., J.F.S., K.V., C.W., J.E.W., M.W., B.W., K.Z., M. Endres, M. Ebinger, H.J.A.), Center for Stroke Research Berlin (A.K., C.H.N., J.B.F., M.R., K.V., U.G., M. Endres, M. Ebinger, H.J.A.), German Center for Cardiovascular Research (DZHK), Berlin Partner Site (M. Endres), and German Center for Neurodegenerative Diseases (DZNE), Berlin Partner Site (M. Endres), Charité-Universitätsmedizin Berlin, Germany; Berliner Feuerwehr, Germany (S.K.); and Berlin Institute of Health, Germany (M. Endres)
| | - Michal Rozanski
- From Klinik und Hochschulambulanz für Neurologie (A.K., C.H.N., H.E., J.B.F., F.G., M.R., J.F.S., K.V., C.W., J.E.W., M.W., B.W., K.Z., M. Endres, M. Ebinger, H.J.A.), Center for Stroke Research Berlin (A.K., C.H.N., J.B.F., M.R., K.V., U.G., M. Endres, M. Ebinger, H.J.A.), German Center for Cardiovascular Research (DZHK), Berlin Partner Site (M. Endres), and German Center for Neurodegenerative Diseases (DZNE), Berlin Partner Site (M. Endres), Charité-Universitätsmedizin Berlin, Germany; Berliner Feuerwehr, Germany (S.K.); and Berlin Institute of Health, Germany (M. Endres)
| | - Jan F Scheitz
- From Klinik und Hochschulambulanz für Neurologie (A.K., C.H.N., H.E., J.B.F., F.G., M.R., J.F.S., K.V., C.W., J.E.W., M.W., B.W., K.Z., M. Endres, M. Ebinger, H.J.A.), Center for Stroke Research Berlin (A.K., C.H.N., J.B.F., M.R., K.V., U.G., M. Endres, M. Ebinger, H.J.A.), German Center for Cardiovascular Research (DZHK), Berlin Partner Site (M. Endres), and German Center for Neurodegenerative Diseases (DZNE), Berlin Partner Site (M. Endres), Charité-Universitätsmedizin Berlin, Germany; Berliner Feuerwehr, Germany (S.K.); and Berlin Institute of Health, Germany (M. Endres)
| | - Kersten Villringer
- From Klinik und Hochschulambulanz für Neurologie (A.K., C.H.N., H.E., J.B.F., F.G., M.R., J.F.S., K.V., C.W., J.E.W., M.W., B.W., K.Z., M. Endres, M. Ebinger, H.J.A.), Center for Stroke Research Berlin (A.K., C.H.N., J.B.F., M.R., K.V., U.G., M. Endres, M. Ebinger, H.J.A.), German Center for Cardiovascular Research (DZHK), Berlin Partner Site (M. Endres), and German Center for Neurodegenerative Diseases (DZNE), Berlin Partner Site (M. Endres), Charité-Universitätsmedizin Berlin, Germany; Berliner Feuerwehr, Germany (S.K.); and Berlin Institute of Health, Germany (M. Endres)
| | - Carolin Waldschmidt
- From Klinik und Hochschulambulanz für Neurologie (A.K., C.H.N., H.E., J.B.F., F.G., M.R., J.F.S., K.V., C.W., J.E.W., M.W., B.W., K.Z., M. Endres, M. Ebinger, H.J.A.), Center for Stroke Research Berlin (A.K., C.H.N., J.B.F., M.R., K.V., U.G., M. Endres, M. Ebinger, H.J.A.), German Center for Cardiovascular Research (DZHK), Berlin Partner Site (M. Endres), and German Center for Neurodegenerative Diseases (DZNE), Berlin Partner Site (M. Endres), Charité-Universitätsmedizin Berlin, Germany; Berliner Feuerwehr, Germany (S.K.); and Berlin Institute of Health, Germany (M. Endres)
| | - Joachim E Weber
- From Klinik und Hochschulambulanz für Neurologie (A.K., C.H.N., H.E., J.B.F., F.G., M.R., J.F.S., K.V., C.W., J.E.W., M.W., B.W., K.Z., M. Endres, M. Ebinger, H.J.A.), Center for Stroke Research Berlin (A.K., C.H.N., J.B.F., M.R., K.V., U.G., M. Endres, M. Ebinger, H.J.A.), German Center for Cardiovascular Research (DZHK), Berlin Partner Site (M. Endres), and German Center for Neurodegenerative Diseases (DZNE), Berlin Partner Site (M. Endres), Charité-Universitätsmedizin Berlin, Germany; Berliner Feuerwehr, Germany (S.K.); and Berlin Institute of Health, Germany (M. Endres)
| | - Matthias Wendt
- From Klinik und Hochschulambulanz für Neurologie (A.K., C.H.N., H.E., J.B.F., F.G., M.R., J.F.S., K.V., C.W., J.E.W., M.W., B.W., K.Z., M. Endres, M. Ebinger, H.J.A.), Center for Stroke Research Berlin (A.K., C.H.N., J.B.F., M.R., K.V., U.G., M. Endres, M. Ebinger, H.J.A.), German Center for Cardiovascular Research (DZHK), Berlin Partner Site (M. Endres), and German Center for Neurodegenerative Diseases (DZNE), Berlin Partner Site (M. Endres), Charité-Universitätsmedizin Berlin, Germany; Berliner Feuerwehr, Germany (S.K.); and Berlin Institute of Health, Germany (M. Endres)
| | - Benjamin Winter
- From Klinik und Hochschulambulanz für Neurologie (A.K., C.H.N., H.E., J.B.F., F.G., M.R., J.F.S., K.V., C.W., J.E.W., M.W., B.W., K.Z., M. Endres, M. Ebinger, H.J.A.), Center for Stroke Research Berlin (A.K., C.H.N., J.B.F., M.R., K.V., U.G., M. Endres, M. Ebinger, H.J.A.), German Center for Cardiovascular Research (DZHK), Berlin Partner Site (M. Endres), and German Center for Neurodegenerative Diseases (DZNE), Berlin Partner Site (M. Endres), Charité-Universitätsmedizin Berlin, Germany; Berliner Feuerwehr, Germany (S.K.); and Berlin Institute of Health, Germany (M. Endres)
| | - Katja Zieschang
- From Klinik und Hochschulambulanz für Neurologie (A.K., C.H.N., H.E., J.B.F., F.G., M.R., J.F.S., K.V., C.W., J.E.W., M.W., B.W., K.Z., M. Endres, M. Ebinger, H.J.A.), Center for Stroke Research Berlin (A.K., C.H.N., J.B.F., M.R., K.V., U.G., M. Endres, M. Ebinger, H.J.A.), German Center for Cardiovascular Research (DZHK), Berlin Partner Site (M. Endres), and German Center for Neurodegenerative Diseases (DZNE), Berlin Partner Site (M. Endres), Charité-Universitätsmedizin Berlin, Germany; Berliner Feuerwehr, Germany (S.K.); and Berlin Institute of Health, Germany (M. Endres)
| | - Ulrike Grittner
- From Klinik und Hochschulambulanz für Neurologie (A.K., C.H.N., H.E., J.B.F., F.G., M.R., J.F.S., K.V., C.W., J.E.W., M.W., B.W., K.Z., M. Endres, M. Ebinger, H.J.A.), Center for Stroke Research Berlin (A.K., C.H.N., J.B.F., M.R., K.V., U.G., M. Endres, M. Ebinger, H.J.A.), German Center for Cardiovascular Research (DZHK), Berlin Partner Site (M. Endres), and German Center for Neurodegenerative Diseases (DZNE), Berlin Partner Site (M. Endres), Charité-Universitätsmedizin Berlin, Germany; Berliner Feuerwehr, Germany (S.K.); and Berlin Institute of Health, Germany (M. Endres)
| | - Sabina Kaczmarek
- From Klinik und Hochschulambulanz für Neurologie (A.K., C.H.N., H.E., J.B.F., F.G., M.R., J.F.S., K.V., C.W., J.E.W., M.W., B.W., K.Z., M. Endres, M. Ebinger, H.J.A.), Center for Stroke Research Berlin (A.K., C.H.N., J.B.F., M.R., K.V., U.G., M. Endres, M. Ebinger, H.J.A.), German Center for Cardiovascular Research (DZHK), Berlin Partner Site (M. Endres), and German Center for Neurodegenerative Diseases (DZNE), Berlin Partner Site (M. Endres), Charité-Universitätsmedizin Berlin, Germany; Berliner Feuerwehr, Germany (S.K.); and Berlin Institute of Health, Germany (M. Endres)
| | - Matthias Endres
- From Klinik und Hochschulambulanz für Neurologie (A.K., C.H.N., H.E., J.B.F., F.G., M.R., J.F.S., K.V., C.W., J.E.W., M.W., B.W., K.Z., M. Endres, M. Ebinger, H.J.A.), Center for Stroke Research Berlin (A.K., C.H.N., J.B.F., M.R., K.V., U.G., M. Endres, M. Ebinger, H.J.A.), German Center for Cardiovascular Research (DZHK), Berlin Partner Site (M. Endres), and German Center for Neurodegenerative Diseases (DZNE), Berlin Partner Site (M. Endres), Charité-Universitätsmedizin Berlin, Germany; Berliner Feuerwehr, Germany (S.K.); and Berlin Institute of Health, Germany (M. Endres)
| | - Martin Ebinger
- From Klinik und Hochschulambulanz für Neurologie (A.K., C.H.N., H.E., J.B.F., F.G., M.R., J.F.S., K.V., C.W., J.E.W., M.W., B.W., K.Z., M. Endres, M. Ebinger, H.J.A.), Center for Stroke Research Berlin (A.K., C.H.N., J.B.F., M.R., K.V., U.G., M. Endres, M. Ebinger, H.J.A.), German Center for Cardiovascular Research (DZHK), Berlin Partner Site (M. Endres), and German Center for Neurodegenerative Diseases (DZNE), Berlin Partner Site (M. Endres), Charité-Universitätsmedizin Berlin, Germany; Berliner Feuerwehr, Germany (S.K.); and Berlin Institute of Health, Germany (M. Endres)
| | - Heinrich J Audebert
- From Klinik und Hochschulambulanz für Neurologie (A.K., C.H.N., H.E., J.B.F., F.G., M.R., J.F.S., K.V., C.W., J.E.W., M.W., B.W., K.Z., M. Endres, M. Ebinger, H.J.A.), Center for Stroke Research Berlin (A.K., C.H.N., J.B.F., M.R., K.V., U.G., M. Endres, M. Ebinger, H.J.A.), German Center for Cardiovascular Research (DZHK), Berlin Partner Site (M. Endres), and German Center for Neurodegenerative Diseases (DZNE), Berlin Partner Site (M. Endres), Charité-Universitätsmedizin Berlin, Germany; Berliner Feuerwehr, Germany (S.K.); and Berlin Institute of Health, Germany (M. Endres).
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Dietzel J, Piper SK, Ruschmann R, Wollboldt C, Usnich T, Hellwig S, Galinovic I, Audebert HJ, Endres M, Villringer K, Fiebach JB, Haeusler KG. Impact of pre-admission oral anticoagulation on ischaemic stroke volume, lesion pattern, and frequency of intracranial arterial occlusion in patients with atrial fibrillation. Europace 2018; 20:1758-1765. [PMID: 29165559 DOI: 10.1093/europace/eux333] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 07/25/2017] [Accepted: 10/04/2017] [Indexed: 11/14/2022] Open
Abstract
Aims Therapeutic oral anticoagulation on hospital admission reduces morbidity and mortality after acute ischaemic stroke in patients with atrial fibrillation (AF). The underlying mechanism is not fully understood. In order to assess the impact of INR-level on admission on stroke volume, lesion pattern and the frequency of intracranial arterial occlusion, we analysed serial MRI measurements in AF patients suffering acute ischaemic stroke. Methods and results This subgroup analysis of the prospective '1000Plus' study included patients with acute ischaemic stroke and known AF or a first episode of AF in hospital. All patients underwent serial brain magnetic resonance imaging. Stroke patients were categorized as follows: Group1, phenprocoumon intake, international normalized ratio (INR) ≥1.7 on admission, no thrombolysis; Group2, INR < 1.7 on admission, thrombolysis; and Group3, INR < 1.7, no thrombolysis. In 98 AF patients {77 ± 9 years, 60% male; median National Institute of Health Stroke Scale [NIHSS] score on admission 5 (interquartile range [IQR] 2-8)} with known AF before admission, territorial infarction was less often found in Group 1 (n = 20) compared with Group 2 + 3 (20% vs. 47%, P = 0.022). Arterial occlusion rate on admission differed among groups (30%, 75%, and 35%, respectively, P = 0.004) but not between Group 1 vs. Group 2 + 3 (30% vs. 45%, P = 0.31). Median FLAIR volume on Days 5-7 was lower in Group1 compared with Group 2 (n = 20) [3.2 cm3 (IQR 1.1-11.3) vs. 18.6 cm3 (IQR 8.2-49.4); P = 0.009] but not compared with Group 2 + 3 [7.8 cm3 (IQR 1.6-25.9); P = 0.23]. An INR ≥ 1.7 on admission was not associated with smaller stroke volume in multivariable regression analysis. Adding 57 patients with a first AF episode during the in-hospital stay, similar results were observed in 155 AF patients. Conclusion In this AF cohort, an INR ≥ 1.7 at stroke onset affects lesion pattern but does not affect significantly lower stroke volume and the frequency of arterial occlusion on admission.
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Affiliation(s)
- Joanna Dietzel
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin, Germany
| | - Sophie K Piper
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin, Germany
- Institute of Biostatistics and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Rudi Ruschmann
- Department of Cardiology, Klinik Husum, Erichsenweg 16, Husum, Germany
| | - Christian Wollboldt
- Department of Neurology, Charité-Universitätsmedizin Hindenburgdamm 30, Berlin, Germany
| | - Tatiana Usnich
- Department of Neurology, Charité-Universitätsmedizin Hindenburgdamm 30, Berlin, Germany
| | - Simon Hellwig
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Hindenburgdamm 30, Berlin, Germany
| | - Ivana Galinovic
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin, Germany
| | - Heinrich J Audebert
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Hindenburgdamm 30, Berlin, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Hindenburgdamm 30, Berlin, Germany
- German Center for Neurodegenerative Disease (DZNE), Partner Site Berlin, Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin, Germany
| | - Karl Georg Haeusler
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Hindenburgdamm 30, Berlin, Germany
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29
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Rillig A, Bellmann B, Skurk C, Leistner DM, Haeusler KG, Lin T, Geran R, Koehler L, Guttmann S, Steffens D, Kasner M, Jakob P, Tscholl V, Roser M, Lenz K, Villringer K, Park JW, Fiebach JB, Landmesser U. Left atrial appendage angiography is associated with the incidence and number of magnetic resonance imaging-detected brain lesions after percutaneous catheter-based left atrial appendage closure. Heart Rhythm 2018; 15:3-8. [PMID: 29304951 DOI: 10.1016/j.hrthm.2017.11.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Percutaneous catheter-based left atrial appendage closure (LAAC) is a procedure being increasingly performed in patients with atrial fibrillation and high bleeding risk. OBJECTIVE The purpose of this study was to evaluate the incidence of magnetic resonance imaging (MRI)-detected acute brain lesions (ABLs) as well as potential changes in neurocognitive function after percutaneous LAAC in patients with atrial fibrillation. METHODS Brain MRI at 3 T was performed within 24 hours before and after LAAC along with neurologic (National Institutes of Health Stroke Scale [NIHSS] score) and cognitive (Montreal Cognitive Assessment [MoCA] test) assessment. Acquired MRI sequences included high-resolution diffusion-weighted imaging as well as fluid-attenuated inversion recovery. RESULTS Successful device implantation was achieved in all 23 patients (age 74.1 ± 10.5 years; 16 male) using the Amulet (n = 18), Occlutech (n = 3), or LAmbre (n = 2) device. Thirty-seven ABLs were detected by MRI in 12 of 23 patients (52%) after LAAC. The number of periprocedural LAA angiographies was significantly higher in patients with ABL than in those without ABL (1.67 ± 0.65 vs 1.18 ± 0.41; P = .048) and was associated with a higher number of ABL (ρ = 0.615; P = .033). Compared to pre-LAAC assessment, post-LAAC MoCA and NIHSS scores revealed similar results. After LAAC, MoCA test (mean 24.1 ± 4.6 vs 23.2 ± 4.6; P = .09) and NIHSS score (mean 1.0 ± 1.7 vs 1.2 ± 1.8; P = .1) were similar between patients with and those without ABL, respectively. CONCLUSION MRI-detected ABLs are commonly observed after percutaneous LAAC. The number of LAA angiographies is significantly associated with the number of ABLs; however, the clinical implications of ABL have yet to be determined.
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Affiliation(s)
- Andreas Rillig
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany.
| | - Barbara Bellmann
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Carsten Skurk
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - David Manuel Leistner
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Karl Georg Haeusler
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany; Department of Neurology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Tina Lin
- Heartcare Victoria, Melbourne, Australia
| | - Rohat Geran
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Luzie Koehler
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Selma Guttmann
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Daniel Steffens
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Mario Kasner
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Philipp Jakob
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Verena Tscholl
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Mattias Roser
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Klaus Lenz
- Institute for Biometry and Clinical Epidemiology, Charité-Universitätsmedizin, Berlin, Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Jai-Wun Park
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany; Berlin Institute of Health, Berlin, Germany; Deutsches Zentrum für Herz- und Kreislaufforschung (DZHK), Partner Site Berlin, Germany
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30
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Thomalla G, Simonsen CZ, Boutitie F, Andersen G, Berthezene Y, Cheng B, Cheripelli B, Cho TH, Fazekas F, Fiehler J, Ford I, Galinovic I, Gellissen S, Golsari A, Gregori J, Günther M, Guibernau J, Häusler KG, Hennerici M, Kemmling A, Marstrand J, Modrau B, Neeb L, Perez de la Ossa N, Puig J, Ringleb P, Roy P, Scheel E, Schonewille W, Serena J, Sunaert S, Villringer K, Wouters A, Thijs V, Ebinger M, Endres M, Fiebach JB, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Gerloff C. MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset. N Engl J Med 2018; 379:611-622. [PMID: 29766770 DOI: 10.1056/nejmoa1804355] [Citation(s) in RCA: 718] [Impact Index Per Article: 119.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Under current guidelines, intravenous thrombolysis is used to treat acute stroke only if it can be ascertained that the time since the onset of symptoms was less than 4.5 hours. We sought to determine whether patients with stroke with an unknown time of onset and features suggesting recent cerebral infarction on magnetic resonance imaging (MRI) would benefit from thrombolysis with the use of intravenous alteplase. METHODS In a multicenter trial, we randomly assigned patients who had an unknown time of onset of stroke to receive either intravenous alteplase or placebo. All the patients had an ischemic lesion that was visible on MRI diffusion-weighted imaging but no parenchymal hyperintensity on fluid-attenuated inversion recovery (FLAIR), which indicated that the stroke had occurred approximately within the previous 4.5 hours. We excluded patients for whom thrombectomy was planned. The primary end point was favorable outcome, as defined by a score of 0 or 1 on the modified Rankin scale of neurologic disability (which ranges from 0 [no symptoms] to 6 [death]) at 90 days. A secondary outcome was the likelihood that alteplase would lead to lower ordinal scores on the modified Rankin scale than would placebo (shift analysis). RESULTS The trial was stopped early owing to cessation of funding after the enrollment of 503 of an anticipated 800 patients. Of these patients, 254 were randomly assigned to receive alteplase and 249 to receive placebo. A favorable outcome at 90 days was reported in 131 of 246 patients (53.3%) in the alteplase group and in 102 of 244 patients (41.8%) in the placebo group (adjusted odds ratio, 1.61; 95% confidence interval [CI], 1.09 to 2.36; P=0.02). The median score on the modified Rankin scale at 90 days was 1 in the alteplase group and 2 in the placebo group (adjusted common odds ratio, 1.62; 95% CI, 1.17 to 2.23; P=0.003). There were 10 deaths (4.1%) in the alteplase group and 3 (1.2%) in the placebo group (odds ratio, 3.38; 95% CI, 0.92 to 12.52; P=0.07). The rate of symptomatic intracranial hemorrhage was 2.0% in the alteplase group and 0.4% in the placebo group (odds ratio, 4.95; 95% CI, 0.57 to 42.87; P=0.15). CONCLUSIONS In patients with acute stroke with an unknown time of onset, intravenous alteplase guided by a mismatch between diffusion-weighted imaging and FLAIR in the region of ischemia resulted in a significantly better functional outcome and numerically more intracranial hemorrhages than placebo at 90 days. (Funded by the European Union Seventh Framework Program; WAKE-UP ClinicalTrials.gov number, NCT01525290; and EudraCT number, 2011-005906-32 .).
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Affiliation(s)
- Götz Thomalla
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Claus Z Simonsen
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Florent Boutitie
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Grethe Andersen
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Yves Berthezene
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Bastian Cheng
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Bharath Cheripelli
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Tae-Hee Cho
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Franz Fazekas
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Jens Fiehler
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Ian Ford
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Ivana Galinovic
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Susanne Gellissen
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Amir Golsari
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Johannes Gregori
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Matthias Günther
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Jorge Guibernau
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Karl Georg Häusler
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Michael Hennerici
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - André Kemmling
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Jacob Marstrand
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Boris Modrau
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Lars Neeb
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Natalia Perez de la Ossa
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Josep Puig
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Peter Ringleb
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Pascal Roy
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Enno Scheel
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Wouter Schonewille
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Joaquin Serena
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Stefan Sunaert
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Kersten Villringer
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Anke Wouters
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Vincent Thijs
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Martin Ebinger
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Matthias Endres
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Jochen B Fiebach
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Robin Lemmens
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Keith W Muir
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Norbert Nighoghossian
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Salvador Pedraza
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
| | - Christian Gerloff
- From Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf (G.T., B. Cheng, S.G., A.G., C.G.), the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf (J.F.), and ZytoService Deutschland (E.S.), Hamburg, Universitätsklinik für Neurologie, Medizinische Universität Graz, Graz (F.F.), Centrum für Schlaganfallforschung Berlin (I.G., K.G.H., K.V., M. Ebinger, M. Endres, J.B.F.) and Klinik und Hochschulambulanz für Neurologie (K.G.H., L.N., M. Endres), Charité-Universitätsmedizin Berlin, and Neurologie der Rehaklinik Medical Park Humboldtmühle (M. Ebinger), Berlin, Mediri (J. Gregori, M.G.), the Department of Neurology, Medical Faculty Mannheim, University of Heidelberg (M.H.), and Neurologische Klinik, Universitätsklinikum Heidelberg (P. Ringleb), Heidelberg, Fraunhofer MEVIS and University of Bremen, Bremen (M.G.), and Institut für Neuroradiologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck (A.K.) - all in Germany; the Department of Neurology, Aarhus University Hospital, Aarhus (C.Z.S., G.A.), the Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen (J.M.), and Department of Neurology, Stroke Unit, Aalborg University Hospital, Aalborg (B.M.) - all in Denmark; Hospices Civils de Lyon, Service de Biostatistique (F.B., P. Roy), the Neuroradiology Department, Neurological Hospital, University Lyon (Y.B.), and the Department of Stroke Medicine, Université Claude Bernard Lyon 1, and Hospices Civils de Lyon (T.-H.C., N.N.), Lyon, and Université Lyon 1 and Centre National de la Recherche Scientifique, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne (F.B., P. Roy) - all in France; the Institute of Neuroscience and Psychology (B. Cheripelli, K.W.M.) and the Robertson Centre for Biostatistics (I.F.), University of Glasgow, Glasgow, United Kingdom (I.F.); Fundació Salut Empordà Hospital, Figueres (J. Guibernau), Stroke Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Barcelona (N.P.O.), and the Department of Radiology (J.P., S.P.) and the Stroke Unit (J.S.), Hospital Universitari Doctor Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona - all in Spain; the Department of Neurology, St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht (W.S.) - both in the Netherlands; the Department of Imaging and Pathology, University of Leuven (S.S.), the Department of Neurology, University Hospitals Leuven (A.W., R.L.), KU Leuven-University of Leuven, Department of Neurosciences, Experimental Neurology (A.W., R.L.), and the VIB-KU Leuven Center for Brain and Disease Research, Laboratory of Neurobiology (A.W., R.L.), Leuven, Belgium; and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (V.T.)
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Bellmann B, Rillig A, Skurk C, Leistner DM, Haeusler KG, Lin T, Geran R, Koehler L, Guttmann S, Tscholl V, Roser M, Lenz K, Villringer K, Wun Park J, Fiebach JB, Landmesser U. Long-term follow up of 3 T MRI-detected brain lesions after percutaneous catheter-based left atrial appendage closure. Catheter Cardiovasc Interv 2018; 92:327-333. [PMID: 29737618 DOI: 10.1002/ccd.27611] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/05/2018] [Accepted: 03/02/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND Left atrial appendage closure (LAAC) for stroke prevention is an increasingly performed intervention. AIMS This prospective study aims to evaluate the incidence of long-term magnetic resonance imaging (MRI)-detected brain lesions as well as potential changes of neurocognitive function after percutaneous LAAC. METHODS Brain MRI at 3 T was performed within 24 hr before and after LAAC. A follow-up MRI was carried out after three months. Neuro-cognitive examination using the National Institutes of Health Stroke Scale (NIHSS) score and the Montreal Cognitive Assessment (MoCA) Test was performed. RESULTS Successful device implantation was achieved in all 25 patients (age 74.6 ± 10.2 years, male = 17) using the Amulet (n = 20), Occlutech (n = 3), or a Lambre (n = 2) device. In 12/25 (48%) patients, acute brain lesions (ABL) were detected after LAAC. A three-month follow-up MRI was performed in seven patients, and no new ABLs were seen. In 5/7 (71%) patients, there were no residual changes from the ABLs detectable. However, the FLAIR sequence was still positive in two patients. After LAAC, there were no significant differences in the MoCA-test (mean 24.3 ± 4.5 vs. 23.5 ± 4.5; P = 0.1) and the NIHSS-score (mean 0.9 ± 1.6 vs. 1.2 ± 1.8; P = 0.1). This was the same at the three-month follow-up (MoCA-test 23.5 ± 4.5 vs. 23.8 ± 2.7; P = 0.3; NIHSS-score 1.2 ± 1.8 vs. 1.0 ± 0.8; P = 0.4). CONCLUSION While new MRI-detected brain lesions are commonly observed after percutaneous LAAC, ABLs were no longer detectable in 71% of the patients at the three-month follow-up. There were no significant changes in neurocognitive function after LAAC and at the three-month follow-up.
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Affiliation(s)
- Barbara Bellmann
- Department of Cardiology, Charité - Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Andreas Rillig
- Department of Cardiology, Charité - Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Carsten Skurk
- Department of Cardiology, Charité - Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - David Manuel Leistner
- Department of Cardiology, Charité - Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Karl Georg Haeusler
- Charité - Universitätsmedizin Berlin, University Hospital, Center for Stroke Research Berlin, Berlin, Germany
- Department of Neurology, Charité - Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Tina Lin
- HeartCare Victoria, Melbourne, Australia
| | - Rohat Geran
- Charité - Universitätsmedizin Berlin, University Hospital, Center for Stroke Research Berlin, Berlin, Germany
| | - Luzie Koehler
- Charité - Universitätsmedizin Berlin, University Hospital, Center for Stroke Research Berlin, Berlin, Germany
| | - Selma Guttmann
- Department of Cardiology, Charité - Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Verena Tscholl
- Department of Cardiology, Charité - Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Mattias Roser
- Department of Cardiology, Charité - Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Klaus Lenz
- Institute for Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Kersten Villringer
- Charité - Universitätsmedizin Berlin, University Hospital, Center for Stroke Research Berlin, Berlin, Germany
| | - Jai- Wun Park
- Department of Cardiology, Charité - Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Jochen B Fiebach
- Charité - Universitätsmedizin Berlin, University Hospital, Center for Stroke Research Berlin, Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology, Charité - Universitätsmedizin Berlin, University Hospital, Berlin, Germany
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Rackoll T, Nave A, Grittner U, Mousa H, Villringer K, Ebinger M, Flöel A. P60. Direct and long term influence of cardiovascular training on cognition in subacute stroke patients. Clin Neurophysiol 2018. [DOI: 10.1016/j.clinph.2018.04.696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Galinovic I, Dicken V, Heitz J, Klein J, Puig J, Guibernau J, Kemmling A, Gellissen S, Villringer K, Neeb L, Gregori J, Weiler F, Pedraza S, Thomalla G, Fiehler J, Gerloff C, Fiebach JB. Homogeneous application of imaging criteria in a multicenter trial supported by investigator training: A report from the WAKE-UP study. Eur J Radiol 2018; 104:115-119. [DOI: 10.1016/j.ejrad.2018.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/27/2018] [Accepted: 05/10/2018] [Indexed: 10/16/2022]
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Nolte CH, Ebinger M, Scheitz JF, Kunz A, Erdur H, Geisler F, Braemswig TB, Rozanski M, Weber JE, Wendt M, Zieschang K, Fiebach JB, Villringer K, Grittner U, Kaczmarek S, Endres M, Audebert HJ. Effects of Prehospital Thrombolysis in Stroke Patients With Prestroke Dependency. Stroke 2018; 49:646-651. [DOI: 10.1161/strokeaha.117.019060] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 12/13/2017] [Accepted: 01/03/2018] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Data on effects of intravenous thrombolysis on outcome of patients with ischemic stroke who are dependent on assistance in activities of daily living prestroke are scarce. Recent registry based analyses in activities of daily –independent patients suggest that earlier start of intravenous thrombolysis in the prehospital setting leads to better outcomes when compared with the treatment start in hospital. We evaluated whether these observations can be corroborated in patients with prestroke dependency.
Methods—
This observational, retrospective analysis included all patients with acute ischemic stroke depending on assistance before stroke who received intravenous thrombolysis either on the Stroke Emergency Mobile (STEMO) or through conventional in-hospital care (CC) in a tertiary stroke center (Charité, Campus Benjamin Franklin, Berlin) during routine care. Prespecified outcomes were modified Rankin Scale scores of 0 to 3 and survival at 3 months, as well as symptomatic intracranial hemorrhage. Outcomes were adjusted in multivariable logistic regression.
Results—
Between February 2011 and March 2015, 122 of 427 patients (28%) treated on STEMO and 142 of 505 patients (28%) treated via CC needed assistance before stroke. Median onset-to-treatment times were 97 (interquartile range, 69–159; STEMO) and 135 (interquartile range, 98–184; CC;
P
<0.001) minutes. After 3 months, modified Rankin Scale scores of 0 to 3 was observed in 48 STEMO patients (39%) versus 35 CC patients (25%;
P
=0.01) and 86 (70%, STEMO) versus 85 (60%, CC) patients were alive (
P
=0.07). After adjustment, STEMO care was favorable with respect to modified Rankin Scale scores of 0 to 3 (odds ratio, 1.99; 95% confidence interval, 1.02–3.87;
P
=0.042) with a nonsignificant result for survival (odds ratio, 1.73; 95% confidence interval, 0.95–3.16;
P
=0.07). Symptomatic intracranial hemorrhage occurred in 5 STEMO versus 12 CC patients (4.2% versus 8.5%;
P
=0.167).
Conclusions—
The results of this study suggest that earlier, prehospital (as compared with in-hospital) start of intravenous thrombolysis in acute ischemic stroke may translate into better clinical outcome in patients with prestroke dependency.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT02358772.
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Affiliation(s)
- Christian H. Nolte
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Martin Ebinger
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Jan F. Scheitz
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Alexander Kunz
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Hebun Erdur
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Frederik Geisler
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Tim Bastian Braemswig
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Michal Rozanski
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Joachim E. Weber
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Matthias Wendt
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Katja Zieschang
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Jochen B. Fiebach
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Kersten Villringer
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Ulrike Grittner
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Sabina Kaczmarek
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Matthias Endres
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
| | - Heinrich J. Audebert
- From the Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Department of Neurology, Berlin Institute of Health, Berlin, Germany (C.H.N., M. Ebinger, J.F.S., A.K., H.E., F.G., T.B.B., M.R., J.E.W., M.W., K.Z., J.B.F., K.V., M. Endres, H.J.A.); Center for Stroke Research Berlin, Charité – Universitätsmedizin
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Villringer K, Florczak-Rzepka M, Grittner U, Brunecker P, Tepe H, Nolte CH, Fiebach JB. Characteristics associated with outcome in patients with first-ever posterior fossa stroke. Eur J Neurol 2018; 25:818-824. [PMID: 29431878 DOI: 10.1111/ene.13596] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 06/06/2017] [Accepted: 02/06/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Factors such as infarct volume, infarct location and symptom severity can considerably influence long-term outcome in posterior fossa strokes. The decision about therapy can sometimes be complicated by discrepancies between infarct volume and clinical severity. We aimed to evaluate imaging and clinical parameters possibly influencing long-term outcome in patients with first-ever posterior fossa stroke. METHODS Imaging was performed on a 3-T magnetic resonance imaging scanner. Sixty-one of 1795 patients from the observational 1000Plus and LOBI studies (NCT00715533 and NCT02077582, clinicaltrials.org) were enrolled, meeting the inclusion criteria of first-ever posterior fossa stroke and magnetic resonance imaging examination within 24 h after symptom onset. Infarcts were classified as belonging to a proximal, middle or distal territory location in the posterior fossa. Good outcome was defined as a modified Rankin scale score of ≤1 at 3 months. RESULTS The largest lesion volumes on diffusion-weighted imaging on day 0 and fluid attenuation inversion recovery (FLAIR) on day 6 were found in the middle territory location with a median volume of 0.4 mL on diffusion-weighted imaging and 1.0 mL on FLAIR on day 6 versus 0.1/0.3 mL in the proximal and 0.1/0.1 mL in the distal territory location of the posterior fossa, respectively. Parameters associated with poor outcome were older age (P = 0.005), higher National Institutes of Health Stroke Scale score on admission/discharge (P = 0.016; P = 0.001), larger lesion volumes on FLAIR on day 6 (P = 0.013) and dysphagia (P = 0.02). There was no significant association between infarct location and modified Rankin scale score on day 90. CONCLUSION Infarct volume and clinical severity, but not infarct location, were the main contributors to poor long-term outcome in first-ever posterior fossa strokes.
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Affiliation(s)
- K Villringer
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - M Florczak-Rzepka
- Department of Radiology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - U Grittner
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Biostatistics and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin
| | - P Brunecker
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - H Tepe
- Department of Radiology, Charité-Universitätsmedizin Berlin, Berlin
| | - C H Nolte
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - J B Fiebach
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Galinovic I, Kochova E, Khalil A, Villringer K, Piper SK, Fiebach JB. The ratio between cerebral blood flow and Tmax predicts the quality of collaterals in acute ischemic stroke. PLoS One 2018; 13:e0190811. [PMID: 29381701 PMCID: PMC5790218 DOI: 10.1371/journal.pone.0190811] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 12/20/2017] [Indexed: 11/18/2022] Open
Abstract
Background In acute ischemic stroke the status of collateral circulation is a critical factor in determining outcome. We propose a less invasive alternative to digital subtraction angiography for evaluating collaterals based on dynamic-susceptibility contrast magnetic resonance imaging. Methods Perfusion maps of Tmax and cerebral blood flow (CBF) were created for 35 patients with baseline occlusion of a major cerebral artery. Volumes of hypoperfusion were defined as having a Tmax delay of > 4 seconds (Tmax4s) and > 6 seconds (Tmax6s) and a CBF drop below 80% of healthy, contralateral tissue. For each patient a ratio between the volume of the CBF and the Tmax based perfusion deficit was calculated. Associations with collateral status and radiological outcome were assessed with the Mann-Whitney-U test, uni- and multivariable logistic regression analyses as well as area under the receiver-operator-characteristic (ROC) curve. Results The CBF/Tmax volume ratios were significantly associated with bad collateral status in crude logistic regression analysis as well as with adjustment for NIHSS at admission and baseline infarct volume (OR = 2.5 95% CI[1.2–5.4] p = 0.020 for CBF/Tmax 4s volume ratio and OR = 1.6 95% CI[1.0–2.6] p = 0.031 for CBF/Tmax6s volume ratio). Moreover, the ratios were significantly correlated to final infarct size (Spearman’s rho = 0.711 and 0.619, respectively for the CBF/Tmax4s volume ratio and CBF/Tmax6s volume ration, all p<0.001). The ratios also had a high area under the ROC curve of 0.93 95%CI[0.86–1.00]) and 0.90 95%CI[0.80–1.00]respectively for predicting poor radiological outcome. Conclusions In the setting of acute ischemic stroke the CBF/Tmax volume ratio can be used to differentiate between good and insufficient collateral circulation without the need for invasive procedures like conventional angiography.
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Affiliation(s)
- Ivana Galinovic
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
- * E-mail:
| | - Elena Kochova
- International Graduate Program Medical Neurosciences, Charité – University Medicine Berlin, Berlin, Germany
| | - Ahmed Khalil
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
- Berlin School of Mind and Brain, Humboldt-Universitaet zu Berlin, Berlin, Germany
- Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sophie K. Piper
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
- Institute of Medical Biometrics and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen B. Fiebach
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany
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Ganeshan R, Nave AH, Scheitz JF, Schindlbeck KA, Haeusler KG, Nolte CH, Villringer K, Fiebach JB. Assessment of thrombus length in acute ischemic stroke by post-contrast magnetic resonance angiography. J Neurointerv Surg 2017; 10:756-760. [PMID: 29151041 DOI: 10.1136/neurintsurg-2017-013454] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 09/16/2017] [Revised: 11/04/2017] [Accepted: 11/07/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Post-contrast magnetic resonance angiography (PC-MRA) enables visualization of vessel segments distal to an intra-arterial thrombus in acute ischemic stroke. We hypothesized that PC-MRA also allows clot length measurement in different intracranial vessels. METHODS Patients with MRI-confirmed ischemic stroke and intracranial artery occlusion within 24 hours of symptom onset were prospectively evaluated. PC-MRA was added to a standard stroke MRI protocol. Thrombus length was measured on thick slab maximum intensity projection images. Clinical outcome at hospital discharge was assessed by modified Rankin Scale (mRS). RESULTS Thirty-four patients (median age 72 years) presenting with a median National Institutes of Health Stroke Scale score of 11 and a median onset to imaging time of 116 min were included. PC-MRA enabled precise depiction of proximal and distal terminus of the thrombus in 31 patients (91%), whereas in three patients (9%) PC-MRA presented a partial occlusion. Median thrombus length in patients with complete occlusion was 9.9 mm. In patients with poor outcome (mRS ≥3) median thrombus length was significantly longer than in those with good outcome (mRS ≤2;P=0.011). CONCLUSIONS PC-MRA demonstrates intra-arterial thrombus length at different vessel occlusion sites. Longer thrombus length is associated with poor clinical outcome. CLINICAL TRIAL REGISTRATION NCT02077582; Results.
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Affiliation(s)
- Ramanan Ganeshan
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Alexander H Nave
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Jan F Scheitz
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Katharina A Schindlbeck
- Department of Neurology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Karl Georg Haeusler
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Christian H Nolte
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
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Krause T, Werner K, Fiebach JB, Villringer K, Piper SK, Haeusler KG, Endres M, Scheitz JF, Nolte CH. Stroke in right dorsal anterior insular cortex Is related to myocardial injury. Ann Neurol 2017; 81:502-511. [DOI: 10.1002/ana.24906] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 02/20/2017] [Accepted: 02/20/2017] [Indexed: 12/18/2022]
Affiliation(s)
- Thomas Krause
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin; Berlin Germany
- Charité-Universitätsmedizin Berlin, Department of Neurology; Berlin Germany
| | - Kathrin Werner
- Charité-Universitätsmedizin Berlin, Department of Neurology; Berlin Germany
| | - Jochen B. Fiebach
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin; Berlin Germany
| | - Kersten Villringer
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin; Berlin Germany
| | - Sophie K. Piper
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin; Berlin Germany
| | - Karl Georg Haeusler
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin; Berlin Germany
- Charité-Universitätsmedizin Berlin, Department of Neurology; Berlin Germany
| | - Matthias Endres
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin; Berlin Germany
- Charité-Universitätsmedizin Berlin, Department of Neurology; Berlin Germany
- German Center for Cardiovascular Research (DZHK); Berlin Germany
- German Center for Neurodegenerative Diseases (DZNE); Berlin Germany
- Berlin Institute of Health (BIH); Berlin Germany
| | - Jan F. Scheitz
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin; Berlin Germany
- Charité-Universitätsmedizin Berlin, Department of Neurology; Berlin Germany
| | - Christian H. Nolte
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin; Berlin Germany
- Charité-Universitätsmedizin Berlin, Department of Neurology; Berlin Germany
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Khalil AA, Ostwaldt AC, Nierhaus T, Ganeshan R, Audebert HJ, Villringer K, Villringer A, Fiebach JB. Relationship Between Changes in the Temporal Dynamics of the Blood-Oxygen-Level-Dependent Signal and Hypoperfusion in Acute Ischemic Stroke. Stroke 2017; 48:925-931. [DOI: 10.1161/strokeaha.116.015566] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 12/24/2016] [Accepted: 12/24/2017] [Indexed: 01/22/2023]
Abstract
Background and Purpose—
Changes in the blood-oxygen-level-dependent (BOLD) signal provide a noninvasive measure of blood flow, but a detailed comparison with established perfusion parameters in acute stroke is lacking. We investigated the relationship between BOLD signal temporal delay and dynamic susceptibility contrast magnetic resonance imaging (DSC-MRI) in stroke patients.
Methods—
In 30 patients with acute (<24 hours) ischemic stroke, we performed Pearson correlation and multiple linear regression between DSC-MRI parameters (time to maximum [Tmax], mean transit time, cerebral blood flow, and cerebral blood volume) and BOLD-based parameters (BOLD delay and coefficient of BOLD variation). Prediction of severe hypoperfusion (Tmax >6 seconds) was assessed using receiver–operator characteristic (ROC) analysis.
Results—
Correlation was highest between Tmax and BOLD delay (venous sinus reference; time shift range 7; median
r
=0.60; interquartile range=0.49–0.71). Coefficient of BOLD variation correlated with cerebral blood volume (median
r
= 0.37; interquartile range=0.24–0.51). Mean
R
2
for predicting BOLD delay by DSC-MRI was 0.54 (SD=0.2) and for predicting coefficient of BOLD variation was 0.37 (SD=0.17). BOLD delay (whole-brain reference, time shift range 3) had an area under the curve of 0.76 for predicting severe hypoperfusion (sensitivity=69.2%; specificity=80%), whereas BOLD delay (venous sinus reference, time shift range 3) had an area under the curve of 0.76 (sensitivity=67.3%; specificity=83.5%).
Conclusions—
BOLD delay is related to macrovascular delay and microvascular hypoperfusion, can identify severely hypoperfused tissue in acute stroke, and is a promising alternative to gadolinium contrast agent–based perfusion assessment in acute stroke.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00715533 and NCT02077582.
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Affiliation(s)
- Ahmed A. Khalil
- From the Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany (A.A.K., A.-C.O., R.G., H.J.A., K.V., J.B.F.); Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany (A.A.K., T.N., A.V.); Mind, Brain, Body Institute, Berlin School of Mind and Brain, Humboldt-University, Berlin, Germany (A.A.K., A.V.); and Center for Cognitive Neuroscience Berlin (CCNB), Department of Education and Psychology, Freie Universität Berlin, Germany (T
| | - Ann-Christin Ostwaldt
- From the Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany (A.A.K., A.-C.O., R.G., H.J.A., K.V., J.B.F.); Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany (A.A.K., T.N., A.V.); Mind, Brain, Body Institute, Berlin School of Mind and Brain, Humboldt-University, Berlin, Germany (A.A.K., A.V.); and Center for Cognitive Neuroscience Berlin (CCNB), Department of Education and Psychology, Freie Universität Berlin, Germany (T
| | - Till Nierhaus
- From the Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany (A.A.K., A.-C.O., R.G., H.J.A., K.V., J.B.F.); Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany (A.A.K., T.N., A.V.); Mind, Brain, Body Institute, Berlin School of Mind and Brain, Humboldt-University, Berlin, Germany (A.A.K., A.V.); and Center for Cognitive Neuroscience Berlin (CCNB), Department of Education and Psychology, Freie Universität Berlin, Germany (T
| | - Ramanan Ganeshan
- From the Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany (A.A.K., A.-C.O., R.G., H.J.A., K.V., J.B.F.); Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany (A.A.K., T.N., A.V.); Mind, Brain, Body Institute, Berlin School of Mind and Brain, Humboldt-University, Berlin, Germany (A.A.K., A.V.); and Center for Cognitive Neuroscience Berlin (CCNB), Department of Education and Psychology, Freie Universität Berlin, Germany (T
| | - Heinrich J. Audebert
- From the Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany (A.A.K., A.-C.O., R.G., H.J.A., K.V., J.B.F.); Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany (A.A.K., T.N., A.V.); Mind, Brain, Body Institute, Berlin School of Mind and Brain, Humboldt-University, Berlin, Germany (A.A.K., A.V.); and Center for Cognitive Neuroscience Berlin (CCNB), Department of Education and Psychology, Freie Universität Berlin, Germany (T
| | - Kersten Villringer
- From the Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany (A.A.K., A.-C.O., R.G., H.J.A., K.V., J.B.F.); Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany (A.A.K., T.N., A.V.); Mind, Brain, Body Institute, Berlin School of Mind and Brain, Humboldt-University, Berlin, Germany (A.A.K., A.V.); and Center for Cognitive Neuroscience Berlin (CCNB), Department of Education and Psychology, Freie Universität Berlin, Germany (T
| | - Arno Villringer
- From the Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany (A.A.K., A.-C.O., R.G., H.J.A., K.V., J.B.F.); Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany (A.A.K., T.N., A.V.); Mind, Brain, Body Institute, Berlin School of Mind and Brain, Humboldt-University, Berlin, Germany (A.A.K., A.V.); and Center for Cognitive Neuroscience Berlin (CCNB), Department of Education and Psychology, Freie Universität Berlin, Germany (T
| | - Jochen B. Fiebach
- From the Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany (A.A.K., A.-C.O., R.G., H.J.A., K.V., J.B.F.); Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany (A.A.K., T.N., A.V.); Mind, Brain, Body Institute, Berlin School of Mind and Brain, Humboldt-University, Berlin, Germany (A.A.K., A.V.); and Center for Cognitive Neuroscience Berlin (CCNB), Department of Education and Psychology, Freie Universität Berlin, Germany (T
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Neeb L, Bastian K, Villringer K, Israel H, Reuter U, Fiebach JB. Structural Gray Matter Alterations in Chronic Migraine: Implications for a Progressive Disease? Headache 2016; 57:400-416. [DOI: 10.1111/head.13012] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 09/30/2016] [Accepted: 10/25/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Lars Neeb
- Department of Neurology; Charité Universitätsmedizin Berlin; Berlin Germany
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin; Berlin Germany
| | - Kaili Bastian
- Department of Neurology; Charité Universitätsmedizin Berlin; Berlin Germany
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin; Berlin Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin; Berlin Germany
| | - Heike Israel
- Department of Neurology; Charité Universitätsmedizin Berlin; Berlin Germany
| | - Uwe Reuter
- Department of Neurology; Charité Universitätsmedizin Berlin; Berlin Germany
| | - Jochen B. Fiebach
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin; Berlin Germany
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Villringer K, Sanz Cuesta BE, Ostwaldt AC, Grittner U, Brunecker P, Khalil AA, Schindler K, Eisenblätter O, Audebert H, Fiebach JB. DCE-MRI blood–brain barrier assessment in acute ischemic stroke. Neurology 2016; 88:433-440. [DOI: 10.1212/wnl.0000000000003566] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 10/31/2016] [Indexed: 02/05/2023] Open
Abstract
Objective:To quantitatively evaluate blood–brain barrier changes in ischemic stroke patients using dynamic contrast-enhanced (DCE) MRI.Methods:We examined 54 stroke patients (clinicaltrials.govNCT00715533, NCT02077582) in a 3T MRI scanner within 48 hours after symptom onset. Twenty-eight patients had a follow-up examination on day 5–7. DCE T1 mapping and Patlak analysis were employed to assess BBB permeability changes.Results:Median stroke Ktrans values (0.7 × 10−3 min−1 [interquartile range (IQR) 0.4–1.8] × 10−3 min−1) were more than 3-fold higher compared to median mirror Ktrans values (0.2 × 10−3 min−1, IQR 0.1–0.7 × 10−3 min−1, p < 0.001) and further increased at follow-up (n = 28, 2.3 × 10−3 min−1, IQR 0.8–4.6 × 10−3 min−1, p < 0.001). By contrast, mirror Ktrans values decreased over time with a clear interaction of timepoint and stroke/mirror side (p < 0.001). Median stroke Ktrans values were 2.5 times lower than in hemorrhagic transformed regions (0.7 vs 1.8 × 10−3 min−1; p = 0.055). There was no association between stroke Ktrans values and the delay from symptom onset to baseline examination, age, and presence of hyperintense acute reperfusion marker.Conclusion:BBB in acute stroke patients can be successfully assessed quantitatively. The decrease of BBB permeability in unaffected regions at follow-up may be an indicator of global BBB leakage even in vessel territories remote from the index infarct.
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Rozanski M, Waldschmidt C, Kunz A, Grittner U, Ebinger M, Wendt M, Winter B, Bollweg K, Villringer K, Fiebach JB, Audebert HJ. Glial Fibrillary Acidic Protein for Prehospital Diagnosis of Intracerebral Hemorrhage. Cerebrovasc Dis 2016; 43:76-81. [PMID: 27951536 DOI: 10.1159/000453460] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 11/14/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Both, acute ischemic stroke (AIS) and hemorrhage stroke (intracerebral hemorrhage, ICH) require early attention but different treatment strategies. Plasma glial fibrillary acidic protein (GFAP) levels were found to be elevated in ICH patients after they arrived in the hospital. Because treatment options differed, we sought to determine whether GFAP can be used to accurately differentiate between of AIS and ICH in the prehospital setting. METHODS We assessed acute stroke patients in the Stroke Emergency Mobile (STEMO). STEMO is a stroke ambulance staffed by a specialized team including a neurologist and equipped with a computed tomography scanner plus a point-of-care laboratory. The STEMO ambulance is integrated in the emergency medical system of Berlin, Germany. Following prehospital stroke diagnosis, blood was drawn and subsequently analysed using research assays from Roche diagnostics. The clinical accuracy of plasma GFAP was tested using a cut-off value of 0.29 ng/ml. RESULTS Blood samples of 74 patients were analysed. Twenty-five patients had ICH (mean age 69 ± 11 years, median National Institutes of Health Stroke Scale (NIHSS) 15) and 49 IS (mean age 75 ± 10 years, median NIHSS 6). Nine ICH (0 IS patients) had GFAP-levels above 0.29 ng/ml. The sensitivity and specificity of GFAP for differentiating between ICH and AIS were 36.0 and 100%. The sensitivity for ICH volume >15 ml was 61.5%. ICH patients without GFAP elevation had significantly smaller hemorrhage volumes (median 4.5 vs. 37.6 ml, p = 0.004) and were less likely to deteriorate (19 vs. 56%, p = 0.087). CONCLUSIONS GFAP levels >0.29 ng/ml were seen only in ICH, thus confirming the diagnosis of ICH during prehospital care. However, sensitivity is low particularly in smaller hemorrhages.
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Affiliation(s)
- Michal Rozanski
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin, Berlin, Germany
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43
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Hanne L, Brunecker P, Grittner U, Endres M, Villringer K, Fiebach JB, Ebinger M. Right insular infarction and mortality after ischaemic stroke. Eur J Neurol 2016; 24:67-72. [PMID: 27647694 DOI: 10.1111/ene.13131] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [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: 02/18/2016] [Accepted: 08/09/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Several studies have described an association between insular infarction and mortality. Large infarcts often include the insula and lesion size is associated with mortality. We hypothesized that there is an association between insular infarction and mortality independent of lesion volume. METHODS We included consecutive stroke patients between 1 September 2008 and 11 November 2012 from the 1000Plus database with an acute ischaemic lesion on diffusion-weighted imaging on day 1 and a completed 90-day follow-up. Insular infarct location was determined using the in-house software Stroke Lesion Atlas. In multiple Cox regression analysis (dependent variable: mortality), we adjusted for insular infarcts, age, lesion volume, history of atrial fibrillation, National Institutes of Health Stroke Scale and previous stroke. RESULTS We included 736 patients, of whom 168 had an insular infarction. Within a medium follow-up time of 107 days, cumulative survival was 90% in patients with insular infarction and 99% in patients without insular infarction (P < 0.001). Right insular infarction was independently associated with mortality (hazard ratio, 2.60; confidence interval, 1.3-5.4; P = 0.010). CONCLUSIONS In our study, right insular involvement was a prognostic marker for mortality after ischaemic stroke. A selection bias towards patients able to give informed consent warrants further studies.
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Affiliation(s)
- L Hanne
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin
| | - P Brunecker
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin
| | - U Grittner
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin
| | - M Endres
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin.,Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin.,German Center for Cardiovascular Research, Charité - Universitätsmedizin Berlin, DZHK, Berlin.,Excellence Cluster NeuroCure, Charité - Universtiätsmedizin Berlin, Berlin.,German Center for Neurodegenerative Diseases, Helmholtz Association of German Research Centres, DZNE, Berlin, Germany
| | - K Villringer
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin.,Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin
| | - J B Fiebach
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin.,Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin
| | - M Ebinger
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin.,Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin
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44
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Kunz A, Ebinger M, Geisler F, Rozanski M, Waldschmidt C, Weber JE, Wendt M, Winter B, Zieschang K, Fiebach JB, Villringer K, Erdur H, Scheitz JF, Tütüncü S, Bollweg K, Grittner U, Kaczmarek S, Endres M, Nolte CH, Audebert HJ. Functional outcomes of pre-hospital thrombolysis in a mobile stroke treatment unit compared with conventional care: an observational registry study. Lancet Neurol 2016; 15:1035-43. [DOI: 10.1016/s1474-4422(16)30129-6] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 05/02/2016] [Accepted: 06/08/2016] [Indexed: 11/30/2022]
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45
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Khalil AA, Hohenhaus M, Kunze C, Schmidt W, Brunecker P, Villringer K, Merboldt KD, Frahm J, Fiebach JB. Sensitivity of Diffusion-Weighted STEAM MRI and EPI-DWI to Infratentorial Ischemic Stroke. PLoS One 2016; 11:e0161416. [PMID: 27529697 PMCID: PMC4987060 DOI: 10.1371/journal.pone.0161416] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 08/01/2016] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To assess the sensitivity of stimulated echo acquisition mode diffusion weighted imaging (STEAM-DWI) to ischemic stroke in comparison to echo-planar imaging diffusion weighted imaging (EPI-DWI) in the infratentorial compartment. METHODS Fifty-seven patients presenting with clinical features of infratentorial stroke underwent STEAM-DWI, high-resolution EPI-DWI (HR-DWI, 2.5 mm slice thickness) and low-resolution EPI-DWI (LR-DWI, 5 mm slice thickness). Four readers assessed the presence of ischemic lesions and artifacts. Agreement between sequences and interobserver agreement on the presence of ischemia were calculated. The sensitivities of the DWI sequences were calculated in 45 patients with a confirmed diagnosis of infratentorial stroke. RESULTS Median time from symptom onset to imaging was 24 hours. STEAM-DWI agreed with LR-DWI in 89.5% of cases (kappa = 0.72, p<0.0001) and with HR-DWI in 89.5% of cases (kappa = 0.68, p<0.0001). STEAM-DWI showed fewer intraparenchymal artifacts (1/57) than HR-DWI (44/57) and LR-DWI (41/57). Ischemia was visible in 87% of cases for LR-DWI, 93% of cases for HR-DWI, and 89% of cases for STEAM-DWI. Interobserver agreement was good for STEAM-DWI (kappa = 0.62, p<0.0001). CONCLUSIONS Compared to the best currently available MR sequence for detecting ischemia (HR-DWI), STEAM-DWI shows fewer artifacts and a similar sensitivity to infratentorial stroke.
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Affiliation(s)
- Ahmed A. Khalil
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- NeuroCure Cluster of Excellence, Charité – Universitätsmedizin Berlin, Berlin, Germany
- International Graduate Program Medical Neurosciences, Charité – Universitätsmedizin Berlin, Berlin, Germany
- * E-mail:
| | - Marc Hohenhaus
- Klinik für Neurochirurgie, Universitätsklinikum Freiburg, Freiburg im Breisgau, Germany
| | - Claudia Kunze
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Wolf Schmidt
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Brunecker
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Klaus-Dietmar Merboldt
- Biomedizinische NMR Forschungs GmbH am Max-Planck-Institut für biophysikalische Chemie, Göttingen, Germany
| | - Jens Frahm
- Biomedizinische NMR Forschungs GmbH am Max-Planck-Institut für biophysikalische Chemie, Göttingen, Germany
| | - Jochen B. Fiebach
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
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Schaafs LA, Porter D, Audebert HJ, Fiebach JB, Villringer K. Optimising MR perfusion imaging: comparison of different software-based approaches in acute ischaemic stroke. Eur Radiol 2016; 26:4204-4212. [PMID: 26852218 DOI: 10.1007/s00330-016-4244-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [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: 09/24/2015] [Revised: 01/05/2016] [Accepted: 01/22/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Perfusion imaging (PI) is susceptible to confounding factors such as motion artefacts as well as delay and dispersion (D/D). We evaluate the influence of different post-processing algorithms on hypoperfusion assessment in PI analysis software packages to improve the clinical accuracy of stroke PI. METHODS Fifty patients with acute ischaemic stroke underwent MRI imaging in the first 24 h after onset. Diverging approaches to motion and D/D correction were applied. The calculated MTT and CBF perfusion maps were assessed by volumetry of lesions and tested for agreement with a standard approach and with the final lesion volume (FLV) on day 6 in patients with persisting vessel occlusion. RESULTS MTT map lesion volumes were significantly smaller throughout the software packages with correction of motion and D/D when compared to the commonly used approach with no correction (p = 0.001-0.022). Volumes on CBF maps did not differ significantly (p = 0.207-0.925). All packages with advanced post-processing algorithms showed a high level of agreement with FLV (ICC = 0.704-0.879). CONCLUSIONS Correction of D/D had a significant influence on estimated lesion volumes and leads to significantly smaller lesion volumes on MTT maps. This may improve patient selection. KEY POINTS • Assessment on hypoperfusion using advanced post-processing with correction for motion and D/D. • CBF appears to be more robust regarding differences in post-processing. • Tissue at risk is estimated more accurately by correcting software algorithms. • Advanced post-processing algorithms show a higher agreement with the final lesion volume.
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Affiliation(s)
- Lars-Arne Schaafs
- Department of Radiology, Charité-Universitätsmedizin, Hindenburgdamm 30, 12203, Berlin, Germany. .,Academic Neuroradiology, Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin, Berlin, Germany.
| | - David Porter
- Fraunhofer Institute for Medical Image Computing MEVIS, Bremen, Germany
| | - Heinrich J Audebert
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin, Berlin, Germany
| | - Jochen B Fiebach
- Academic Neuroradiology, Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin, Berlin, Germany
| | - Kersten Villringer
- Academic Neuroradiology, Department of Neurology and Center for Stroke Research, Charité-Universitätsmedizin, Berlin, Germany
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Kunz AK, Nolte C, Fiebach JB, Geisler F, Rozanski M, Scheitz JF, Villringer K, Waldschmidt C, Weber J, Wendt M, Winter B, Zieschang K, Grittner U, Kaczmarek S, Endres M, Ebinger M, Audebert HJ. Abstract 179: Functional Outcomes of Pre-hospital Stroke Thrombolysis Compared to Conventional Care; the Stroke Emergency Mobile (STEMO) Project. Stroke 2016. [DOI: 10.1161/str.47.suppl_1.179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Specialized CT-equipped stroke ambulances can shorten time to intravenous thrombolysis (IVT) in acute ischemic stroke. Although efficacy of thrombolytic treatment is known to be time-sensitive, effects of pre-hospital thrombolysis on functional outcomes have not yet been evaluated.
Methods:
We compared outcomes of all consecutive stroke patients who received thrombolysis during the same period cared for either by the Berlin Stroke Emergency Mobile (STEMO) or within conventional care (normal ambulance and in-hospital thrombolysis). Treatment and outcomes were documented in prospective registries. Patients who lived at home without assistance prior to their stroke were included. Primary outcome was modified Rankin Scale (mRS) ≤1 at 3 month. Secondary outcome was 3-month mortality. Outcomes were adjusted in multivariable regression for demographics, co-morbidities and stroke severity.
Results:
From Feb. 5, 2011 to Mar 5, 2015, 427 patients were treated on STEMO and 513 in conventional care. 303 (mean age: 71y, female gender: 48%, median NIHSS: 7) and 357 (mean age: 70y, female gender: 36%, median NIHSS: 7) of them had lived at home without assistance pre-stroke, respectively. Mean onset to treatment time was 34 minutes shorter in STEMO care (96±60 vs. 130±56min). The primary outcome of mRS≤1 was observed in 167 (55%) and 168 (47%) patients (p=0.039); 17 (6%) vs 38 (11%) had died (p=0.02), respectively. Adjusted odds ratios were favorable for STEMO care: OR 1.56 (95%-CI: 1.11-2.20; p=0.01) for mRS≤1 and OR 0.50 (95%-CI: 0.26-0.98; p=0.04) for death.
Conclusions:
The data suggest that earlier start of IVT by specialized prehospital stroke care leads to improved outcome.
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Affiliation(s)
- Alexander Kunz Kunz
- Neurology, Cntr for Stroke Rsch, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Nolte
- Neurology, Cntr for Stroke Rsch, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen B Fiebach
- Neuroradiology, Cntr for Stroke Rsch, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Frederik Geisler
- Neurology, Cntr for Stroke Rsch, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Michal Rozanski
- Neurology, Cntr for Stroke Rsch, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jan F Scheitz
- Neurology, Cntr for Stroke Rsch, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Kersten Villringer
- Neuroradiology, Cntr for Stroke Rsch, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Carolin Waldschmidt
- Neurology, Cntr for Stroke Rsch, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Joachim Weber
- Neurology, Cntr for Stroke Rsch, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Wendt
- Neurology, Cntr for Stroke Rsch, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Benjamin Winter
- Neurology, Cntr for Stroke Rsch, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Katja Zieschang
- Neurology, Cntr for Stroke Rsch, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrike Grittner
- Cntr for Stroke Rsch, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Matthias Endres
- Neurology, Cntr for Stroke Rsch, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Ebinger
- Neurology, Cntr for Stroke Rsch, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Heinrich J Audebert
- Neurology, Cntr for Stroke Rsch, Charité Universitätsmedizin Berlin, Berlin, Germany
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Villringer K, Khalil AA, Brunecker P, Nolte C, Villringer A, Fiebach J. Abstract TP47: Inverse PWI/DWI Mismatch is a Typical Feature of Acute Subcortical Ischemic Stroke. Stroke 2016. [DOI: 10.1161/str.47.suppl_1.tp47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction / Hypothesis:
Diffusion/perfusion mismatch (MM) is commonly used to assess tissue at risk in stroke patients. In small subcortical infarcts (SSI) the reverse pattern i.e. “inverse mismatch” (IM) has been shown [1]. We aimed to evaluate the frequency and characteristics of IM in a larger cohort using two different perfusion diffusion analysis approaches.
Methods:
We enrolled 129 patients with SSI within 24 hours of symptom onset (1000+ study, NCT00715533) comprising 44 infarcts of the thalamus, 9 located juxtacortically, 58 in the anterior choroidal artery, 18 in the lenticulostriate territory. Lesion volumes were assessed on DWI images using AnToNIa software. To evaluate perfusion maps a time-shift insensitive technique using a block-circulant matrix for deconvolution (oSVD) [2] was employed. Perfusion lesions were evaluated on MTT and Tmax (delay >2s and >6s) maps. A perfusion/diffusion ratio of 0.7 was used to define IM and 1.3 to define mismatch (MM).
Results:
Results are summarized in table1. For all types of data analysis and all time points, IM was the by far most frequent pathophysiological pattern. Obviously, IM was seen most often at Tmax>6s, but it was still clearly observed with looser thresholds (Tmax>2s, MTT). At earlier time of onset IM occurred less often, but was still the most frequent pattern (p=0.0026). No significant association between infarct location and perfusion pattern was observed
Conclusion:
IM is the most common pathophysiological constellation in SSI. We hypothesize that this is due to a lack of collateral circulation in these “endstream infarcts” and that the diffusion changes in areas without perfusion deficit reflect cytotoxic mechanisms.
1. Doege CA et al. AJNR 2003;24:1355-63
2. Wu O et al. Magn Reson Med 2003;50:164-174
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Affiliation(s)
| | - Ahmed A Khalil
- Cntr for Stroke Rsch, Academic Neuroradiology, Berlin, Germany
| | | | | | | | - Jochen Fiebach
- Cntr for Stroke Rsch, Academic Neuroradiology, Berlin, Germany
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49
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Schindlbeck KA, Santaella A, Galinovic I, Krause T, Rocco A, Nolte CH, Villringer K, Fiebach JB. Spot Sign in Acute Intracerebral Hemorrhage in Dynamic T1-Weighted Magnetic Resonance Imaging. Stroke 2015; 47:417-23. [PMID: 26715459 DOI: 10.1161/strokeaha.115.011570] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [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: 09/19/2015] [Accepted: 11/18/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE In computed tomographic imaging of acute intracerebral hemorrhage spot sign on computed tomographic angiography has been established as a marker for hematoma expansion and poor clinical outcome. Although, magnetic resonance imaging (MRI) can accurately visualize acute intracerebral hemorrhage, a corresponding MRI marker is lacking to date. METHODS We prospectively examined 50 consecutive patients with acute intracerebral hemorrhage within 24 hours of symptom onset. The MRI protocol consisted of a standard stroke protocol and dynamic contrast-enhanced T1-weighted imaging with a time resolution of 7.07 s/batch. Stroke scores were assessed at admission and at time of discharge. Volume measurements of hematoma size and spot sign were performed with MRIcron. RESULTS Contrast extravasation within sites of the hemorrhage (MRI spot sign) was seen in 46% of the patients. Patients with an MRI spot sign had a significantly shorter time to imaging than those without (P<0.001). The clinical outcome measured by the modified Rankin Scale was significantly worse in patients with spot sign compared with those without (P≤0.001). Hematoma expansion was observed in the spot sign group compared with the nonspot sign group, although the differences were not significant. CONCLUSIONS Spot sign can be detected using MRI on postcontrast T1-weighted and dynamic T1-weighted images. It is associated with worse clinical outcome. The time course of contrast extravasation in dynamic T1 images indicates that these spots represent ongoing bleeding.
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Affiliation(s)
- Katharina A Schindlbeck
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.).
| | - Anna Santaella
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Ivana Galinovic
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Thomas Krause
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Andrea Rocco
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Christian H Nolte
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Kersten Villringer
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Jochen B Fiebach
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
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50
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Fiebach JB, Stief JD, Ganeshan R, Hotter B, Ostwaldt AC, Nolte CH, Villringer K. Reliability of Two Diameters Method in Determining Acute Infarct Size. Validation as New Imaging Biomarker. PLoS One 2015; 10:e0140065. [PMID: 26447761 PMCID: PMC4598169 DOI: 10.1371/journal.pone.0140065] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 09/20/2015] [Indexed: 11/18/2022] Open
Abstract
Background In order to select patients most likely to benefit for thrombolysis and to predict patient outcome in acute ischemic stroke, the volumetric assessment of the infarcted tissue is used. However, infarct volume estimation on Diffusion weighted imaging (DWI) has moderate interrater variability despite the excellent contrast between ischemic lesion and healthy tissue. In this study, we compared volumetric measurements of DWI hyperintensity to a simple maximum orthogonal diameter approach to identify thresholds indicating infarct size >70 ml and >100 ml. Methods Patients presenting with ischemic stroke with an NIHSS of ≥ 8 were examined with stroke MRI within 24 h after symptom onset. For assessment of the orthogonal DWI lesion diameters (od-values) the image with the largest lesion appearance was chosen. The maximal diameter of the lesion was determined and a second diameter was measured perpendicular. Both diameters were multiplied. Od-values were compared to volumetric measurement and od-value thresholds identifying a lesion size of > 70 ml and > 100 ml were determined. In a selected dataset with an even distribution of lesion sizes we compared the results of the od value thresholds with results of the ABC/2 and estimations of lesion volumes made by two resident physicians. Results For 108 included patients (53 female, mean age 71.36 years) with a median infarct volume of 13.4 ml we found an excellent correlation between volumetric measures and od-values (r2 = 0.951). Infarct volume >100 ml corresponds to an od-value cut off of 42; > 70 ml corresponds to an od-value of 32. In the compiled dataset (n = 50) od-value thresholds identified infarcts > 100 ml / > 70 ml with a sensitivity of 90%/ 93% and with a specificity of 98%/ 89%. The od-value offered a higher accuracy in identifying large infarctions compared to both visual estimations and the ABC/2 method. Conclusion The simple od-value enables identification of large DWI lesions in acute stroke. The cutoff of 42 is useful to identify large infarctions with volume larger than 100 ml. Further studies can analyze the therapeutic utility of this new method. Trail Registration ClinicalTrials.org NCT00715533
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Affiliation(s)
- Jochen B. Fiebach
- Center for Stroke Research Berlin (CSB), Department of Neurology, Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
- * E-mail:
| | - Jonas D. Stief
- Center for Stroke Research Berlin (CSB), Department of Neurology, Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
- Department of Radiology, Charité—Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Ramanan Ganeshan
- Center for Stroke Research Berlin (CSB), Department of Neurology, Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Benjamin Hotter
- Center for Stroke Research Berlin (CSB), Department of Neurology, Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Ann-Christin Ostwaldt
- Center for Stroke Research Berlin (CSB), Department of Neurology, Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
- Massachusetts General Hospital, Center for Human Genetic Research, 185 Cambridge Street, Boston, MA, 02114, United States of America
| | - Christian H. Nolte
- Center for Stroke Research Berlin (CSB), Department of Neurology, Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin (CSB), Department of Neurology, Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
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