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Timing of anticoagulation after acute ischemic stroke in patients with atrial fibrillation. Neurol Sci 2022:1-12. [PMID: 35762354 DOI: 10.1017/cjn.2022.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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2
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Lansberg MG, Wintermark M, Kidwell CS, Albers GW. Magnetic Resonance Imaging of Cerebrovascular Diseases. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00048-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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3
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A Review of Risk Factors and Predictors for Hemorrhagic Transformation in Patients with Acute Ischemic Stroke. Int J Vasc Med 2021; 2021:4244267. [PMID: 34912581 PMCID: PMC8668348 DOI: 10.1155/2021/4244267] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 12/26/2022] Open
Abstract
Acute ischemic strokes (AIS) and hemorrhagic strokes lead to disabling neuropsychiatric and cognitive deficits. A serious and fatal complication of AIS is the occurrence of hemorrhagic transformation (HT). HT is cerebral bleeding that occurs after an ischemic event in the infarcted areas. This review summarises how specific risk factors such as demographic factors like age, gender, and race/ethnicity, comorbidities including essential hypertension, atrial fibrillation, diabetes mellitus, congestive heart failure, and ischemic heart disease along with predictors like higher NIHSS score, larger infarction size, cardioembolic strokes, systolic blood pressure/pulse pressure variability, higher plasma glucose levels, and higher body temperature during ischemic event, lower low-density lipoprotein and total cholesterol, early ischemic changes on imaging modalities, and some rare causes make an individual more susceptible to developing HT. We also discuss few other risk factors such as the role of blood-brain barrier, increased arterial stiffness, and globulin levels in patients postreperfusion using thrombolysis and mechanical thrombectomy. In addition, we discuss the implications of dual antiplatelet therapy and the length of treatment in reference to the incidence of developing HT. Current research into inflammatory mediators and biomarkers such as Cyclooxygenase-2, matrix metalloproteinases, and soluble ST2 and their potential role as treatment options for HT is also briefly discussed. Finally, this review calls for more research into use of dual antiplatelet and the timing of antiplatelet and anticoagulant use in reference to hemorrhagic transformation.
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D'Anna L, Filippidis FT, Harvey K, Marinescu M, Bentley P, Korompoki E, Veltkamp R. Extent of white matter lesion is associated with early hemorrhagic transformation in acute ischemic stroke related to atrial fibrillation. Brain Behav 2021; 11:e2250. [PMID: 34124834 PMCID: PMC8413731 DOI: 10.1002/brb3.2250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/27/2021] [Accepted: 05/29/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Hemorrhagic transformation (HT) after stroke, related to atrial fibrillation (AF), is a frequent complication, and it can be associated with a delay in the (re-)initiation of oral anticoagulation therapy. We investigated the effect of the presence and severity of white matter disease (WMD) on early HT after stroke related to AF. METHODS A consecutive series of patients with recent (<4 weeks) ischemic stroke and AF, treated at the Hyper Acute Stroke Unit of the Imperial College London between 2010 and 2017, were enrolled. Patients with brain MRI performed 24-72 h from stroke onset and not yet started on anticoagulant treatment were included. WMD was graded using the Fazekas score. RESULTS Among the 441 patients eligible for the analysis, 91 (20.6%) had any HT. Patients with and without HT showed similar clinical characteristics. Patients with HT had a larger diffusion-weighted imaging (DWI) infarct volume compared to patients without HT (p < .001) and significant difference in the distribution of the Fazekas score (p = .001). On multivariable analysis, HT was independently associated with increasing DWI infarct volume (odd ratio (OR), 1.03; 95% confidence interval (CI), 1.01-1.05; p < .001), higher Fazekas scores (OR, 1.94; 95% CI, 1.47-2.57; p < .001) and history of previous intracranial hemorrhage (OR, 4.80; 95% CI, 1.11-20.80; p = .036). CONCLUSIONS Presence and severity of WMD is associated with increased risk of development of early HT in patients with stroke and AF. Further evidence is needed to provide reliable radiological predictors of the risk of HT in cardioembolic stroke.
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Affiliation(s)
- Lucio D'Anna
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK.,Department of Brain Sciences, Imperial College London, London, UK
| | - Filippos T Filippidis
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Kirsten Harvey
- Department of Brain Sciences, Imperial College London, London, UK
| | | | - Paul Bentley
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK.,Department of Brain Sciences, Imperial College London, London, UK
| | - Eleni Korompoki
- Department of Brain Sciences, Imperial College London, London, UK
| | - Roland Veltkamp
- Department of Brain Sciences, Imperial College London, London, UK.,Department of Neurology, Alfried-Krupp Krankenhaus, Essen, Germany.,Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
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Maïer B, Desilles JP, Mazighi M. Intracranial Hemorrhage After Reperfusion Therapies in Acute Ischemic Stroke Patients. Front Neurol 2020; 11:599908. [PMID: 33362701 PMCID: PMC7759548 DOI: 10.3389/fneur.2020.599908] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/17/2020] [Indexed: 12/11/2022] Open
Abstract
Reperfusion therapies are the mainstay of acute ischemic stroke (AIS) treatments and overall improve functional outcome. Among the established complications of intravenous (IV) tissue-type plasminogen activator (tPA), intracranial hemorrhage (ICH) is by far the most feared and has been extensively described by seminal works over the last two decades. Indeed, IV tPA is associated with increased odds of any ICH and symptomatic ICH responsible for increased mortality rate during the first week after an AIS. Despite these results, IV tPA has been found beneficial in several pioneering randomized trials and improves functional outcome at 3 months. Endovascular therapy (EVT) combined with IV tPA for AIS patients consecutive to an anterior circulation large-vessel occlusion does not increase ICH occurrence. Of note, EVT following IV tPA leads to significantly higher rates of early reperfusion than with IV tPA alone, with no difference in ICH, which challenges the paradigm of reperfusion as a major prognostic factor for ICH complications. However, several blood biomarkers (glycemia, platelet and neutrophil count), clinical factors (age, AIS severity, blood pressure management, diabetes mellitus), and neuroradiological factors (cerebral microbleeds, infarct size) have been identified as risk factors for ICH after reperfusion therapy. In the years to come, the ultimate goal will be to further improve either reperfusion rates and functional outcome, while reducing hemorrhagic complications. To this end, various approaches being investigated are discussed in this review, such as blood-pressure control after reperfusion or the use of new antiplatelet agents as an adjunct to IV tPA and exhibit reduced hemorrhagic potential during the early phase of AIS.
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Affiliation(s)
- Benjamin Maïer
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France
- Université de Paris, Paris, France
- Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Jean Philippe Desilles
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France
- Université de Paris, Paris, France
- Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
| | - Mikael Mazighi
- Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France
- Université de Paris, Paris, France
- Laboratory of Vascular Translational Science, INSERM U1148, Paris, France
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Elsaid N, Mustafa W, Saied A. Radiological predictors of hemorrhagic transformation after acute ischemic stroke: An evidence-based analysis. Neuroradiol J 2020; 33:118-133. [PMID: 31971093 PMCID: PMC7140299 DOI: 10.1177/1971400919900275] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Hemorrhagic transformation (HT) is one of the most common adverse events related to acute ischemic stroke (AIS) that affects the treatment plan and clinical outcome. Identification of a sensitive radiological marker may influence the controversial thrombolytic decision in the setting of AIS and may at a minimum indicate more intensive monitoring or further prophylactic interventions. In this article we summarize possible radiological biomarkers and the role of different radiological modalities including computed tomography (CT), magnetic resonance imaging, angiography, and ultrasound in predicting HT. Different radiological indices of early ischemic changes, large ischemic lesion volume, severe blood flow restriction, blood-brain barrier disruption, poor collaterals and high blood flow velocities have been reported to be associated with higher risk of HT. The current levels of evidence of the available studies highlight the role of the different CT perfusion parameters in predicting HT. Further large standardized studies are recommended to compare the sensitivity and specificity of the different radiological markers combined and delineate the most reliable predictor.
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Affiliation(s)
- Nada Elsaid
- Department of Neurology, University of Mansoura
Faculty of Medicine, Egypt
| | - Wessam Mustafa
- Department of Neurology, University of Mansoura
Faculty of Medicine, Egypt
| | - Ahmed Saied
- Department of Neurology, University of Mansoura
Faculty of Medicine, Egypt
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Kim J, Kim CH, Kang J, Kwon OY. Predicting parenchymal hematoma associated with endovascular thrombectomy for acute occlusion of anterior circulation large vessel: the GuEss-MALiGn scale. JOURNAL OF NEUROCRITICAL CARE 2020. [DOI: 10.18700/jnc.190104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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El Nawar R, Yeung J, Labreuche J, Chadenat ML, Duong DL, De Malherbe M, Cordoliani YS, Lapergue B, Pico F. MRI-Based Predictors of Hemorrhagic Transformation in Patients With Stroke Treated by Intravenous Thrombolysis. Front Neurol 2019; 10:897. [PMID: 31507511 PMCID: PMC6719609 DOI: 10.3389/fneur.2019.00897] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 08/02/2019] [Indexed: 11/24/2022] Open
Abstract
Background: Clinical and biological risk factors for hemorrhagic transformation (HT) after intravenous thrombolysis (IT) have been well-established in several registries. The added value of magnetic resonance imaging (MRI) variables has been studied in small samples, and is controversial. We aimed to assess the added value of MRI variables in HT, beyond that of clinical and biological factors. Methods: We enrolled 474 consecutive patients with brain infarction treated by IT alone at our primary stroke center between January 2011 and August 2017. Baseline demographic, clinical, biological, and imaging characteristics were collected. MRI variables were: brain infarction volume in cm3; parenchymal fluid attenuated inversion recovery (FLAIR) hyperintensity; FLAIR hyperintense vessel signs; number of microbleeds; subcortical white matter hyperintensity; and thrombus length. Results: Overall, 301 patients were included out of 474 (64%). The main causes of exclusion were combined thrombectomy (n = 98) and no MRI before IT (n = 44). In the bivariate analysis, HT was significantly associated with the presence of more FLAIR hyperintense vessel signs, thrombus length (>8 mm), and larger brain infarction volume (diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) < 500 × 10-6 mm2/s). In the multivariable analysis, only brain infarction volume was significantly associated with HT. The discrimination value of the multivariable model, including both the DWI volume and the clinical model (area under the receiver operating characteristic curve, 0.80; 95% confidence interval 0.74-0.86), was improved significantly compared with the model based only on clinical variables (P = 0.012). Conclusions: Brain infarction volume on DWI was the only MRI variable that added value to clinico biological variables for predicting HT after IT.
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Affiliation(s)
- Rody El Nawar
- Department of Neurology and Stroke Center, Hopital Mignot, Centre Hospitalier de Versailles, Versailles, France
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University Medical Center, Beirut, Lebanon
| | - Jennifer Yeung
- Department of Neurology and Stroke Center, Hopital Mignot, Centre Hospitalier de Versailles, Versailles, France
| | - Julien Labreuche
- Université de Lille, CHU Lille, EA 2694, Santé Publique: Épidémiologie et Qualité des Soins, Lille, France
| | - Marie-Laure Chadenat
- Department of Neurology and Stroke Center, Hopital Mignot, Centre Hospitalier de Versailles, Versailles, France
| | - Duc Long Duong
- Department of Neurology and Stroke Center, Hopital Mignot, Centre Hospitalier de Versailles, Versailles, France
| | - Maxime De Malherbe
- Department of Radiology, Centre Hospitalier de Versailles, Versailles, France
| | | | - Bertrand Lapergue
- Department of Neurology and Stroke Center, Hopital Foch, Suresnes, France
- Université Versailles Saint-Quentin en Yvelines et Paris Saclay, Versailles, France
| | - Fernando Pico
- Department of Neurology and Stroke Center, Hopital Mignot, Centre Hospitalier de Versailles, Versailles, France
- Université Versailles Saint-Quentin en Yvelines et Paris Saclay, Versailles, France
- INSERM U1148 LVTS (Laboratory for Vascular Translational Science), Team 5 (Research into “Atherothrombotic Disease in Heart and Brain”), Hôpital Bichat, Paris, France
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Langel C, Popovic KS. Infarct-core CT perfusion parameters in predicting post-thrombolysis hemorrhagic transformation of acute ischemic stroke. Radiol Oncol 2019; 53:25-30. [PMID: 30864425 PMCID: PMC6411018 DOI: 10.2478/raon-2018-0048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 11/11/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Intravenous thrombolysis (IVT) is the method of choice in reperfusion treatment of patients with signs and symptoms of acute ischemic stroke (AIS) lasting less than 4.5 hours. Hemorrhagic transformation (HT) of acute ischemic stroke is a serious complication of IVT and occurs in 4.5-68.0% of clinical cases. The aim of our study was to determine the infarct core CT perfusion parameter (CTPP) most predictive of HT. PATIENTS AND METHODS Seventy-five patients with AIS who had undergone CT perfusion (CTP) imaging and were treated with IVT were enrolled in this retrospective study. Patients with and without HT after IVT were defined as cases and controls, respectively. Controls were found by matching for time from AIS symptom onset to IVT ± 0.5 h. The following CTPPs were measured: cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), relative CBF (rCBF) and relative CBV (rCBV). Receiver operating characteristic analysis curves of significant CTPPs determined cut-off values that best predict HT. RESULTS There was a significant difference between cases and controls for CBF (p = 0.004), CBV (p = 0.009), rCBF (p < 0.001) and rCBV (p = 0.001). Receiver operating characteristic analysis revealed that rCBF < 4.5% of the contralateral mean (area under the curve = 0.736) allowed prediction of HT with a sensitivity of 71.0% and specificity of 52.5%. CONCLUSIONS CTP imaging has a considerable role in HT prediction, assisting in selection of patients that are likely to benefit from IVT. rCBF proved to have the highest HT predictive value.
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Affiliation(s)
- Crt Langel
- Novo Mesto General Hospital, Novo MestoSlovenia
| | - Katarina Surlan Popovic
- Institute of Radiology, University Medical Centre Ljubljana, LjubljanaSlovenia
- Assoc. Prof. Šurlan Popović Katarina, M.D., Ph.D., Institute of Radiology, University Medical Centre Ljubljana, Zaloška cesta 7, SI-1000 Ljubljana, Slovenia. Phone: +386 1 522 85 30
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Kaesmacher J, Kaesmacher M, Maegerlein C, Zimmer C, Gersing AS, Wunderlich S, Friedrich B, Boeckh-Behrens T, Kleine JF. Hemorrhagic Transformations after Thrombectomy: Risk Factors and Clinical Relevance. Cerebrovasc Dis 2017; 43:294-304. [PMID: 28343220 DOI: 10.1159/000460265] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/28/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hemorrhagic transformation (HT) is a major complication of acute ischemic stroke, potentially associated with clinical deterioration. We attempted to identify risk factors and evaluated clinical relevance of minor and major HTs following endovascular thrombectomy (ET) in isolated middle cerebral artery (MCA) occlusions. METHODS This is a retrospective single-center analysis of 409 patients with isolated MCA occlusion treated with ET. Patients' and procedural characteristics, severity of HT according to the European Cooperative Acute Stroke Study criteria, and clinical outcomes were analyzed. Multivariate logistic regression models with standard retention criteria (p < 0.1) were used to determine risk factors and clinical relevance of HT. Results are shown as adjusted OR (aOR) and respective 95% CIs. Good neurologic short-term outcome was defined as National Institutes of Health Stroke Scale (NIHSS) score <5 at the day of discharge. RESULTS Of 299 patients included, hemorrhagic infarction (HI) was detected in 87 patients, while 13 patients developed parenchymal hematoma (PH). Higher age (aOR 0.970, 95% CI 0.947-0.993, p = 0.012), eligibility for intravenous recombinant tissue plasminogen activator (IV rtPA; aOR 0.512, 95% CI 0.267-0.982, p = 0.044), and complete recanalization (TICI 3, aOR 0.408, 95% CI 0.210-0.789, p = 0.008) were associated with a lower risk of HI. Risk factors for HI included higher admission NIHSS score (aOR 1.080, 95% CI 1.010-1.153, p = 0.024) and higher admission glucose levels (aOR 1.493, 95% CI 1.170-1.904, p = 0.001). Further, female sex tended to be associated with a lower risk of HI (aOR 0.601, 95% CI 0.316-1.143, p = 0.121), while a statistical trend was observable for proximal MCA occlusion (aOR 1.856, 95% CI 0.945-3.646, p = 0.073) and a history of hypertension (aOR 2.176, 95% CI 0.932-5.080, p = 0.072) to increase risk of HI. Longer intervals from symptom onset to first digital subtraction angiography runs (aOR 1.013, 95% CI 1.003-1.022, p = 0.009), lower preinterventional Alberta Stroke Program Early CT score (aOR 0.536, 95% CI 0.307-0.936, p = 0.028) and wake-up stroke (aOR 18.540, 95% CI 1.352-254.276, p = 0.029) were associated with PH. Both, PH and HI were independently associated with lower rates of good neurologic outcome (aOR 0.086, 95% CI 0.008-0.902, p = 0.041 and aOR 0.282, 95% CI 0.131-0.606, p = 0.001). CONCLUSION Risk of HI following MCA occlusion and subsequent ET is mainly determined by factors influencing infarct severity. Good recanalization results seem to be protective against subsequent HI. Our results support the notion that occurrence of PH after ET is time dependent and risk increases with more extensive early ischemic damage. Both, HI and PH do not seem to be facilitated by bridging therapy with IV rtPA or the use of oral anticoagulants, but were independently associated with more severe neurologic disability. These results support the notion that HI is not a "benign" imaging sign.
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Affiliation(s)
- Johannes Kaesmacher
- Department of Neuroradiology, Klinikum rechts der Isar, TU München, Munich, Germany
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Magnetic Resonance Imaging of Cerebrovascular Diseases. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00048-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Ibatullin MM, Kalinin MN, Curado AT, Khasanova DR. [Neurovisualisation predictors of malignant cerebral infarction and hemorrhagic transformation]. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:3-11. [PMID: 26120991 DOI: 10.17116/jnevro2015115323-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neuroimaging plays a central role in the assessment of patients with acute ischemic stroke. Within a few minutes, modern multimodal imaging protocols can provide one with comprehensive information about prognosis, management, and outcome of the disease, and may detect changes in the intracranial structures reflecting severity of the ischemic injury depicted by four Ps: parenchyma (of the brain), pipes (i.e., the cerebral blood vessels), penumbra, and permeability (of the blood brain barrier). In this article, we have reviewed neuroradiological predictors of malignant middle cerebral artery infarction and hemorrhagic transformation in light of the aforementioned four Ps.
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Affiliation(s)
| | | | - A T Curado
- Interregional Clinical Diagnostic Center, Kazan
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Morgan CD, Stephens M, Zuckerman SL, Waitara MS, Morone PJ, Dewan MC, Mocco J. Physiologic imaging in acute stroke: Patient selection. Interv Neuroradiol 2015; 21:499-510. [PMID: 26063695 DOI: 10.1177/1591019915587227] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Treatment of acute stroke is changing, as endovascular intervention becomes an important adjunct to tissue plasminogen activator. An increasing number of sophisticated physiologic imaging techniques have unique advantages and applications in the evaluation, diagnosis, and treatment-decision making of acute ischemic stroke. In this review, we first highlight the strengths, weaknesses, and possible indications for various stroke imaging techniques. How acute imaging findings in each modality have been used to predict functional outcome is discussed. Furthermore, there is an increasing emphasis on using these state-of-the-art imaging modalities to offer maximal patient benefit through IV therapy, endovascular thrombolytics, and clot retrieval. We review the burgeoning literature in the determination of stroke treatment based on acute, physiologic imaging findings.
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Affiliation(s)
- Clinton D Morgan
- Department of Neurological Surgery, Vanderbilt University School of Medicine, USA
| | | | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University School of Medicine, USA
| | | | - Peter J Morone
- Department of Neurological Surgery, Vanderbilt University School of Medicine, USA
| | - Michael C Dewan
- Department of Neurological Surgery, Vanderbilt University School of Medicine, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mouth Sinai, USA
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Morales H, Lu A, Kurosawa Y, Clark JF, Leach J, Weiss K, Tomsick T. Decreased infarct volume and intracranial hemorrhage associated with intra-arterial nonionic iso-osmolar contrast material in an MCA occlusion/reperfusion model. AJNR Am J Neuroradiol 2014; 35:1885-91. [PMID: 24812016 DOI: 10.3174/ajnr.a3953] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Infarct volume and intracranial hemorrhage after reperfusion with nonionic low-osmolar and iso-osmolar iodinated IRCM has not been previously compared. We postulated that iso-osmolar and low-osmolar iodinated contrast media exert varied effects on cerebral infarct after intra-arterial injection. We compared infarct volume and hemorrhagic changes following intra-arterial infusion of iodixanol, iopamidol, or normal saline in a rat MCA occlusion/reperfusion model. MATERIALS AND METHODS Infarct was induced in 30 rats by a previously validated method of MCA suture occlusion. Reperfusion was performed after 5 hours with either iodixanol (n = 9), iopamidol (n = 12), or saline (n = 9). MR images were obtained at both 6 and 24 hours after ischemia, followed by sacrifice. Infarct volume was measured with T2WI and DWI by semiautomatic segmentation. Incidence and area of hemorrhage were measured on brain sections postmortem. RESULTS T2WI mean infarct volumes were 242 ± 89, 324 ± 70, and 345 ± 92 mm(3) at 6 hours, and 341 ± 147,470 ± 91, and 462 ± 71 mm(3) at 24 hours in the iodixanol, iopamidol, and saline groups, respectively. Differences in infarct volume among groups were significant at 6 hours (P < .03) and 24 hours (P < .05). In the iodixanol, iopamidol, and saline groups, mean areas for cortical intracranial hemorrhage were 0.8, 18.2, and 25.7 mm(2); and 28, 31, and 56.7 mm(2), respectively, for deep intracranial hemorrhage. The differences in intracranial hemorrhage area among groups were statistically significant for cortical intracranial hemorrhage (P < .01). CONCLUSIONS Intra-arterial infusion of nonionic iso-osmolar iodixanol showed reduced infarct volume and reduced cortical intracranial hemorrhage areas in comparison with nonionic low-osmolar iopamidol and saline. Our results may be relevant in the setting of intra-arterial therapy for acute stroke in humans, warranting further investigation.
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Affiliation(s)
- H Morales
- From the Departments of Radiology (H.M., J.L., T.T.)
| | - A Lu
- Neurology (A.L., Y.K., J.F.C.), University of Cincinnati, Cincinnati, Ohio
| | - Y Kurosawa
- Neurology (A.L., Y.K., J.F.C.), University of Cincinnati, Cincinnati, Ohio
| | - J F Clark
- Neurology (A.L., Y.K., J.F.C.), University of Cincinnati, Cincinnati, Ohio
| | - J Leach
- From the Departments of Radiology (H.M., J.L., T.T.)
| | - K Weiss
- Department of Radiology (K.W.), University of Mississippi, Oxford, Mississippi
| | - T Tomsick
- From the Departments of Radiology (H.M., J.L., T.T.)
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Hemorrhagic transformation after ischemic stroke in animals and humans. J Cereb Blood Flow Metab 2014; 34:185-99. [PMID: 24281743 PMCID: PMC3915212 DOI: 10.1038/jcbfm.2013.203] [Citation(s) in RCA: 360] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 10/10/2013] [Accepted: 10/28/2013] [Indexed: 01/12/2023]
Abstract
Hemorrhagic transformation (HT) is a common complication of ischemic stroke that is exacerbated by thrombolytic therapy. Methods to better prevent, predict, and treat HT are needed. In this review, we summarize studies of HT in both animals and humans. We propose that early HT (<18 to 24 hours after stroke onset) relates to leukocyte-derived matrix metalloproteinase-9 (MMP-9) and brain-derived MMP-2 that damage the neurovascular unit and promote blood-brain barrier (BBB) disruption. This contrasts to delayed HT (>18 to 24 hours after stroke) that relates to ischemia activation of brain proteases (MMP-2, MMP-3, MMP-9, and endogenous tissue plasminogen activator), neuroinflammation, and factors that promote vascular remodeling (vascular endothelial growth factor and high-moblity-group-box-1). Processes that mediate BBB repair and reduce HT risk are discussed, including transforming growth factor beta signaling in monocytes, Src kinase signaling, MMP inhibitors, and inhibitors of reactive oxygen species. Finally, clinical features associated with HT in patients with stroke are reviewed, including approaches to predict HT by clinical factors, brain imaging, and blood biomarkers. Though remarkable advances in our understanding of HT have been made, additional efforts are needed to translate these discoveries to the clinic and reduce the impact of HT on patients with ischemic stroke.
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Jain AR, Jain M, Kanthala AR, Damania D, Stead LG, Wang HZ, Jahromi BS. Association of CT perfusion parameters with hemorrhagic transformation in acute ischemic stroke. AJNR Am J Neuroradiol 2013; 34:1895-900. [PMID: 23598828 DOI: 10.3174/ajnr.a3502] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Prediction of hemorrhagic transformation in acute ischemic stroke could help determine treatment and prognostication. With increasing numbers of patients with acute ischemic stroke undergoing multimodal CT imaging, we examined whether CT perfusion could predict hemorrhagic transformation in acute ischemic stroke. MATERIALS AND METHODS Patients with acute ischemic stroke who underwent CTP scanning within 12 hours of symptom onset were examined. Patients with and without hemorrhagic transformation were defined as cases and controls, respectively, and were matched as to IV rtPA administration and presentation NIHSS score (± 2). Relative mean transit time, relative CBF, and relative CBV values were calculated from CTP maps and normalized to the contralateral side. Receiver operating characteristic analysis curves were created, and threshold values for significant CTP parameters were obtained to predict hemorrhagic transformation. RESULTS Of 83 patients with acute ischemic stroke, 16 developed hemorrhagic transformation (19.28%). By matching, 38 controls were found for only 14 patients with hemorrhagic transformation. Among the matched patients with hemorrhagic transformation, 13 developed hemorrhagic infarction (6 hemorrhagic infarction 1 and 7 hemorrhagic infarction 2) and 1 developed parenchymal hematoma 2. There was no significant difference between cases and controls with respect to age, sex, time to presentation from symptom onset, and comorbidities. Cases had significantly lower median rCBV (8% lower) compared with controls (11% higher) (P = .009; odds ratio, 1.14 for a 0.1-U decrease in rCBV). There was no difference in median total volume of ischemia, rMTT, and rCBF among cases and controls. The area under the receiver operating characteristic was computed to be 0.83 (standard error, 0.08), with a cutoff point for rCBV of 1.09. CONCLUSIONS Of the examined CTP parameters, only lower rCBV was found to be significantly associated with a relatively higher chance of hemorrhagic transformation.
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Lev MH. Perfusion Imaging of Acute Stroke: Its Role in Current and Future Clinical Practice. Radiology 2013; 266:22-7. [DOI: 10.1148/radiol.12121355] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Guo G, Yang Y, Yang W. Validation of hyperintense middle cerebral artery sign in acute ischemic stroke: Comparison between magnetic resonance imaging and angiography. Neural Regen Res 2012; 7:229-34. [PMID: 25767505 PMCID: PMC4353121 DOI: 10.3969/j.issn.1673-5374.2012.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2011] [Accepted: 11/12/2011] [Indexed: 11/18/2022] Open
Abstract
We performed a retrospective analysis of non-contrast computed tomography (CT) scans, immediately subsequent magnetic resonance imaging (MRI), and cerebral angiography data from 30 consecutive patients with acute ischemic stroke within 6 hours after symptom onset. Results showed that eleven patients developed subsequent hemorrhagic transformation at follow-up. A hyperintense middle cerebral artery sign on MRI was found in six hemorrhagic patients, all of who had acute thrombosis formation on magnetic resonance angiography and digital subtraction angiography. No patients in the non-hemorrhagic group had hyperintense middle cerebral artery sign on MRI. The sensitivity, specificity, and positive predictive values of the hyperintense middle cerebral artery sign on MRI T1-weighted image for subsequent hemorrhagic transformation were 54.5%, 100%, and 100% respectively. Hyperdense middle cerebral artery sign on non-contrast CT was observed in nine patients, five of who developed hemorrhagic transformation. These data suggest that hyperintense middle cerebral artery sign on MRI T1-weighted image is a highly specific and moderately sensitive indicator of subsequent hemorrhagic transformation in patients after acute ischemic stroke, and its specificity is superior to CT.
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Affiliation(s)
- Gang Guo
- Department of Radiology, Xiamen Second Hospital, Teaching Hospital of Fujian Medical University, Xiamen 361021, Fujian Province, China
| | - Yonggui Yang
- Department of Radiology, Xiamen Second Hospital, Teaching Hospital of Fujian Medical University, Xiamen 361021, Fujian Province, China
| | - Weiqun Yang
- Department of Radiology, Xiamen Second Hospital, Teaching Hospital of Fujian Medical University, Xiamen 361021, Fujian Province, China
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Fung SH, Roccatagliata L, Gonzalez RG, Schaefer PW. MR Diffusion Imaging in Ischemic Stroke. Neuroimaging Clin N Am 2011; 21:345-77, xi. [DOI: 10.1016/j.nic.2011.03.001] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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21
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Warach S, Baird AE, Dani KA, Wintermark M, Kidwell CS. Magnetic Resonance Imaging of Cerebrovascular Diseases. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10046-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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22
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Derex L, Nighoghossian N. Thrombolysis, stroke-unit admission and early rehabilitation in elderly patients. Nat Rev Neurol 2009; 5:506-11. [DOI: 10.1038/nrneurol.2009.127] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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23
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Imaging in Acute Stroke – a Personal View*. Clin Neuroradiol 2009; 19:20-30. [DOI: 10.1007/s00062-009-8030-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2008] [Accepted: 10/26/2008] [Indexed: 11/27/2022]
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Usman MHU, Notaro LA, Nagarakanti R, Brahin E, Dessain S, Gracely E, Ezekowitz MD. Combination antiplatelet therapy for secondary stroke prevention: enhanced efficacy or double trouble? Am J Cardiol 2009; 103:1107-12. [PMID: 19361598 DOI: 10.1016/j.amjcard.2009.01.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Revised: 01/05/2009] [Accepted: 01/05/2009] [Indexed: 11/17/2022]
Abstract
The evaluation of antithrombotic agents for secondary stroke prevention has focused on stroke reduction. The aim of this analysis was to focus specifically on the increase in bleeding risk. The annualized rates of total and major bleeding events in secondary stroke prevention trials of antithrombotics were assessed and cross compared. A Medline search for major randomized clinical studies with a follow-up duration of > or =1 year identified 13 studies. Pooled data sets were used to compare mean bleeding rates for aspirin (< or =325 mg/day), clopidogrel, anticoagulants (warfarin and other vitamin K antagonists), aspirin plus clopidogrel, and aspirin plus extended-release dipyridamole (ER-DP). Total bleeding occurred at mean rates of 4.8% with aspirin (< or =325 mg/day) alone, 2.9% with clopidogrel alone, 3.6% with aspirin plus ER-DP, 10.1% with aspirin plus clopidogrel, and 16.8% with anticoagulation. Major bleeding occurred at mean rates of 1% with aspirin (< or =325 mg/day) alone, 0.85% with clopidogrel, 0.93% with aspirin plus ER-DP, 1.7% with aspirin plus clopidogrel, and 2.5% with anticoagulation. In conclusion, the combination of aspirin and clopidogrel is associated with significantly greater bleeding than either aspirin (< or =325 mg/day) or clopidogrel alone. Aspirin plus ER-DP has a greater bleeding rate than clopidogrel but a lower rate than aspirin (< or =325 mg/day) alone.
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Affiliation(s)
- M Haris U Usman
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
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Mechanisms and markers for hemorrhagic transformation after stroke. ACTA NEUROCHIRURGICA. SUPPLEMENT 2009; 105:173-8. [PMID: 19066105 DOI: 10.1007/978-3-211-09469-3_34] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Intracerebral hemorrhagic transformation is a multifactorial phenomenon in which ischemic brain tissue converts into a hemorrhagic lesion with blood vessel leakage. Hemorrhagic transformation can significantly contribute to additional brain injury after stroke. Especially threatening are the thrombolytic-induced hemorrhages after reperfusion therapy with tissue plasminogen activator (tPA), the only treatment available for ischemic stroke. In this context, it is important to understand its underlying mechanisms and identify early markers of hemorrhagic transformation, so that we can both search for new treatments as well as predict clinical outcomes in patients. In this review, we discuss the emerging mechanisms for hemorrhagic transformation after stroke, and briefly survey potential molecular, genetic, and neuroimaging markers that might be used for early detection of this challenging clinical problem.
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Christoforidis GA, Karakasis C, Mohammad Y, Caragine LP, Yang M, Slivka AP. Predictors of hemorrhage following intra-arterial thrombolysis for acute ischemic stroke: the role of pial collateral formation. AJNR Am J Neuroradiol 2009; 30:165-70. [PMID: 18768718 DOI: 10.3174/ajnr.a1276] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The extent of pial collateral formation during acute ischemic stroke has been shown to influence outcomes. This study examines whether angiographic assessment of pial collateral formation is predictive of hemorrhagic transformation following intra-arterial thrombolysis (IAT) for acute ischemic stroke. MATERIALS AND METHODS Rates of any hemorrhage and significant hemorrhage (>25 mL) were reviewed in 104 consecutive patients who underwent IAT following acute ischemic stroke. The influence of the anatomic extent of pial collateral formation on the rates of hemorrhage and significant hemorrhage relative to known predictors for hemorrhagic transformation (presenting systolic blood pressure, blood glucose level, platelet level, and National Institutes of Health Stroke Scale [NIHSS] score, history of diabetes, time to treatment, age, sex, occlusion site, and extent of reperfusion) was analyzed by using logistic regression models. RESULTS Rates of any hemorrhage and significant hemorrhage were 25.2% (26/104) and 9.7% (10/104), respectively. The rate of significant hemorrhage was 25.0% (8/32) in patients with poor pial collaterals and 2.78% (2/72) in those with good pial collaterals (P = .0004, Pearson correlation). The rate of any hemorrhage was also significantly higher in patients with poor pial collaterals (40.6% versus 18.1%; P = .0142, Pearson correlation). Logistic regression analyses revealed that pial collateral formation (odds ratio [OR] = 3.04), history of diabetes (OR = 4.83), platelets <200,000/microL (OR = 2.95), and time to treatment <3 hours (OR = 12.0) were statistically significant predictors of hemorrhage, whereas pial collateral formation (OR = 13.1) and platelets <200,000/microL (OR = 8.1) were statistically significant predictors of significant hemorrhage. CONCLUSIONS Poor pial collateral formation is associated with higher incidence and larger size of hemorrhage following IAT.
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Affiliation(s)
- G A Christoforidis
- Department of Radiology, The Ohio State University College of Medicine, Columbus, Ohio 43210, USA.
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Schaefer PW, Copen WA, Lev MH, Gonzalez RG. Diffusion-Weighted Imaging in Acute Stroke. Magn Reson Imaging Clin N Am 2006; 14:141-68. [PMID: 16873008 DOI: 10.1016/j.mric.2006.06.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Diffusion MR imaging has improved evaluation of acute ischemic stroke vastly. It is highly sensitive and specific in the detection of infarction at early time points when CT and conventional MR sequences are unreliable. The initial DWI lesion is believed to represent infarction core and usually progresses to infarction unless there is early reperfusion. The initial DWI lesion volume and ADC ratios correlate highly with final infarction volume and with acute and chronic neurologic assessment tests. ADC values may be useful in differentiating tissue destined to infarct from that potentially salvageable with reperfusion therapy. ADC values also may be useful for determining tissue at risk of HT after reperfusion therapy. DTI can quantify differences in the responses of gray versus white matter to ischemia. FA may be important in determining stroke onset time, and tractography provides early detection of wallerian degeneration that may be important in determining prognosis. Finally, DWI can determine which patients who have TIA are at risk for subsequent large vessel infarction and can differentiate stroke from stroke mimics. With improvements in MR software and hardware, diffusion MR undoubtedly will continue to improve the management of patients who have acute stroke.
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Affiliation(s)
- Pamela W Schaefer
- Massachusetts General Hospital, and Harvard Medical School, Boston, MA 02114, USA.
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Willey J, Schumacher HC, Meyers PM. Future directions for recanalization therapy in acute ischemic stroke. FUTURE NEUROLOGY 2006. [DOI: 10.2217/14796708.1.1.107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Currently, the only treatment approved by the US Food and Drug Administration for the treatment of acute stroke is the intravenous recombinant tissue plasminogen activator, which must be administered within a 3 h window. The majority of ischemic stroke patients do not receive intravenous thrombolysis, primarily because they enter the healthcare system too late. Alternative treatment strategies being used or investigated include intra-arterial thrombolysis, endovascular clot disruption, and manipulation and angioplasty with or without stenting. The most promising new revascularization technologies beyond conventional thrombolysis for acute ischemic stroke are ultrasound-enhanced thrombolysis, mechanical clot extraction devices and stent angioplasty. Advances in neuroimaging may allow physicians to determine the etiology of a stroke and tailor treatment accordingly for the maximal clinical benefit for affected patients.
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30
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Schaefer PW, Copen WA, Lev MH, Gonzalez RG. Diffusion-Weighted Imaging in Acute Stroke. Neuroimaging Clin N Am 2005; 15:503-30, ix-x. [PMID: 16360586 DOI: 10.1016/j.nic.2005.08.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In magnetic resonance diffusion-weighted imaging (DWI), regions of the brain are depicted not only on the basis of physical properties, such as T2 relaxation and spin density, which influence image contrast in conventional MR imaging, but also by local characteristics of water molecule diffusion. The diffusion of water molecules is altered in a variety of disease processes, including ischemic stroke. The changes that occur in acute infarction enable DWI to detect very early ischemia. Also, because predictable progression of diffusion findings occurs during the evolution of ischemia, DWI enables more precise estimation of the time of stroke onset than does conventional imaging.
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31
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Rowley HA. Extending the Time Window for Thrombolysis: Evidence from Acute Stroke Trials. Neuroimaging Clin N Am 2005; 15:575-87, x. [PMID: 16360590 DOI: 10.1016/j.nic.2005.08.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Data from intravenous tissue plasminogen activator studies have shown rapidly diminishing clinical benefit beyond 3 hours when noncontrast CT is used for treatment triage. Newer trials, such as the Desmoteplase in Acute Ischemic Stroke trial, have now successfully pushed the time window out to 9 hours using the concept of penumbral imaging and treatment of the perfusion-diffusion mismatch. Advanced imaging with CT or MR imaging protocols is providing a means for rational physiologic selection and outcomes assessment in stroke treatment.
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Affiliation(s)
- Howard A Rowley
- Department of Radiology, University of Wisconsin, Madison, WI 53792, USA.
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32
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Abstract
Unenhanced CT remains the most widely used imaging technique and is the standard of care for acute stroke evaluation. Early ischemic signs (EIS) within the first 3 to 6 hours of symptom onset (eg, parenchymal hypodensity, sulcal effacement, and dense vessel) have been advocated as a triage tool for thrombolytic therapy. Recent studies have challenged the relevance of these EIS within 3 hours of stroke onset, with advanced MR and CT methods increasingly competing with unenhanced CT as the primary imaging modality for acute ischemia. Nonetheless, the insights regarding acute stroke physiology provided by studying the CT evolution of early ischemic signs continue to be valuable for the informed interpretation of all stroke images. It is these insights that comprise the topic of this article.
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Affiliation(s)
- Thomas Kucinski
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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33
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Fiehler J, Remmele C, Kucinski T, Rosenkranz M, Thomalla G, Weiller C, Zeumer H, Röther J. Reperfusion after Severe Local Perfusion Deficit Precedes Hemorrhagic Transformation: An MRI Study in Acute Stroke Patients. Cerebrovasc Dis 2005; 19:117-24. [PMID: 15640606 DOI: 10.1159/000083180] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2003] [Accepted: 07/24/2004] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We applied magnetic resonance imaging to analyze the degree of local diffusion and perfusion abnormalities and the status of reperfusion in regions with subsequent hemorrhagic transformation (HT). METHODS 51 patients with acute ischemic stroke were studied by diffusion- and perfusion-weighted imaging within 3.0 +/- 0.8 h, on day 1 and days 5-8. After realignment of the image data sets, the parameter maps of the apparent diffusion coefficient (ADC), cerebral blood flow (CBF) and cerebral blood volume (CBV), and mean transit time were analyzed in the area of subsequent HT. The degree of local diffusion and perfusion impairment in the HT area was compared with the entire diffusion and perfusion abnormality. Reperfusion status was separately assessed for the entire perfusion abnormality and the HT area. RESULTS HT was observed in 19/51 patients (37.2%) within 8 days after symptom onset. Areas destined for HT revealed a more severe decrease in ADC (to 70 +/- 13%; p < 0.01), CBV (to 31 +/- 26%; p < 0.001) and CBF (to 28 +/- 19%; p < 0.001) compared to the entire perfusion abnormality. Local reperfusion in the HT area was seen in 18/19 patients. The presence of HT did not coincide with a worse clinical outcome. DISCUSSION HT is the result of reperfusion in the region with the most severe local perfusion impairment and does not influence the neurological outcome.
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Affiliation(s)
- Jens Fiehler
- Department of Neuroradiology, University Hospital Eppendorf, University of Hamburg, Hamburg, Germany.
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34
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Derex L, Hermier M, Adeleine P, Pialat JB, Wiart M, Berthezène Y, Philippeau F, Honnorat J, Froment JC, Trouillas P, Nighoghossian N. Clinical and imaging predictors of intracerebral haemorrhage in stroke patients treated with intravenous tissue plasminogen activator. J Neurol Neurosurg Psychiatry 2005; 76:70-5. [PMID: 15607998 PMCID: PMC1739325 DOI: 10.1136/jnnp.2004.038158] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate clinical, biological, and pretreatment imaging variables for predictors of tissue plasminogen activator (tPA) related intracerebral haemorrhage (ICH) in stroke patients. METHODS 48 consecutive patients with hemispheric stroke were given intravenous tPA within seven hours of symptom onset, after computed tomography (CT) and magnetic resonance imaging (MRI) of the brain. Baseline diffusion weighted (DWI) and perfusion weighted (PWI) imaging volumes, time to peak, mean transit time, regional cerebral blood flow index, and regional cerebral blood volume were evaluated. The distribution of apparent diffusion coefficient (ADC) values was determined within each DWI lesion. RESULTS The symptomatic ICH rate was 8.3% (four of 48); the rate for any ICH was 43.8% (21 of 48). Univariate analysis showed that age, weight, history of hyperlipidaemia, baseline NIHSS score, glucose level, red blood cell count, and lacunar state on MRI were associated with ICH. However, mean 24 hour systolic blood pressure and a hyperdense artery sign on pretreatment CT were the only independent predictors of ICH. Patients with a hyperdense artery sign had larger pretreatment PWI and DWI lesion volumes and a higher NIHSS score. Analysis of the distribution of ADC values within DWI lesions showed that a greater percentage of pixels had lower ADCs (< 400 x 10(-6) mm(2)/s) in patients who experienced ICH than in those who did not. CONCLUSION Key clinical and biological variables, pretreatment CT signs, and MRI indices are associated with tPA related intracerebral haemorrhage.
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Affiliation(s)
- L Derex
- Service d'Urgences Neurovasculaires, Hôpital Neurologique, 59 boulevard Pinel, 69003 Lyon, France.
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Lee PH, Oh SH, Bang OY, Joo IS, Huh K. Isolated middle cerebral artery disease: clinical and neuroradiological features depending on the pathogenesis. J Neurol Neurosurg Psychiatry 2004; 75:727-32. [PMID: 15090568 PMCID: PMC1763587 DOI: 10.1136/jnnp.2003.022574] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Isolated atherosclerotic middle cerebral artery (MCA) disease is often difficult to differentiate from cardioembolic disease if intracranial atherosclerosis coexists with cardiac disease. OBJECTIVES To evaluate whether clinical and neuroradiological features of isolated MCA disease differ according to the underlying aetiology. METHODS Isolated MCA disease was defined as a unilateral angiographically occlusive lesion of the MCA on the symptomatic side without lesions of other intracranial or extracranial vessels. Patients with isolated MCA disease were divided into atherosclerotic and potentially cardioembolic, and the clinical, laboratory, and neuroradiological data analysed. RESULTS Among the 850 consecutive patients with acute ischaemic stroke or transient ischaemic attack, 107 (12.6%) met the criteria for isolated MCA disease (76 with atherosclerotic disease and 31 with a potential source of cardiac embolism). Total anterior circulation infarcts were more common and baseline NIHSS score was higher in potentially embolic occlusions than in atherosclerotic disease (each p<0.001). While cortical infarcts and territorial infarcts were more common in the potential embolism group (p = 0.028 and p<0.001, respectively), subcortical border zone infarcts were more common in the atherosclerotic group (p<0.001). Multiple regression analysis showed that border zone infarcts and mild stroke were independently associated with atherosclerotic MCA disease, while territorial and cortical infarcts were associated with potential cardiac embolic disease. CONCLUSIONS Clinical and neuroradiological characteristics can differentiate isolated atherosclerotic MCA disease from MCA disease associated with potential sources of cardiac embolism, and may reflect the differences in underlying pathogenesis.
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Affiliation(s)
- P H Lee
- Department of Neurology, School of Medicine, Ajou University, South Korea
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36
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Warach S, Kidwell CS, Baird AE. Magnetic Resonance Imaging. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50024-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
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Croquelois A, Wintermark M, Reichhart M, Meuli R, Bogousslavsky J. Aphasia in hyperacute stroke: language follows brain penumbra dynamics. Ann Neurol 2003; 54:321-9. [PMID: 12953264 DOI: 10.1002/ana.10657] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
During the first few hours after onset, stroke symptoms may evolve rapidly. We studied the correlation between brain perfusion and aphasia changes during the hyperacute phase of stroke using a new technique of perfusion computed tomography (P-CT). Using an aphasia score developed for each language modality, language was evaluated within 6 hours after onset, then sequentially during the first week. Maps of the penumbra and infarct obtained from P-CT images and definite infarct size evaluated using T2 and diffusion-weighted MRI (DWI) on day 3 were rated by a neuroradiologist, blinded to the clinical deficit. Within 6 hours, deficits in all language modalities were present in 13 out of 24 consecutive patients, corresponding to large anterior-posterior perfusion deficits of the left middle cerebral artery (MCA) territory. The aphasia score correlated with a corresponding perfusion deficit in specific areas of the MCA territory, and showed significantly less improvement when the penumbra evolved toward infarction than when at least part of the penumbra was rescued. Our findings suggest a particularly good correlation between the evolution of aphasic symptoms and penumbra dynamics. Further studies on the relevance of penumbra dynamics in function-specific brain areas to decision taking in hyperacute stroke management are required.
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Affiliation(s)
- Alexandre Croquelois
- Neurology Department, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 46, 1011 Lausanne, Switzerland
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38
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Abstract
PURPOSE OF REVIEW There is rapidly growing appreciation that stroke morbidity and the risk of an ischaemic stroke becoming haemorrhagic can be influenced by new information about prophylaxis, rapid diagnosis and treatment. RECENT FINDINGS Strokes are strongly associated with hypertension mainly because hypertension is strongly associated with atheromatous deposits blocking or narrowing brain arteries, predisposing to local clot formation. Atheroma and its ischaemic consequences may damage cerebral arterioles and the brain tissue they supply. Cerebral infarcts are more common than spontaneous cerebral haemorrhages. High blood pressure itself cannot directly rupture cerebral blood vessels because their small size protects them and intracerebral haemorrhage usually follows previous ischaemic vascular damage. It is obvious that lowering blood pressure would reduce the risk and extent of bleeding into the brain once a break in an arteriolar wall has occurred, but it is not clear why lowering blood pressure should protect against cerebral infarction. One might expect that slowing down the rate of cerebral blood flow would give more time for local clots to form. It seems most likely that induced hypotension protects against ischaemic strokes by preventing pressure- or ischaemia-induced arteriolar spasm and by advantageous vasodilation of some of the more ischaemic territories. Added protection can be provided by coenzyme-A reductase inhibitors (statins), but probably not by antioxidants. SUMMARY Lowering blood pressure strongly protects against ischaemic and haemorrhagic stroke. Recent work shows that more accurate and faster diagnosis of stroke pathology is urgently needed, so that appropriate treatment (e.g. with tissue plasminogen activators) can be started before local bleeding has occurred.
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Affiliation(s)
- C John Dickinson
- Wolfson Institute of Preventive Medicine, Queen Mary, University of London, UK.
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39
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Latour LL, Warach S. Cerebral spinal fluid contamination of the measurement of the apparent diffusion coefficient of water in acute stroke. Magn Reson Med 2002; 48:478-86. [PMID: 12210912 DOI: 10.1002/mrm.10238] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The measurement of the apparent diffusion coefficient (ADC) of water in brains of stroke patients is used in models developed to help distinguish reversible from irreversible ischemic injury. The ADC by conventional methods may be overestimated by the presence of cerebral spinal fluid (CSF) in sulci and perivascular spaces. In this study the hypothesis that DWI with CSF suppression (FLAIR-DWI) would result in different ADC values than those obtained with the conventional DWI technique was investigated. Thirty-one patients with stroke onset of less than 6 hr and an acute lesion on conventional DWI were studied. Both conventional isotropic DWI and FLAIR-DWI were performed using a single-shot echo-planar technique. In all 31 patients, CSF-suppressed ADC was lower than conventional ADC. The mean (SD) of the 31 patients' lesion ADC was 0.64 (0.08) x 10(-3) mm(2) s(-1) with FLAIR-DWI and 0.72 (0.09) x 10(-3) mm(2) s(-1) with conventional DWI (P < 0.001). The overestimation of ADC in conventional DWI corresponded to the percentage of the voxel that contained CSF. Suppression of CSF leads to lesion ADC values that are more homogeneous and more than 15% lower than those obtained with conventional DWI techniques. This suggests that FLAIR-DWI ADC measurements are more accurate than conventional ADC maps.
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Affiliation(s)
- Lawrence L Latour
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland 20878, USA.
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Adami A, Thijs V, Tong DC, Beaulieu C, Moseley ME, Yenari MA. Use of diffusion weighted MRI to predict the occurrence and severity of hemorrhagic transformation in a rabbit model of embolic stroke. Brain Res 2002; 944:32-9. [PMID: 12106663 DOI: 10.1016/s0006-8993(02)02704-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Severe hemorrhagic transformation (HT) is an important complication of thrombolytic therapy. A method to identify stroke victims destined to severe HT could improve the patient selection and thus the safety of such treatment. In this study, we investigated whether very early serial diffusion weighted magnetic resonance imaging (DWI) could predict the occurrence of HT in an embolic model of experimental stroke. We tested the hypothesis that the ischemic brains with very low initial apparent diffusion coefficients (ADC) are destined to severe early (<or=5.5 h) HT. We retrospectively analyzed DWI scans of 45 New Zealand white rabbits subjected to thromboembolic stroke and treated with thrombolysis. DWI was obtained 0.5, 2, 3 and 5 h after embolization. Various thrombolytics were administered 1 h post embolization. The percentage of pixels within the ischemic hemisphere with ADC values below 550 x 10(-6) mm(2)/s was calculated and then compared to the severity of HT observed on gross brain sections at 5.5 h. As early as 30 min after embolization, ischemic brains destined to severe HT exhibited a significantly greater percentage of pixels below the cut-off value compared to those without HT: severe HT: 25%, 18.75-37.25% vs. no HT: 12%, 5.00-16.00% (median, 25th-75th %, P<0.001). Petechial HT when percentages were in the intermediate range. Quantitative analysis of initial ADC value might identify individual stroke patients at risk of severe HT.
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Affiliation(s)
- Alessandro Adami
- Department of Neurology and Neurological Sciences, Stanford University, CA 94305-5487, USA
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Schaefer PW, Romero JM, Grant PE, Wu O, Sorensen AG, Koroshetz W, González RG. Perfusion magnetic resonance imaging of acute ischemic stroke. Semin Roentgenol 2002; 37:230-6. [PMID: 12226902 DOI: 10.1016/s0037-198x(02)80023-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Pamela W Schaefer
- Neuroradiology Division, Stroke Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Hillis AE, Wityk RJ, Tuffiash E, Beauchamp NJ, Jacobs MA, Barker PB, Selnes OA. Hypoperfusion of Wernicke's area predicts severity of semantic deficit in acute stroke. Ann Neurol 2001; 50:561-6. [PMID: 11706960 DOI: 10.1002/ana.1265] [Citation(s) in RCA: 163] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Based on earlier findings that the presence of word comprehension impairment (a deficit in the meaning of words, or lexical semantics) in acute stroke was strongly associated with the presence of hypoperfusion or infarct in Wernicke's area, we tested the hypothesis that the severity of word comprehension impairment was correlated with the magnitude of delay in perfusion of Wernicke's area on magnetic resonance perfusion-weighted imaging. Eighty patients were prospectively studied within 24 hours of onset or progression of acute left hemisphere stroke symptoms, with diffusion-weighted imaging, perfusion-weighted imaging, and detailed language tests. For 50 patients without infarct in Wernicke's area, we found a strong Pearson correlation between the rate of errors on a word comprehension test and the mean number of seconds of delay in time-to-peak concentration of contrast in Wernicke's area, relative to the homologous region on the right. These results add further evidence for the crucial role of Wernicke's area (Brodmann's area 22) in word comprehension and indicate that the magnitude of delay on PWI may be a gross indicator of tissue dysfunction.
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Affiliation(s)
- A E Hillis
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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