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Sebök M, van der Wouden F, Mader C, Pangalu A, Treyer V, Fisher JA, Mikulis DJ, Hüllner M, Regli L, Fierstra J, van Niftrik CHB. Hemodynamic Failure Staging With Blood Oxygenation Level-Dependent Cerebrovascular Reactivity and Acetazolamide-Challenged ( 15O-)H 2O-Positron Emission Tomography Across Individual Cerebrovascular Territories. J Am Heart Assoc 2023; 12:e029491. [PMID: 38084716 PMCID: PMC10863778 DOI: 10.1161/jaha.123.029491] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/11/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Staging of hemodynamic failure (HF) in symptomatic patients with cerebrovascular steno-occlusive disease is required to assess the risk of ischemic stroke. Since the gold standard positron emission tomography-based perfusion reserve is unsuitable as a routine clinical imaging tool, blood oxygenation level-dependent cerebrovascular reactivity (BOLD-CVR) with CO2 is a promising surrogate imaging approach. We investigated the accuracy of standardized BOLD-CVR to classify the extent of HF. METHODS AND RESULTS Patients with symptomatic unilateral cerebrovascular steno-occlusive disease, who underwent both an acetazolamide challenge (15O-)H2O-positron emission tomography and BOLD-CVR examination, were included. HF staging of vascular territories was assessed using qualitative inspection of the positron emission tomography perfusion reserve images. The optimum BOLD-CVR cutoff points between HF stages 0-1-2 were determined by comparing the quantitative BOLD-CVR data to the qualitative (15O-)H2O-positron emission tomography classification using the 3-dimensional accuracy index to the randomly assigned training and test data sets with the following determination of a single cutoff for clinical application. In the 2-case scenario, classifying data points as HF 0 or 1-2 and HF 0-1 or 2, BOLD-CVR showed an accuracy of >0.7 for all vascular territories for HF 1 and HF 2 cutoff points. In particular, the middle cerebral artery territory had an accuracy of 0.79 for HF 1 and 0.83 for HF 2, whereas the anterior cerebral artery had an accuracy of 0.78 for HF 1 and 0.82 for HF 2. CONCLUSIONS Standardized and clinically accessible BOLD-CVR examinations harbor sufficient data to provide specific cerebrovascular reactivity cutoff points for HF staging across individual vascular territories in symptomatic patients with unilateral cerebrovascular steno-occlusive disease.
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Affiliation(s)
- Martina Sebök
- Department of NeurosurgeryUniversity Hospital Zurich, University of ZurichSwitzerland
- Clinical Neuroscience CenterUniversity Hospital Zurich, University of ZurichSwitzerland
| | | | - Cäcilia Mader
- Department of Nuclear MedicineUniversity Hospital Zurich, University of ZurichSwitzerland
| | - Athina Pangalu
- Clinical Neuroscience CenterUniversity Hospital Zurich, University of ZurichSwitzerland
- Department of NeuroradiologyUniversity Hospital Zurich, University of ZurichSwitzerland
| | - Valerie Treyer
- Department of Nuclear MedicineUniversity Hospital Zurich, University of ZurichSwitzerland
| | - Joseph Arnold Fisher
- Department of Anesthesia and Pain ManagementUniversity Health NetworkTorontoOntarioCanada
- Institute of Medical ScienceUniversity of TorontoTorontoOntarioCanada
| | - David John Mikulis
- Institute of Medical ScienceUniversity of TorontoTorontoOntarioCanada
- Joint Department of Medical Imaging and the Functional Neuroimaging LaboratoryUniversity Health NetworkTorontoOntarioCanada
| | - Martin Hüllner
- Department of Nuclear MedicineUniversity Hospital Zurich, University of ZurichSwitzerland
| | - Luca Regli
- Department of NeurosurgeryUniversity Hospital Zurich, University of ZurichSwitzerland
- Clinical Neuroscience CenterUniversity Hospital Zurich, University of ZurichSwitzerland
| | - Jorn Fierstra
- Department of NeurosurgeryUniversity Hospital Zurich, University of ZurichSwitzerland
- Clinical Neuroscience CenterUniversity Hospital Zurich, University of ZurichSwitzerland
| | - Christiaan Hendrik Bas van Niftrik
- Department of NeurosurgeryUniversity Hospital Zurich, University of ZurichSwitzerland
- Clinical Neuroscience CenterUniversity Hospital Zurich, University of ZurichSwitzerland
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Comoretto RI, Azzolina D, Amigoni A, Stoppa G, Todino F, Wolfler A, Gregori D. Predicting Hemodynamic Failure Development in PICU Using Machine Learning Techniques. Diagnostics (Basel) 2021; 11:diagnostics11071299. [PMID: 34359385 PMCID: PMC8303657 DOI: 10.3390/diagnostics11071299] [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: 05/31/2021] [Revised: 07/12/2021] [Accepted: 07/16/2021] [Indexed: 11/16/2022] Open
Abstract
The present work aims to identify the predictors of hemodynamic failure (HF) developed during pediatric intensive care unit (PICU) stay testing a set of machine learning techniques (MLTs), comparing their ability to predict the outcome of interest. The study involved patients admitted to PICUs between 2010 and 2020. Data were extracted from the Italian Network of Pediatric Intensive Care Units (TIPNet) registry. The algorithms considered were generalized linear model (GLM), recursive partition tree (RPART), random forest (RF), neural networks models, and extreme gradient boosting (XGB). Since the outcome is rare, upsampling and downsampling algorithms have been applied for imbalance control. For each approach, the main performance measures were reported. Among an overall sample of 29,494 subjects, only 399 developed HF during the PICU stay. The median age was about two years, and the male gender was the most prevalent. The XGB algorithm outperformed other MLTs in predicting HF development, with a median ROC measure of 0.780 (IQR 0.770-0.793). PIM 3, age, and base excess were found to be the strongest predictors of outcome. The present work provides insights for the prediction of HF development during PICU stay using machine-learning algorithms.
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Affiliation(s)
- Rosanna I. Comoretto
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35131 Padova, Italy; (R.I.C.); (D.A.); (G.S.); (F.T.)
| | - Danila Azzolina
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35131 Padova, Italy; (R.I.C.); (D.A.); (G.S.); (F.T.)
- Department of Medical Sciences, University of Ferrara, 44100 Ferrara, Italy
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padua, Via Giustiniani 2, 35128 Padova, Italy;
| | - Giorgia Stoppa
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35131 Padova, Italy; (R.I.C.); (D.A.); (G.S.); (F.T.)
| | - Federica Todino
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35131 Padova, Italy; (R.I.C.); (D.A.); (G.S.); (F.T.)
| | - Andrea Wolfler
- Department of Anaesthesia, Gaslini Hospital, 16147 Genova, Italy;
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35131 Padova, Italy; (R.I.C.); (D.A.); (G.S.); (F.T.)
- Correspondence: ; Tel.: +39-049-8275-384; Fax: +39-02-700-445-089
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Abstract
PURPOSE OF REVIEW Hemodynamic monitoring is an essential component in the care for critically ill patients. A range of tools are available and new approaches have been developed. This review summarizes their availability, affordability and feasibility for hospital settings in resource-limited settings. RECENT FINDINGS Evidence for the performance of specific hemodynamic monitoring tools or strategies in low-income and middle-income countries (LMICs) is limited. Repeated physical examination and basic observations remain a cornerstone for patient monitoring and have a high sensitivity for detecting organ hypoperfusion, but with a low specificity. Additional feasible approaches for hemodynamic monitoring in LMICs include: for tissue perfusion monitoring: urine output, skin mottling score, capillary refill time, skin temperature gradients, and blood lactate measurements; for cardiovascular monitoring: echocardiography and noninvasive or minimally invasive cardiac output measurements; and for fluid status monitoring: inferior vena cava distensibility index, mini-fluid challenge test, passive leg raising test, end-expiratory occlusion test and lung ultrasound. Tools with currently limited applicability in LMICs include microcirculatory monitoring devices and pulmonary artery catheterization, because of costs and limited added value. Especially ultrasound is a promising and affordable monitoring device for LMICs, and is increasingly available. SUMMARY A set of basic tools and approaches is available for adequate hemodynamic monitoring in resource-limited settings. Future research should focus on the development and trialing of robust and context-appropriate monitoring technologies.
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Affiliation(s)
| | - Marcus J. Schultz
- Mahidol–Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine Mahidol University, Bangkok, Thailand
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK
| | - Arjen M. Dondorp
- Mahidol–Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine Mahidol University, Bangkok, Thailand
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK
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Takahashi JC, Funaki T, Houkin K, Kuroda S, Fujimura M, Tomata Y, Miyamoto S. Impact of cortical hemodynamic failure on both subsequent hemorrhagic stroke and effect of bypass surgery in hemorrhagic moyamoya disease: a supplementary analysis of the Japan Adult Moyamoya Trial. J Neurosurg 2020; 134:940-945. [PMID: 32168484 DOI: 10.3171/2020.1.jns192392] [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] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 01/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Here, the authors aimed to determine whether the presence of cerebral hemodynamic failure predicts subsequent bleeding attacks and how it correlates with the effect of direct bypass surgery in hemorrhagic moyamoya disease. METHODS Data from the Japanese Adult Moyamoya (JAM) Trial were used in this study: 158 hemispheres in 79 patients. A newly formed expert panel evaluated the SPECT results submitted at trial enrollment and classified the cortical hemodynamic state of the middle cerebral artery territory of each hemisphere into one of the following three groups: SPECT stage (SS) 0 as normal, SS1 as decreased cerebrovascular reserve (CVR), and SS2 as decreased CVR with decreased baseline blood flow. In the nonsurgical cohort of the JAM Trial, the subsequent hemorrhage rate during the 5-year follow-up was compared between the SS0 (hemodynamic failure negative) and SS1+2 (hemodynamic failure positive) groups. The effect of direct or combined direct/indirect bypass surgery on hemorrhage prevention was examined in each subgroup. RESULTS The hemodynamic grade was SS0 in 59 (37.3%) hemispheres, SS1 in 87 (55.1%), and SS2 in 12 (7.6%). In the nonsurgical cohort, subsequent hemorrhage rates in the SS0 and SS1+2 groups were 12 cases per 1000 person-years and 67 cases per 1000 person-years, respectively. Kaplan-Meier analysis revealed that hemorrhagic events were significantly more common in the SS1+2 group (p = 0.019, log-rank test). Cox regression analysis showed that hemodynamic failure was an independent risk factor for subsequent hemorrhage (HR 5.37, 95% CI 1.07-27.02). In the SS1+2 subgroup, bypass surgery significantly suppressed hemorrhagic events during 5 years (p = 0.001, HR 0.16, 95% CI 0.04-0.57), with no significant effect in the SS0 group (p = 0.655, HR 1.56, 95% CI 0.22-11.10). Examination of effect modification revealed that the effect of surgery tended to differ nonsignificantly between these two subgroups (p = 0.056). CONCLUSIONS Hemodynamic failure is an independent risk factor for subsequent hemorrhage in hemorrhagic moyamoya disease. Direct bypass surgery showed a significant preventive effect in the hemodynamically impaired hemispheres. Thus, hemodynamic failure, as well as previously proposed factors such as choroidal anastomosis, should be considered for the surgical indication in hemorrhagic moyamoya disease.Clinical trial registration no.: C000000166 (umin.ac.jp).
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Affiliation(s)
- Jun C Takahashi
- 1Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita
| | - Takeshi Funaki
- 2Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto
| | - Kiyohiro Houkin
- 3Department of Neurological Cell Therapy, Hokkaido University Hospital, Sapporo
| | - Satoshi Kuroda
- 4Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama
| | - Miki Fujimura
- 5Department of Neurosurgery, Kohnan Hospital, Sendai; and
| | - Yasutake Tomata
- 6Division of Epidemiology, Department of Health Informatics and Public Health, Tohoku University School of Public Health, Graduate School of Medicine, Sendai, Japan
| | - Susumu Miyamoto
- 2Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto
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Abstract
The cerebral vasculature incorporates several fail-safes that must be breached before an irreversible ischemic event takes place. In particular, when autoregulatory vasodilatation fails secondary to falling cerebral perfusion pressure (CPP; stage I hemodynamic failure), increases in the oxygen extraction fraction work to maintain the cerebral metabolic rate of oxygen. Previously, failure of this mechanism, stage II hemodynamic failure, or misery perfusion, has been imaged via positron emission tomography/computed tomography (PET/CT). Current susceptibility-weighted sequences (SWI) allow for more efficient imaging of this physiology. In this case, we identify an incident of reversible ischemia caused by spontaneous carotid artery dissection using a combination of diffusion weighted imaging (DWI) and SWI. The level of hemodynamic failure identified by the imaging sequences elevated the urgency of neurointervention, expediting the patient's arrival to the neurointerventional table and thus avoiding impending irreversible ischemia.
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Affiliation(s)
- Arian Mashhood
- Department of Radiology, Loma Linda University Hospital, Loma Linda, USA
| | - Paggie Kim
- Department of Radiology, Loma Linda University Hospital, Loma Linda, USA
| | - Frankis Almaguel
- Department of Radiology, Loma Linda University Hospital, Loma Linda, USA
| | - Geoffery McWilliams
- Department of Radiology, University of California, Davis, Medical Center, Sacramento, USA
| | - J Paul Jacobson
- Department of Radiology, Loma Linda University Hospital, Loma Linda, USA
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