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Alotaibi FF, Alshahrani A, Mohamed G, AlShamrani MA, Bin Amir H, Alsaeed A, Heji A, Alghanmi S, Alqurishi M, Alanazi A, Aldraye H, Asiri M, Alqahtani M, Alreshaid AA, AlKawi A, AlHazzani A, AlZawahmah M, Alokaili RN, Shuaib A, Al-Ajlan FS. Diagnostic accuracy of large and medium vessel occlusions in acute stroke imaging by neurology residents and stroke fellows: A comparison of CT angiography alone and CT angiography with CT perfusion. Eur Stroke J 2024; 9:356-365. [PMID: 37990504 DOI: 10.1177/23969873231214218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023] Open
Abstract
INTRODUCTION Neurology senior residents and stroke fellows are first to clinically assess and interpret imaging studies of patients presenting to the emergency department with acute stroke. The aim of this study was to compare the diagnostic accuracy of brain CT angiography (CTA) with and without CT perfusion (CTP) between neurology senior residents and stroke fellows. METHODS In this neuroimaging study, nine practitioners (four senior neurology residents (SNRs) and five stroke fellows (SFs)) clinically assessed and interpreted the imaging data of 50 cases (15 normal images, 21 large vessel occlusions (LVOs) and 14 medium vessel occlusions (MeVOs) in two sessions, 1 week apart in comparison to final diagnosis of experienced neuroradiologist and experienced stroke neurologist consensus. Interrater agreement of CTA alone and CTA with CTP was quantified using kappa statistics, sensitivity, specificity and overall accuracy. RESULTS Overall, arterial occlusions were correctly identified in 221/315 (70.1%) with CTA alone and in 266/315 (84.4%) with CTA and CTP (p < 0.001). The sensitivity of overall arterial occlusions detection with CTA alone was 94.2% (95% CI: 90.8%-96.6%) while with addition of CTP was 98% (95% CI: 95.6%-99.3%), The specificity of CTA alone was 74.7% (95% CI: 67.2%-81.3%) which increased with CTP to 84.4% (95% CI: 77.7%-89.8%). The likelihood of correct identification with CTA alone was 156/189 (82.54%) for LVOs and 65/126 (51.59%) for MeVOs. This increased to 169/189 (89.42%; p = 0.054) for LVOs and 97/126 (76.98%; p < 0.001) for MeVOs when the CTA images with CTP were viewed. There was good overall interrater agreement between readers when using CTA alone (k 0.71, 95% CI, 0.62-0.80) and almost perfect (k 0.85, 95% CI, 0.76-0.94) when CTP was added to the image for interpretation. CTA and CTP had a significantly lower median interquartile range (IQR) interpretation time than CTA alone (114 [IQR, 103-120] s vs 156 [IQR, 133-160] s, p < 0.001). DISCUSSION In cerebral arterial occlusions, the rate of LVO and MeVOs detections increases when adding CTP to CTA. The accuracy and time for diagnosing arterial occlusion can be significantly improved if CTP is added to CTA. As MeVOs are commonly missed by front-line neurology senior residents or stroke fellows, cases with significant deficits and no apparent arterial occlusions need to be reviewed with neuroradiological expertise.
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Affiliation(s)
- Fawaz F Alotaibi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Asma Alshahrani
- Department of Biostatistics, Epidemiology, and Scientific Computing, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Gamal Mohamed
- Department of Biostatistics, Epidemiology, and Scientific Computing, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mohamed A AlShamrani
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hussain Bin Amir
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ali Alsaeed
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Alaa Heji
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Suwaidi Alghanmi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mohammed Alqurishi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Azhar Alanazi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hamad Aldraye
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Muhannad Asiri
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mohammed Alqahtani
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Abdulrahman A Alreshaid
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
| | - Ammar AlKawi
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
| | - Adel AlHazzani
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
| | - Mohamed AlZawahmah
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Riyadh N Alokaili
- Department of Radiology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ashfaq Shuaib
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Fahad S Al-Ajlan
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
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Nogueira RG, Doheim MF, Al-Bayati AR, Lee JS, Haussen DC, Mohammaden M, Lang M, Starr M, Rocha M, da Câmara CP, Gross BA, Bhatt NR. Distal Medium Vessel Occlusion Strokes: Understanding the Present and Paving the Way for a Better Future. J Stroke 2024; 26:190-202. [PMID: 38836268 DOI: 10.5853/jos.2023.02649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 02/06/2024] [Indexed: 06/06/2024] Open
Abstract
Distal medium vessel occlusions (DMVOs) are thought to cause as many as 25% to 40% of all acute ischemic strokes and may result in substantial disability amongst survivors. Although intravenous thrombolysis (IVT) is more effective for distal than proximal vessel occlusions, the overall efficacy of IVT remains limited in DMVO with less than 50% of patients achieving reperfusion and about 1/3 to 1/4 of the patients failing to achieve functional independence. Data regarding mechanical thrombectomy (MT) among these patients remains limited. The smaller, thinner, and more tortuous vessels involved in DMVO are presumably associated with higher procedural risks whereas a lower benefit might be expected given the smaller amount of tissue territory at risk. Recent advances in technology have shown promising results in endovascular treatment of DMVOs with room for future improvement. In this review, we discuss some of the key technical and clinical considerations in DMVO treatment including the anatomical and clinical terminology, diagnostic modalities, the role of IVT and MT, existing technology, and technical challenges as well as the contemporary evidence and future treatment directions.
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Affiliation(s)
- Raul G Nogueira
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mohamed F Doheim
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alhamza R Al-Bayati
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jin Soo Lee
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, Korea
| | - Diogo C Haussen
- Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Mahmoud Mohammaden
- Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael Lang
- UPMC Stroke Institute, Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Matthew Starr
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Marcelo Rocha
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Bradley A Gross
- UPMC Stroke Institute, Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nirav R Bhatt
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Lima FO, Rocha FA, Silva HC, Puetz V, Dippel D, van den Wijngaard I, Majoie C, Yoo AJ, van Zwam W, de Lucena AF, Bandeira DDA, Arndt M, Barlinn K, Gerber JC, Langezaal LCM, Schonewille WJ, Pontes Neto OM, Dias FA, Martins SO, Mont’Alverne FJDA. Posterior circulation collaterals as predictors of outcome in basilar artery occlusion: a sub-analysis of the BASICS randomized trial. Front Neurol 2024; 15:1360335. [PMID: 38606280 PMCID: PMC11007200 DOI: 10.3389/fneur.2024.1360335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/13/2024] [Indexed: 04/13/2024] Open
Abstract
Introduction and purpose Basilar artery occlusion (BAO) is still one of the most devastating neurological conditions associated with high morbidity and mortality. In the present study, we aimed to assess the role of posterior circulation collaterals as predictors of outcome in the BASICS trial and to compare two grading systems (BATMAN score and PC-CS) in terms of prognostic value. Methods We performed a sub-analysis of the BASICS trial. Baseline clinical and imaging variables were analyzed. For the imaging analysis, baseline CT and CTA were analyzed by a central core lab. Only those patients with good or moderate quality of baseline CTA and with confirmed BAO were included. Multivariable binary logistic regression analysis was used to test the independent association of clinical and imaging characteristics with a favorable outcome at 3 months (defined as a modified Rankin Score of ≤3). ROC curve analysis was used to assess and compare accuracy between the two collateral grading systems. Results The mean age was 67.0 (±12.5) years, 196 (65.3%) patients were males and the median NIHSS was 21.5 (IQR 11-35). Median NCCT pc-ASPECTS was 10 (IQR10-10) and median collateral scores for BATMAN and PC-CS were 8 (IQR 7-9) and 7 (IQR 6-8) respectively. Collateral scores were associated with favorable outcome at 3 months for both BATMAN and PC-CS but only with a modest accuracy on ROC curve analysis (AUC 0.62, 95% CI [0.55-0.69] and 0.67, 95% CI [0.60-0.74] respectively). Age (OR 0.97, 95% CI [0.95-1.00]), NIHSS (OR 0.91, 95% CI [0.89-0.94]) and collateral score (PC-CS - OR 1.2495% CI [1.02-1.51]) were independently associated with clinical outcome. Conclusion The two collateral grading systems presented modest prognostic accuracy. Only the PC-CS was independently associated with a favorable outcome at 3 months.
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Affiliation(s)
- Fabricio O. Lima
- Neurology Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
| | - Felipe A. Rocha
- Neurointerventional Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
| | - Henrique C. Silva
- Neurointerventional Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
| | - Volker Puetz
- Department of Neurology, Technical University Dresden, Dresden, Germany
- Dresden Neurovascular Center, Technical University Dresden, Dresden, Germany
| | - Diederik Dippel
- Erasmus MC University Medical Center, Rotterdam, Netherlands
| | | | | | | | - Wim van Zwam
- Interventional Radiology Department, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Adson F. de Lucena
- Neurointerventional Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
| | | | - Martin Arndt
- Department of Neurology, Technical University Dresden, Dresden, Germany
- Dresden Neurovascular Center, Technical University Dresden, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, Technical University Dresden, Dresden, Germany
- Dresden Neurovascular Center, Technical University Dresden, Dresden, Germany
| | - Johannes C. Gerber
- Dresden Neurovascular Center, Technical University Dresden, Dresden, Germany
- Institute of Neuroradiology, Dresden Neurovascular Center, Universitätsklinik Dresden, Dresden, Germany
| | | | | | - Octávio M. Pontes Neto
- Stroke Service, Neurology Division, Department of Neurosciences and Behavioral Sciences, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirao Preto, Brazil
| | - Francisco Antunes Dias
- Stroke Service, Neurology Division, Department of Neurosciences and Behavioral Sciences, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirao Preto, Brazil
| | - Sheila Ouriques Martins
- Department of Neurology, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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Zhang ZMY, Si QQ, Chen HS, Yang Y, Zhang M, Wu SW, Meng Y, Li ML, Lin QQ, Liebeskind DS, Huang YN, Xu WH. High-resolution magnetic resonance imaging of acute intracranial artery thrombus. Eur J Neurol 2023; 30:3172-3181. [PMID: 37452734 DOI: 10.1111/ene.15985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/03/2023] [Accepted: 07/11/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND AND PURPOSE The development of high-resolution magnetic resonance imaging (HR-MRI) has enabled submillimeter-level evaluation of intracranial artery plaque and luminal thrombus. We sought to investigate the value of HR-MRI in assessing the pathogenesis of acute intracranial artery thrombus. METHODS We examined the presence of intracranial thrombus on three-dimensional T1-weighted HR-MRI in acute ischemic stroke patients with intracranial artery occlusion on magnetic resonance angiography. We defined two thrombus-related HR-MRI features (peri-thrombus plaque and distal residual flow beyond the thrombus) and analyzed their association with potential embolic sources. RESULTS Luminal thrombus and a shrunken artery without luminal thrombus were detected in 162 (96.4%) and six (3.6%) of 168 patients with intracranial artery occlusion, respectively. Among 111 patients with culprit major artery thrombus, peri-thrombus plaques were observed in 46.8% and distal residual flow beyond the thrombus in 64.0%. Patients with peri-thrombus plaque had a higher prevalence of diabetes (44.2% vs. 25.4%; p = 0.037), a lower prevalence of potential sources of cardioembolism (0% vs. 16.9%; p = 0.002), and a nonsignificantly lower prevalence of potential embolic sources from extracranial arteries (9.6% vs. 20.3%; p = 0.186) than those without. Patients with distal residual flow beyond the thrombus had a lower prevalence of potential sources of cardioembolism (1.4% vs. 22.5%; p < 0.001) and smaller infarct volumes (5.0 [1.4-12.7] mL vs. 16.6 [2.4-94.6] mL; p = 0.012) than those without. CONCLUSIONS Our study showed that HR-MRI helps clarify the pathogenesis of acute intracranial artery thrombus. The presence of peri-thrombus plaque and distal residual flow beyond the thrombus favor the stroke mechanism of atherosclerosis rather than cardioembolism.
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Affiliation(s)
- Zong-Mu-Yu Zhang
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qian-Qian Si
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yi Yang
- Department of Neurology, the First Hospital of Jilin University, Changchun, China
| | - Meng Zhang
- Department of Neurology, Army Medical Center of PLA, Beijing, China
| | - Shi-Wen Wu
- Department of Neurology and Radiology, General Hospital of Chinese People's Armed Police Forces, Beijing, China
| | - Yao Meng
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming-Li Li
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qian-Qian Lin
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - David S Liebeskind
- UCLA Department of Neurology, Neurovascular Imaging Research Core and UCLA Comprehensive Stroke Center, Los Angeles, California, USA
| | - Yi-Ning Huang
- Department of Neurology, Peking University First Hospital, Peking University, Beijing, China
| | - Wei-Hai Xu
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Gruber P, Valbuena P, Sassenburg R, Anon J, Andereggen L, Berberat J, Remonda L. Anatomical distribution and clinical significance of middle cerebral artery M2 segment vessel occlusions and its cortical branches in acute ischaemic stroke patients. BMJ Neurol Open 2023; 5:e000450. [PMID: 37457626 PMCID: PMC10347505 DOI: 10.1136/bmjno-2023-000450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023] Open
Abstract
Background Characterisation of anatomical distribution and the clinical impact of middle cerebral artery M2 (MCA-M2) segment occlusion and its subsequent cortical branches (CBs) in acute ischaemic stroke patients (AIS). Methods Retrospective, monocentric study analysing radiological and clinical data of AIS patients with MCA-M2 segment occlusion with regard to the anatomic distribution of MCA-M2 occlusion and its subsequent CB. Results A total of 203 patients (median age 77 (IQR 66-83) years, 112 women) were included. There was an equal distribution of right-sided versus left-sided MCA-M2 vessel occlusions (right: n=97; left: n=106), as well as with a median number of affected MCA-M2 CBs of 4 (IQR, 3-6) and a median National Institute of Health Stroke Scale score (NIHSS) on admission of 9 (3-15). For both hemispheres, CBs of the inferior trunks were significantly more affected than the superior trunks. Endovascular treatment (EVT, n=94) was associated with a significant better outcome compared with patients with medical management alone (p=0.027). Conclusion In acute MCA-M2 segment occlusions, inferior trunks are significantly more affected compared with the superior trunks. The subsequent CBs of the paracentral region of both hemispheres are more commonly involved. In eloquent vascular territories, EVT was more often performed.
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Affiliation(s)
- Philipp Gruber
- Department of Neuroradiology, Kantonsspital Aarau AG, Aarau, Switzerland
| | - Paola Valbuena
- Department of Neuroradiology, Kantonsspital Aarau AG, Aarau, Switzerland
| | - Renske Sassenburg
- Department of Neuroradiology, Kantonsspital Aarau AG, Aarau, Switzerland
| | - Javier Anon
- Department of Neuroradiology, Kantonsspital Aarau AG, Aarau, Switzerland
| | - Lukas Andereggen
- Department of Neurosurgery, Kantonsspital Aarau AG, Aarau, Switzerland
| | - Jatta Berberat
- Department of Neuroradiology, Kantonsspital Aarau AG, Aarau, Switzerland
| | - Luca Remonda
- Department of Neuroradiology, Kantonsspital Aarau AG, Aarau, Switzerland
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Toh KZX, Koh MY, Loh EDW, Kwok GYR, Teo YH, Teo YN, Goh CXY, Syn NLX, Ho AFW, Sia CH, Brouwer PA, Andersson T, Meyer L, Fiehler J, Bhogal P, Sharma VK, Tan BYQ, Yeo LLL. Distal medium vessel occlusions in acute ischaemic stroke - Stent retriever versus direct aspiration: A systematic review and meta-analysis. Eur Stroke J 2023; 8:434-447. [PMID: 37231692 PMCID: PMC10334182 DOI: 10.1177/23969873231151262] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 12/28/2022] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Acute ischaemic stroke due to distal medium vessel occlusion (AIS-DMVO) causes significant morbidity. Endovascular thrombectomy advancement has made treating AIS-DMVO with stent retrievers (SR) and aspiration catheters (AC) possible, however the optimal technique remains unknown. We performed a systematic review and meta-analysis to investigate the efficacy and safety of SR use compared to purely AC use in patients with AIS-DMVO. METHODS We systematically searched PubMed, Cochrane Library and EMBASE, from inception to 2nd September 2022, for studies comparing SR or primary combined (SR/PC) against AC in AIS-DMVO. We adopted the Distal Thrombectomy Summit Group's definition of DMVO. Efficacy outcomes were functional independence (modified Rankin Scale (mRS) 0-2 at 90 days), first pass effect (modified Thrombolysis in Cerebral Infarction scale (mTICI) 2c-3 or expanded Thrombolysis in Cerebral Infarction scale (eTICI) 2c-3 at first pass), successful final recanalisation (mTICI or eTICI 2b-3), and excellent final recanalisation (mTICI or eTICI 2c-3). Safety outcomes were symptomatic intracranial haemorrhage (sICH) and 90-day mortality. RESULTS 12 cohort studies and 1 randomised-controlled trial were included, involving 1881 patients with 1274 receiving SR/PC and 607 receiving AC only. SR/PC achieved higher odds of functional independence (odds ratio (OR) 1.33, 95% confidence interval (CI) 1.06-1.67) and lower odds of mortality (OR 0.69, 95% CI 0.50-0.94) than AC. Odds of successful/excellent recanalisation and sICH were similar between both groups. Stratified to compare only SR and only AC, the use of only SR, achieved significantly higher odds of successful recanalisation as compared to only AC (OR 1.80, 95% CI 1.17-2.78). CONCLUSION There is potential for efficacy and safety benefits in SR/PC use as compared to AC only in AIS-DMVO. Further trials are necessary to validate the efficacy and safety of SR use in AIS-DMVO.
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Affiliation(s)
- Keith Zhi Xian Toh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Ming Yi Koh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Enver De Wei Loh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Gabriel Yi Ren Kwok
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Claire Xin Yi Goh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicholas Li Xun Syn
- Department of Surgery, University Surgical Cluster, National University Health System, Singapore
| | - Andrew Fu Wah Ho
- SingHealth Duke-NUS Emergency Medicine Academic Clinical Program, Singapore
- Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Patrick A Brouwer
- Cerenovus (Johnson & Johnson), Galway Neuro Technology Centre, Galway, Ireland
| | | | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Vijay K Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Benjamin YQ Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Leonard L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
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He R, Zhou J, Xu X, Wei X, Wang F, Li Y. Comparing the predictive value of quantitative magnetic resonance imaging parametric response mapping and conventional perfusion magnetic resonance imaging for clinical outcomes in patients with chronic ischemic stroke. Front Neurosci 2023; 17:1177044. [PMID: 37304032 PMCID: PMC10248057 DOI: 10.3389/fnins.2023.1177044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/02/2023] [Indexed: 06/13/2023] Open
Abstract
Predicting clinical outcomes after stroke, using magnetic resonance imaging (MRI) measures, remains a challenge. The purpose of this study was to investigate the prediction of long-term clinical outcomes after ischemic stroke using parametric response mapping (PRM) based on perfusion MRI data. Multiparametric perfusion MRI datasets from 30 patients with chronic ischemic stroke were acquired at four-time points ranging from V2 (6 weeks) to V5 (7 months) after stroke onset. All perfusion MR parameters were analyzed using the classic whole-lesion approach and voxel-based PRM at each time point. The imaging biomarkers from each acquired MRI metric that was predictive of both neurological and functional outcomes were prospectively investigated. For predicting clinical outcomes at V5, it was identified that PRMTmax-, PRMrCBV-, and PRMrCBV+ at V3 were superior to the mean values of the corresponding maps at V3. We identified correlations between the clinical prognosis after stroke and MRI parameters, emphasizing the superiority of the PRM over the whole-lesion approach for predicting long-term clinical outcomes. This indicates that complementary information for the predictive assessment of clinical outcomes can be obtained using PRM analysis. Moreover, new insights into the heterogeneity of stroke lesions revealed by PRM can help optimize the accurate stratification of patients with stroke and guide rehabilitation.
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Affiliation(s)
- Rui He
- Department of Radiology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jia Zhou
- Department of Radiology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoyu Xu
- Department of Radiology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoer Wei
- Department of Radiology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feng Wang
- Department of Neurology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuehua Li
- Department of Radiology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Werdiger F, Gotla S, Visser M, Kolacz J, Yogendrakumar V, Beharry J, Valente M, Sharobeam A, Parsons MW, Bivard A. Automated occlusion detection for the diagnosis of acute ischemic stroke: A detailed performance review. Eur J Radiol 2023; 164:110845. [PMID: 37148842 DOI: 10.1016/j.ejrad.2023.110845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 04/15/2023] [Accepted: 04/20/2023] [Indexed: 05/08/2023]
Abstract
INTRODUCTION Stroke is a leading cause of adult disability and death worldwide. Automated detection of stroke on brain imaging has promise in a time critical environment. We present a method for the automated detection of intracranial occlusions on dynamic CT Angiography (CTA) causing acute ischemic stroke. METHODS We derived dynamic CTA images from CT Perfusion (CTP) data and utilised advanced image processing to enhance and display major cerebral blood vessels for symmetry analysis. We reviewed the performance of the algorithm on a cohort of 207 patients from the International Stroke Perfusion Imaging Registry (INSPIRE), with Large Vessel Occlusion (LVO) and non-LVO strokes. Included in the data were images with chronic stroke, various artefacts, incomplete vessel occlusions, and images of poorer quality. All images were annotated by stroke experts. In addition, each image was graded in terms of the difficulty of the task of occlusion detection. Performance was evaluated on the overall cohort, and with respect to occlusion location, collateral grade, and task difficulty. We also evaluated the impact of including additional perfusion data. RESULTS Images with a rating of lower difficulty achieved a sensitivity and specificity of 96% and 90%, respectively, while images with a moderate difficulty rating achieved 88% and 50%, respectively. For cases of high difficulty, where more than two experts or additional data were required to reach consensus, sensitivity and specificity was 53% and 11%. The addition of perfusion data to the dCTA images increased the specificity by 38%. CONCLUSION We have provided an unbiased interpretation of algorithm performance. Further developments include generalising to conventional CTA and employing the algorithm in a clinical setting for prospective studies.
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Affiliation(s)
- Freda Werdiger
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia.
| | - Sunay Gotla
- Southwestern Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Milanka Visser
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - James Kolacz
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Vignan Yogendrakumar
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - James Beharry
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, Australia
| | - Michael Valente
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Angelos Sharobeam
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Mark W Parsons
- Apollo Medical Imaging, Melbourne, Australia; Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia; Department of Neurology, Liverpool Hospital, NSW, Australia
| | - Andrew Bivard
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
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9
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Endovascular treatment achieves better outcomes than best medical management in patients with M2 occlusion and high stroke severity: a meta-analysis. J Neurol 2023; 270:2924-2937. [PMID: 36862149 DOI: 10.1007/s00415-023-11653-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 02/24/2023] [Accepted: 02/25/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND The lack of randomized evidence makes it difficult to establish reliable treatment recommendations for patients with M2 occlusion. This study aims to compare the efficacy and safety of endovascular treatment (EVT) with best medical management (BMM) in patients with M2 occlusion, and to investigate whether the optimal treatment varies according to stroke severity. METHODS Comprehensive literature retrieval was conducted to identify studies that directly compared the outcomes of EVT and BMM. According to stroke severity, the study population were classified into those with moderate-severe stroke and those with mild stroke. National Institute of Health Stroke Scale (NIHSS) scores ≥ 6 was defined as moderate-severe stroke, and NIHSS scores 0-5 as mild stroke. Random-effects meta-analyses were performed to measure the symptomatic intracranial hemorrhage (sICH) within 72 h, and the modified Rankin Scale (mRS) scores 0-2 and the mortality at 90 days. RESULTS Totally, 20 studies were identified, including 4358 patients. In the moderate-severe stroke population, the EVT had 82% higher odds for mRS scores 0-2 (OR 1.82, 95% CI 1.34-2.49) and a 43% lower odds for mortality (OR 0.57, 95% CI 0.39-0.82) compared with the BMM. However, no difference was found in the sICH rate (OR 0.88, 95% CI 0.44-1.77). In the mild stroke population, no differences were observed in the mRS scores 0-2 (OR 0.81, 95% CI 0.59-1.10) or mortality (OR 1.23, 95% CI 0.72-2.10) between EVT and BMM, whereas EVT was associated with higher sICH rate (OR 4.21, 95% CI 1.86-9.49). CONCLUSION EVT may be only beneficial for patients with M2 occlusion and high stroke severity, but not for those with NIHSS scores 0-5.
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10
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Cipolla MJ. Therapeutic Induction of Collateral Flow. Transl Stroke Res 2023; 14:53-65. [PMID: 35416577 PMCID: PMC10155807 DOI: 10.1007/s12975-022-01019-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/31/2022] [Accepted: 04/01/2022] [Indexed: 01/31/2023]
Abstract
Therapeutic induction of collateral flow as a means to salvage tissue and improve outcome from acute ischemic stroke is a promising approach in the era in which endovascular therapy is no longer time-dependent but collateral-dependent. The importance of collateral flow enhancement as a therapeutic for acute ischemic stroke extends beyond those patients with large amounts of salvageable tissue. It also has the potential to extend the time window for reperfusion therapies in patients who are ineligible for endovascular thrombectomy. In addition, collateral enhancement may be an important adjuvant to neuroprotective agents by providing a more robust vascular route for which treatments can gain access to at risk tissue. However, our understanding of collateral hemodynamics, including under comorbid conditions that are highly prevalent in the stroke population, has hindered the efficacy of collateral flow augmentation for improving stroke outcome in the clinical setting. This review will discuss our current understanding of pial collateral function and hemodynamics, including vasoactivity that is critical for enhancing penumbral perfusion. In addition, mechanisms by which collateral flow can be increased during acute ischemic stroke to limit ischemic injury, that may be different depending on the state of the brain and vasculature prior to stroke, will also be reviewed.
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Affiliation(s)
- Marilyn J Cipolla
- Department of Neurological Sciences, University of Vermont Robert Larner College of Medicine, 149 Beaumont Ave, HSRF 416A, Burlington, VT, USA.
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Vermont Larner College of Medicine, Burlington, VT, USA.
- Department of Pharmacology, University of Vermont Larner College of Medicine, Burlington, VT, USA.
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11
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Does stress hyperglycemia in diabetic and non-diabetic acute ischemic stroke patients predict unfavorable outcomes following endovascular treatment? Neurol Sci 2023; 44:1695-1702. [PMID: 36652040 DOI: 10.1007/s10072-023-06625-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 01/12/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND Hyperglycemia in hospitalized patients is related to increased morbidity and mortality, we determine if stress hyperglycemia, as assessed by the stress hyperglycemia ratio (SHR) index, increases the risk of adverse events in diabetic and non-diabetic AIS (acute ischemic stroke) patients following EVT (endovascular treatment). METHODS We retrospectively analyzed data of 209 patients who achieved complete recanalization. SHR was defined as [FPG (mmol/L)/HbA1c (%)]. This study comprised 130 non-diabetic AIS patients and 79 people with diabetes, and they were categorized into three different groups based on SHR (Q1-Q3) tertiles. The primary outcome was futile recanalization, characterized as a 3-month modified Rankin scale score (mRS) of 3-6. Multivariable logistic regression analyses were utilized to calculate the relationship between stress hyperglycemia and poor outcomes. RESULTS Non-diabetic patients showed statistically significant differences in the proportion of 3-month all-cause mortality (14.6% for Q1, 63.0% for Q2, 74.4% for Q3, p<0.001) and futile recanalization (2.4% for Q1, 19.6% for Q2, 37.2% for Q3, p<0.001) between the three groups. After adjusting for potential confounders, we found that the highest SHR tertile remained an independent risk factor of futile recanalization (OR 18.13, 95% CI 3.38-97.38, p = 0.001) and 3-month all-cause mortality (OR 15.9, 95% CI 1.46-173.26, p = 0.023) among non-diabetic patients. As demonstrated by restricted cubic splines, the SHR reference was 1.12. CONCLUSIONS Severe stress hyperglycemia independently increased the odds of futile recanalization and 3-month all-cause mortality in AIS patients receiving EVT but without diabetes.
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12
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Xu Y, Fu W, Wang Y, Bi Q, Wang Q, Yang L, Zhang Q, Wang F. Endovascular treatment for acute M2 occlusion stroke within 6 hours-a retrospective real-world evidence. Front Cardiovasc Med 2023; 9:1063078. [PMID: 36704481 PMCID: PMC9871547 DOI: 10.3389/fcvm.2022.1063078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023] Open
Abstract
Background We compared the efficacy and safety of endovascular therapy (EVT), intravenous (IV) thrombolysis and conservative treatment in M2 segment occlusion stroke based on a real-world database. Methods We retrospectively analyzed the database of admitted patients with M2 segment occlusion between January 2018 and December 2020. The patients who were eligible for reperfusion treatment were assigned to EVT, IV thrombolysis or conservative treatment according to the exact management proceeding. The primary outcome was a score of 0 and 1 on the modified Rankin scale (mRS) at 90 days. The odds ratio (OR) for the primary outcome was adjusted for age, baseline National Institute of Health Stroke Scale score, and door-to-treatment time. The secondary outcomes were based on a mRS score from 0 to 2 at 90 days and the safety outcomes including symptomatic intracranial hemorrhage, and all-cause mortality. The data were analyzed by the logistical regression model, including baseline adjustments. Results A total of 109 patients were included. Among them, 42 (38.5%) patients received EVT, 45 (42.5%) received IV thrombolysis and 22 (20.8%) received conservative treatment. The primary outcome based on a mRS score of 0 and 1, occurred in 66.7% of patients in the EVT group and 40% in the IV thrombolysis group (adjusted OR, 1.79; 95% confidence interval [CI], 1.19-2.68; P = 0.01). Symptomatic intracranial hemorrhage occurred in 1 patient (2.3%) in the EVT group and in 2 patients (4.4%) in the IV thrombolysis group (adjusted OR = 0.71, 95% CI: 0.13-4.07). Conclusion EVT showed better functional outcomes than IV thrombolysis and conservative treatment in moderate to severe acute stoke patients with M2 occlusion. There was no significant difference in the three groups concerning the incidence of symptomatic intracranial hemorrhage.
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Affiliation(s)
- Yi Xu
- Department of Neurosurgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wang Fu
- Department of Neurology, Seventh People’s Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yongpeng Wang
- Department of Neurology, Seventh People’s Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qianqian Bi
- Department of Neurology, Seventh People’s Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qiwei Wang
- Department of Neurology, Seventh People’s Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Lu Yang
- Department of Neurology, Seventh People’s Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Quanbin Zhang
- Department of Neurosurgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China,Quanbin Zhang,
| | - Feng Wang
- Department of Neurology, Seventh People’s Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China,*Correspondence: Feng Wang,
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13
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Su J, Wolff L, van Doormaal PJ, Dippel DWJ, van Zwam W, Niessen WJ, van der Lugt A, van Walsum T. Time dependency of automated collateral scores in computed tomography angiography and computed tomography perfusion images in patients with intracranial arterial occlusion. Neuroradiology 2023; 65:313-322. [PMID: 36167825 PMCID: PMC9859867 DOI: 10.1007/s00234-022-03050-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/03/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE The assessment of collateral status may depend on the timing of image acquisition. The purpose of this study is to investigate whether there are optimal time points in CT Perfusion (CTP) for collateral status assessment, and compare collaterals scores at these time points with collateral scores from multiphase CT angiography (mCTA). METHODS Patients with an acute intracranial occlusion who underwent baseline non-contrast CT, mCTA and CT perfusion were selected. Collateral status was assessed using an automatically computed Collateral Ratio (CR) score in mCTA, and predefined time points in CTP acquisition. CRs extracted from CTP were correlated with CRs from mCTA. In addition, all CRs were related to baseline National Institutes of Health Stroke Scale (NIHSS) and Alberta Stoke Program Early CT Score (ASPECTS) with linear regression analysis to find the optimal CR. RESULTS In total 58 subjects (median age 74 years; interquartile range 61-83 years; 33 male) were included. When comparing the CRs from the CTP vs. mCTA acquisition, the strongest correlations were found between CR from baseline mCTA and the CR at the maximal intensity projection of time-resolved CTP (r = 0.81) and the CR at the peak of arterial enhancement point (r = 0.78). Baseline mCTA-derived CR had the highest correlation with ASPECTS (β = 0.36 (95%CI 0.11, 0.61)) and NIHSS (β = - 0.48 (95%CI - 0.72, - 0.16)). CONCLUSION Collateral status assessment strongly depends on the timing of acquisition. Collateral scores obtained from mCTA imaging is close to the optimal collateral score obtained from CTP imaging.
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Affiliation(s)
- Jiahang Su
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands.
| | - Lennard Wolff
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | | | | | - Wim van Zwam
- Department of Radiology, Maastricht UMC +, Maastricht, The Netherlands
| | - Wiro J Niessen
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
- Faculty of Applied Science, Delft University of Technology, Delft, The Netherlands
| | - Aad van der Lugt
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Theo van Walsum
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
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14
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Sousa JA, Sondermann A, Bernardo-Castro S, Varela R, Donato H, Sargento-Freitas J. Diagnostic accuracy of CT angiography and CT perfusion imaging for detecting distal medium vessel occlusions: Protocol for a systematic review and meta-analysis. PLoS One 2023; 18:e0284116. [PMID: 37036841 PMCID: PMC10085008 DOI: 10.1371/journal.pone.0284116] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 03/24/2023] [Indexed: 04/11/2023] Open
Abstract
BACKGROUND Distal medium vessel occlusions (DMVOs) represent 25-40% of all acute ischemic strokes (AIS). DMVO clinical syndromes are heterogenous, but as eloquent brain regions are frequently involved, they are often disabling. Since current intravenous fibrinolytic therapies may fail to recanalize up to two-thirds of DMVOs, endovascular treatment is progressively being considered in this setting. Nevertheless, the optimal imaging method for diagnosis remains to be defined. Stroke centers that use computed tomography as a routine stroke imaging approach rely on either isolated computed tomography angiography (CTA) or combined perfusion (CTP) studies. Despite a simplified non-CTP-dependent approach seeming reasonable for large vessel occlusion AIS diagnosis, CTP may still hold advantages for DMVOs workup. Therefore, this systematic review aims to compare the diagnostic performance of CTA and CTP in detecting DMVOs. METHODS We will perform a systematic search in PubMed, EMBASE, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials. In addition, grey literature and ClinicalTrials.gov will be scanned. We will include any type of study that presents data on the diagnostic accuracy of CTA and/or CTP for detecting DMVOs. Two authors will independently review retrieved studies, and any discrepancies will be resolved by consensus or with a third reviewer. Reviewers will extract the data and assess the risk of bias in the selected studies. Data will be combined in a quantitative meta-analysis following the guidelines provided by the Cochrane Handbook for Systematic Reviews of Interventions. We will assess cumulative evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. DISCUSSION This will be the first systematic review and meta-analysis that compares two different imaging approaches for detecting DMVOs. This study may help to define optimal acute ischemic stroke imaging work-up. TRIAL REGISTRATION PROSPERO registration: CRD42022344006.
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Affiliation(s)
- João André Sousa
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | | | - Sara Bernardo-Castro
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
| | - Ricardo Varela
- Neurology Department, Centro Hospitalar e Universitário de Santo António, Porto, Portugal
| | - Helena Donato
- Documentation and Scientific Information Service, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - João Sargento-Freitas
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
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15
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Gensicke H, Al-Ajlan F, Fladt J, Campbell BCV, Majoie CBLM, Bracard S, Hill MD, Muir KW, Demchuk A, San Román L, van der Lugt A, Liebeskind DS, Brown S, White PM, Guillemin F, Dávalos A, Jovin TG, Saver JL, Dippel DWJ, Goyal M, Mitchell PJ, Menon BK. Comparison of Three Scores of Collateral Status for Their Association With Clinical Outcome: The HERMES Collaboration. Stroke 2022; 53:3548-3556. [PMID: 36252099 DOI: 10.1161/strokeaha.122.039717] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Leptomeningeal collateral status on baseline computed tomographic angiography (CTA) is associated with clinical outcome after acute ischemic stroke treatment. However, assessment of collateral status is not uniform. To compare 3 different CTA collateral scores (CS) and imaging techniques about their association with clinical outcome. METHODS Pooled analysis of patient-level data from the Highly Effective Reperfusion Using Multiple Endovascular Devices collaboration. Patients with large vessel occlusion from 7 randomized controlled trials that compared endovascular thrombectomy with standard medical care were included. Three different CS (Tan CS, regional CS [rCS], and regional Alberta Stroke Program Early CT Score CS) and 2 imaging techniques (single-phase [sCTA] and multiphase/dynamic CTA) were evaluated. Functional independence (modified Rankin Scale score 0-2) at 3 months poststroke was the primary outcome. Furthermore, we assessed the effect of sCTA image acquisition time on collateral status assessment using an adjusted ordinal logistic regression model to obtain predicted values for the trichotomized rCS. RESULTS Among 1147 pooled patients, 948 (82.7%) had sCTA and 199 (17.3%) multiphase/dynamic CTA as baseline angiography. With all 3 collateral scales, better CSs were associated with better 3-month functional outcome. With sCTA images, the rCS (area under the curve [AUC] 0.63) and regional Alberta Stroke Program Early CT Score CS (AUC 0.62) better predicted functional outcome than the Tan CS (AUC 0.60, respectively; P<0.001 and P=0.02). With multiphase/dynamic CTA images, all collateral scales performed similarly in predicting functional outcome (rCS [AUC 0.61]; regional Alberta Stroke Program Early CT Score CS [AUC 0.61] versus Tan CS [AUC 0.61], respectively; P=0.93 and P=0.91). Overall, no endovascular thrombectomy treatment effect modification by collateral status (rCS) was demonstrated (P=0.41). sCTA timing independently influenced CS assessment. On earlier timed sCTA, the predicted proportions of scans with poor collaterals was higher and vice versa. CONCLUSIONS In this data set of highly selected patients with stroke, using a regional CS on sCTA likely allows for the most accurate prediction of functional outcome while on time-resolved CTA, the type of CS did not matter. Patients across all collateral grades benefit from endovascular thrombectomy. sCTA timing independently influenced CS assessment.
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Affiliation(s)
- Henrik Gensicke
- Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (H.G., J.F., M.D.H., A.D., M.G., B.K.M.).,Department of Neurology, Stroke Center, University Hospital Basel, University of Basel, Switzerland (H.G., J.F.)
| | - Fahad Al-Ajlan
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia (F.A.-A.)
| | - Joachim Fladt
- Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (H.G., J.F., M.D.H., A.D., M.G., B.K.M.).,Department of Neurology, Stroke Center, University Hospital Basel, University of Basel, Switzerland (H.G., J.F.)
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (B.C.V.C.), University of Melbourne, Parkville, Australia
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, the Netherlands (C.B.L.M.M.)
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, INSERM U 1254 (S.B.), Université de Lorraine, University Hospital of Nancy, France
| | - Michael D Hill
- Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (H.G., J.F., M.D.H., A.D., M.G., B.K.M.)
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, United Kingdom (K.W.M.)
| | - Andrew Demchuk
- Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (H.G., J.F., M.D.H., A.D., M.G., B.K.M.)
| | - Luis San Román
- Department of Interventional Neuroradiology, CDI, Hospital Clinic of Barcelona, Spain (L.S.R.)
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine (A.v.d.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - David S Liebeskind
- Department of Neurology and Comprehensive Stroke Center (D.S.L.), David Geffen School of Medicine at the University of California, Los Angeles
| | - Scott Brown
- Altair Biostatistics, St Louis Park, MN (S.B.)
| | - Philip M White
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Newcastle upon Tyne Hospitals NHS Trust, United Kingdom (P.M.W.)
| | - Francis Guillemin
- INSERM CIC 1433 Clinical Epidemiology (F.G.), Université de Lorraine, University Hospital of Nancy, France
| | - Antoni Dávalos
- Department of Neuroscience, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Spain (A.D.)
| | - Tudor G Jovin
- Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, PA (T.G.J.)
| | - Jeffrey L Saver
- Department of Neurology (J.L.S.), David Geffen School of Medicine at the University of California, Los Angeles
| | - Diederik W J Dippel
- Department of Neurology (D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Mayank Goyal
- Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (H.G., J.F., M.D.H., A.D., M.G., B.K.M.)
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital (P.J.M.), University of Melbourne, Parkville, Australia
| | - Bijoy K Menon
- Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada (H.G., J.F., M.D.H., A.D., M.G., B.K.M.)
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Middle Cerebral Artery M2 Thrombectomy: Safety and Technical Considerations in the German Stroke Registry (GSR). J Clin Med 2022; 11:jcm11154619. [PMID: 35956233 PMCID: PMC9369518 DOI: 10.3390/jcm11154619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/05/2022] [Accepted: 08/05/2022] [Indexed: 11/16/2022] Open
Abstract
There is ongoing debate concerning the safety and efficacy of various mechanical thrombectomy (MT) approaches for M2 occlusions. We compared these for MT in M2 versus M1 occlusions. Subgroup analyses of different technical approaches within the M2 MT cohort were also performed. Patients were included from the German Stroke Registry (GSR), a multicenter registry of consecutive MT patients. Primary outcomes were reperfusion success events. Secondary outcomes were early clinical improvement (improvement in NIHSS score > 4) and independent survival at 90 days (mRS 0−2). Out of 3804 patients, 2689 presented with M1 (71%) and 1115 with isolated M2 occlusions (29%). The mean age was 76 (CI 65−82) and 77 (CI 66−83) years, respectively. Except for baseline NIHSS (15 (CI 10−18) vs. 11 (CI 6−16), p < 0.001) and ASPECTS (9 (CI 7−10) vs. 9 (CI 8−10, p < 0.001), baseline demographics were balanced. Apart from a more frequent use of dedicated small vessel stent retrievers (svSR) in M2 (17.4% vs. 3.0; p < 0.001), intraprocedural aspects were balanced. There was no difference in ICH at 24 h (11%; p = 1.0), adverse events (14.4% vs. 18.1%; p = 0.63), clinical improvement (62.5% vs. 61.4 %; p = 0.57), mortality (26.9% vs. 22.9%; p = 0.23). In M2 MT, conventional stent retriever (cSR) achieved higher rates of mTICI3 (54.0% vs. 37.7−42.0%; p < 0.001), requiring more MT-maneuvers (7, CI 2−8) vs. 2 (CI 2−7)/(CI 2−2); p < 0.001) and without impact on efficacy and outcome. Real-life MT in M2 can be performed with equal safety and efficacy as in M1 occlusions. Different recanalization techniques including the use of svSR did not result in significant differences regarding safety, efficacy and outcome.
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Zhang Y, Zhuang Y, Ge Y, Wu PY, Zhao J, Wang H, Song B. MRI whole-lesion texture analysis on ADC maps for the prognostic assessment of ischemic stroke. BMC Med Imaging 2022; 22:115. [PMID: 35778678 PMCID: PMC9250246 DOI: 10.1186/s12880-022-00845-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/23/2022] [Indexed: 11/28/2022] Open
Abstract
Background This study aims is to explore whether it is feasible to use magnetic resonance texture analysis (MRTA) in order to distinguish favorable from unfavorable function outcomes and determine the prognostic factors associated with favorable outcomes of stroke. Methods The retrospective study included 103 consecutive patients who confirmed unilateral anterior circulation subacute ischemic stroke by computed tomography angiography between January 2018 and September 2019. Patients were divided into favorable outcome (modified Rankin scale, mRS ≤ 2) and unfavorable outcome (mRS > 2) groups according to mRS scores at day 90. Two radiologists manually segmented the infarction lesions based on diffusion-weighted imaging and transferred the images to corresponding apparent diffusion coefficient (ADC) maps in order to extract texture features. The prediction models including clinical characteristics and texture features were built using multiple logistic regression. A univariate analysis was conducted to assess the performance of the mean ADC value of the infarction lesion. A Delong’s test was used to compare the predictive performance of models through the receiver operating characteristic curve. Results The mean ADC performance was moderate [AUC = 0.60, 95% confidence interval (CI) 0.49–0.71]. The texture feature model of the ADC map (tADC), contained seven texture features, and presented good prediction performance (AUC = 0.83, 95%CI 0.75–0.91). The energy obtained after wavelet transform, and the kurtosis and skewness obtained after Laplacian of Gaussian transformation were identified as independent prognostic factors for the favorable stroke outcomes. In addition, the combination of the tADC model and clinical characteristics (hypertension, diabetes mellitus, smoking, and atrial fibrillation) exhibited a subtly better performance (AUC = 0.86, 95%CI 0.79–0.93; P > 0.05, Delong’s). Conclusion The models based on MRTA on ADC maps are useful to evaluate the clinical function outcomes in patients with unilateral anterior circulation ischemic stroke. Energy obtained after wavelet transform, kurtosis obtained after Laplacian of Gaussian transform, and skewness obtained after Laplacian of Gaussian transform were identified as independent prognostic factors for favorable stroke outcomes.
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Affiliation(s)
- Yuan Zhang
- Department of Radiology, Minhang Hospital, Fudan University, 170 Xinsong Road, Shanghai, 201199, People's Republic of China
| | - Yuzhong Zhuang
- Department of Radiology, Minhang Hospital, Fudan University, 170 Xinsong Road, Shanghai, 201199, People's Republic of China
| | - Yaqiong Ge
- Department of Medicine, GE Healthcare, Shanghai, People's Republic of China
| | - Pu-Yeh Wu
- Department of Medicine, GE Healthcare, Beijing, People's Republic of China
| | - Jing Zhao
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, People's Republic of China
| | - Hao Wang
- Department of Radiology, Minhang Hospital, Fudan University, 170 Xinsong Road, Shanghai, 201199, People's Republic of China.
| | - Bin Song
- Department of Radiology, Minhang Hospital, Fudan University, 170 Xinsong Road, Shanghai, 201199, People's Republic of China.
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18
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Virtanen P, Tomppo L, Martinez-Majander N, Kokkonen T, Sillanpää M, Lappalainen K, Strbian D. Thrombectomy in acute ischemic stroke in the extended time window: Real-life experience in a high-volume center. J Stroke Cerebrovasc Dis 2022; 31:106603. [PMID: 35749938 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/23/2022] [Accepted: 06/12/2022] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Selected patients with acute ischemic stroke (AIS) caused by proximal middle cerebral artery (MCA) or internal carotid artery occlusion benefit from endovascular thrombectomy (EVT) in extended time window (6-24 h from last seen well) based on two landmark randomized controlled trials (RCTs) DAWN and DEFUSE-3. We evaluated patients' outcome in the real-life with the focus on adherence to protocol of the two RCTs. MATERIALS AND METHODS We included consecutive patients with AIS (excluding basilar artery occlusions) referred to EVT in our stroke center in the extended time window between January 2018 and December 2019 and compared the outcome of patients who fulfilled criteria of the RCTs with those who did not. RESULTS Of the total of 100 patients, 23 complied with RCT's criteria and 18 presented with minor non-adherence (lower NIHSS score or longer treatment delay), whereas 22 patients had large baseline ischemia (>1/3 MCA), 28 presented with M2 and more distal occlusions, and 9 patients did not undergo perfusion imaging prior to EVT. Good 3-month outcome (modified Rankin Scale 0-2) was observed in 54% of those who either met the RCT criteria or presented with lower NIHSS score or longer treatment delay, but only in 30% of M2 occlusions, and in none of the patients with large baseline ischemia. CONCLUSIONS Our findings highlight the impact of mostly large baseline ischemia but also vessel status when selecting patients for EVT in the extended time window and emphasize the need for further data in these patient subgroups.
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Affiliation(s)
- Pekka Virtanen
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Finland
| | - Liisa Tomppo
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Finland.
| | | | - Tatu Kokkonen
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Finland
| | - Mikko Sillanpää
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Finland
| | - Kimmo Lappalainen
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Finland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Finland
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19
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The Association between Hypoxia-Induced Low Activity and Apoptosis Strongly Resembles That between TTX-Induced Silencing and Apoptosis. Int J Mol Sci 2022; 23:ijms23052754. [PMID: 35269895 PMCID: PMC8911517 DOI: 10.3390/ijms23052754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/16/2022] [Accepted: 02/26/2022] [Indexed: 01/27/2023] Open
Abstract
In the penumbra of a brain infarct, neurons initially remain structurally intact, but perfusion is insufficient to maintain neuronal activity at physiological levels. Improving neuronal recovery in the penumbra has large potential to advance recovery of stroke patients, but penumbral pathology is incompletely understood, and treatments are scarce. We hypothesize that low activity in the penumbra is associated with apoptosis and thus contributes to irreversible neuronal damage. We explored the putative relationship between low neuronal activity and apoptosis in cultured neurons exposed to variable durations of hypoxia or TTX. We combined electrophysiology and live apoptosis staining in 42 cultures, and compared effects of hypoxia and TTX silencing in terms of network activity and apoptosis. Hypoxia rapidly reduced network activity, but cultures showed limited apoptosis during the first 12 h. After 24 h, widespread apoptosis had occurred. This was associated with full activity recovery observed upon reoxygenation within 12 h, but not after 24 h. Similarly, TTX exposure strongly reduced activity, with full recovery upon washout within 12 h, but not after 24 h. Mean temporal evolution of apoptosis in TTX-treated cultures was the same as in hypoxic cultures. These results suggest that prolonged low activity may be a common factor in the pathways towards apoptosis.
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20
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Fasen BACM, Berendsen RCM, Kwee RM. Artificial intelligence software for diagnosing intracranial arterial occlusion in patients with acute ischemic stroke. Neuroradiology 2022; 64:1579-1583. [PMID: 35137270 DOI: 10.1007/s00234-022-02912-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/01/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE To evaluate the diagnostic performance of AI software in diagnosing intracranial arterial occlusions in the proximal anterior circulation at CT angiography (CTA) and to compare it to manual reading performed in clinical practice. METHODS Patients with acute ischemic stroke underwent CTA to detect arterial occlusion in the proximal anterior circulation. Retrospective review of CTA scans by two neuroradiologists served as reference standard. Sensitivity and specificity of AI software (StrokeViewer) were compared to those of manual reading using the McNemar test. The proportions of correctly detected occlusions in the distal internal carotid artery and/or M1 segment of the middle cerebral artery (large vessel occlusion [LVO]) and in the M2 segment of the middle cerebral artery (medium vessel occlusion [MeVO]) were calculated. RESULTS Of the 474 patients, 75 (15.8%) had an arterial occlusion in the proximal anterior circulation according to the reference standard. Sensitivity of StrokeViewer software was not significantly different compared to that of manual reading (77.3% vs. 78.7%, P = 1.000). Specificity of StrokeViewer software was significantly lower than that of manual reading (88.5% vs. 100%, P < 0.001). StrokeViewer software correctly identified 40 of 42 LVOs (95.2%) and 18 of 33 MeVOs (54.5%). StrokeViewer software detected 8 of 16 (50%) intracranial arterial occlusions which were missed by manual reading. CONCLUSION The current AI software detected intracranial arterial occlusion with moderate sensitivity and fairly high specificity. The AI software may detect additional occlusions which are missed by manual reading. As such, the use of AI software may be of value in clinical stroke care.
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Affiliation(s)
- Bram A C M Fasen
- Department of Radiology, Zuyderland Medical Center, Henri Dunantstraat 5, 6419 PC, Heerlen/Sittard/Geleen, The Netherlands
| | - Ralph C M Berendsen
- Department of Medical Physics, Zuyderland Medical Center, Heerlen/Sittard/Geleen, The Netherlands
| | - Robert M Kwee
- Department of Radiology, Zuyderland Medical Center, Henri Dunantstraat 5, 6419 PC, Heerlen/Sittard/Geleen, The Netherlands.
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21
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Ospel J, Bala F, McDonough R, Volny O, Kashani N, Qiu W, Menon B, Goyal M. Interrater Agreement and Detection Accuracy for Medium-Vessel Occlusions Using Single-Phase and Multiphase CT Angiography. AJNR Am J Neuroradiol 2022; 43:93-97. [PMID: 34824099 PMCID: PMC8757553 DOI: 10.3174/ajnr.a7361] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 09/22/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND PURPOSE Accurate and reliable detection of medium-vessel occlusions is important to establish the diagnosis of acute ischemic stroke and initiate appropriate treatment with intravenous thrombolysis or endovascular thrombectomy. However, medium-vessel occlusions are often challenging to detect, especially for unexperienced readers. We aimed to evaluate the accuracy and interrater agreement of the detection of medium-vessel occlusions using single-phase and multiphase CTA. MATERIALS AND METHODS Single-phase and multiphase CTA of 120 patients with acute ischemic stroke (20 with no occlusion, 44 with large-vessel occlusion, and 56 with medium-vessel occlusion in the anterior and posterior circulation) were assessed by 3 readers with varying levels of experience (session 1: single-phase CTA; session 2: multiphase CTA). Interrater agreement for occlusion type (large-vessel occlusion versus medium-vessel occlusion versus no occlusion) and for detailed occlusion sites was calculated using the Fleiss κ with 95% confidence intervals. Accuracy for the detection of medium-vessel occlusions was calculated for each reader using classification tables. RESULTS Interrater agreement for occlusion type was moderate for single-phase CTA (κ = 0.58; 95% CI, 0.56-0.62) and almost perfect for multiphase CTA (κ = 0.81; 95% CI, 0.78-0.83). Interrater agreement for detailed occlusion sites was moderate for single-phase CTA (κ = 0.55; 95% CI, 0.53-0.56) and substantial for multiphase CTA (κ = 0.71; 95% CI, 0.67-0.74). On single-phase CTA, readers 1, 2, and 3 classified 33/56 (59%), 34/56 (61%), and 32/56 (57%) correctly as medium-vessel occlusions. On multiphase CTA, 48/56 (86%), 50/56 (89%), and 50/56 (89%) medium-vessel occlusions were classified correctly. CONCLUSIONS Interrater agreement for medium-vessel occlusions is moderate when using single-phase CTA and almost perfect with multiphase CTA. Detection accuracy is substantially higher with multiphase CTA compared with single-phase CTA, suggesting that multiphase CTA might be a valuable tool for assessment of medium-vessel occlusion stroke.
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Affiliation(s)
- J.M. Ospel
- From the Department of Diagnostic Imaging (J.M.O., F.B., R.V.M., N.K., W.Q., B.K.M., M.G.),Department of Radiology (J.M.O.), University Hospital of Basel, Basel, Switzerland
| | - F. Bala
- From the Department of Diagnostic Imaging (J.M.O., F.B., R.V.M., N.K., W.Q., B.K.M., M.G.)
| | - R.V. McDonough
- From the Department of Diagnostic Imaging (J.M.O., F.B., R.V.M., N.K., W.Q., B.K.M., M.G.)
| | - O. Volny
- Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (O.V.), Masaryk University, Brno, Czech,Department of Neurology (O.V.), University Hospital Ostrava, Ostrava, Czech
| | - N. Kashani
- From the Department of Diagnostic Imaging (J.M.O., F.B., R.V.M., N.K., W.Q., B.K.M., M.G.),Department of Clinical Neurosciences (N.K., B.K.M., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - W. Qiu
- From the Department of Diagnostic Imaging (J.M.O., F.B., R.V.M., N.K., W.Q., B.K.M., M.G.)
| | - B.K. Menon
- From the Department of Diagnostic Imaging (J.M.O., F.B., R.V.M., N.K., W.Q., B.K.M., M.G.),Department of Clinical Neurosciences (N.K., B.K.M., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - M. Goyal
- From the Department of Diagnostic Imaging (J.M.O., F.B., R.V.M., N.K., W.Q., B.K.M., M.G.),Department of Clinical Neurosciences (N.K., B.K.M., M.G.), University of Calgary, Calgary, Alberta, Canada
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22
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Wevers NR, Nair AL, Fowke TM, Pontier M, Kasi DG, Spijkers XM, Hallard C, Rabussier G, van Vught R, Vulto P, de Vries HE, Lanz HL. Modeling ischemic stroke in a triculture neurovascular unit on-a-chip. Fluids Barriers CNS 2021; 18:59. [PMID: 34906183 PMCID: PMC8670153 DOI: 10.1186/s12987-021-00294-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 11/30/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND In ischemic stroke, the function of the cerebral vasculature is impaired. This vascular structure is formed by the so-called neurovascular unit (NVU). A better understanding of the mechanisms involved in NVU dysfunction and recovery may lead to new insights for the development of highly sought therapeutic approaches. To date, there remains an unmet need for complex human in vitro models of the NVU to study ischemic events seen in the human brain. METHODS We here describe the development of a human NVU on-a-chip model using a platform that allows culture of 40 chips in parallel. The model comprises a perfused vessel of primary human brain endothelial cells in co-culture with induced pluripotent stem cell derived astrocytes and neurons. Ischemic stroke was mimicked using a threefold approach that combines chemical hypoxia, hypoglycemia, and halted perfusion. RESULTS Immunofluorescent staining confirmed expression of endothelial adherens and tight junction proteins, as well as astrocytic and neuronal markers. In addition, the model expresses relevant brain endothelial transporters and shows spontaneous neuronal firing. The NVU on-a-chip model demonstrates tight barrier function, evidenced by retention of small molecule sodium fluorescein in its lumen. Exposure to the toxic compound staurosporine disrupted the endothelial barrier, causing reduced transepithelial electrical resistance and increased permeability to sodium fluorescein. Under stroke mimicking conditions, brain endothelial cells showed strongly reduced barrier function (35-fold higher apparent permeability) and 7.3-fold decreased mitochondrial potential. Furthermore, levels of adenosine triphosphate were significantly reduced on both the blood- and the brain side of the model (4.8-fold and 11.7-fold reduction, respectively). CONCLUSIONS The NVU on-a-chip model presented here can be used for fundamental studies of NVU function in stroke and other neurological diseases and for investigation of potential restorative therapies to fight neurological disorders. Due to the platform's relatively high throughput and compatibility with automation, the model holds potential for drug compound screening.
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Affiliation(s)
- Nienke R Wevers
- MIMETAS BV, Leiden, The Netherlands. .,Department of Molecular Cell Biology and Immunology, Amsterdam UMC, Location VUmc, Amsterdam Neuroscience, Amsterdam, The Netherlands.
| | - Arya Lekshmi Nair
- MIMETAS BV, Leiden, The Netherlands.,Department of Molecular Cell Biology and Immunology, Amsterdam UMC, Location VUmc, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | | | | | | | - Xandor M Spijkers
- MIMETAS BV, Leiden, The Netherlands.,Department of Translational Neuroscience, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | | | - Gwenaëlle Rabussier
- MIMETAS BV, Leiden, The Netherlands.,CARIM School of Cardiovascular Diseases, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | | | | | - Helga E de Vries
- Department of Molecular Cell Biology and Immunology, Amsterdam UMC, Location VUmc, Amsterdam Neuroscience, Amsterdam, The Netherlands
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23
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de Bortoli T, Boehm-Sturm P, Koch SP, Nieminen-Kelhä M, Wessels L, Mueller S, Ielacqua GD, Klohs J, Vajkoczy P, Hecht N. Three-Dimensional Iron Oxide Nanoparticle-Based Contrast-Enhanced Magnetic Resonance Imaging for Characterization of Cerebral Arteriogenesis in the Mouse Neocortex. Front Neurosci 2021; 15:756577. [PMID: 34899163 PMCID: PMC8662986 DOI: 10.3389/fnins.2021.756577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/02/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: Subsurface blood vessels in the cerebral cortex have been identified as a bottleneck in cerebral perfusion with the potential for collateral remodeling. However, valid techniques for non-invasive, longitudinal characterization of neocortical microvessels are still lacking. In this study, we validated contrast-enhanced magnetic resonance imaging (CE-MRI) for in vivo characterization of vascular changes in a model of spontaneous collateral outgrowth following chronic cerebral hypoperfusion. Methods: C57BL/6J mice were randomly assigned to unilateral internal carotid artery occlusion or sham surgery and after 21 days, CE-MRI based on T2*-weighted imaging was performed using ultra-small superparamagnetic iron oxide nanoparticles to obtain subtraction angiographies and steady-state cerebral blood volume (ss-CBV) maps. First pass dynamic susceptibility contrast MRI (DSC-MRI) was performed for internal validation of ss-CBV. Further validation at the histological level was provided by ex vivo serial two-photon tomography (STP). Results: Qualitatively, an increase in vessel density was observed on CE-MRI subtraction angiographies following occlusion; however, a quantitative vessel tracing analysis was prone to errors in our model. Measurements of ss-CBV reliably identified an increase in cortical vasculature, validated by DSC-MRI and STP. Conclusion: Iron oxide nanoparticle-based ss-CBV serves as a robust, non-invasive imaging surrogate marker for neocortical vessels, with the potential to reduce and refine preclinical models targeting the development and outgrowth of cerebral collateralization.
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Affiliation(s)
- Till de Bortoli
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Berlin, Germany
| | - Philipp Boehm-Sturm
- Center for Stroke Research Berlin (CSB), Berlin, Germany.,Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Cluster of Excellence and Charité Core Facility 7T Experimental MRIs, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Stefan P Koch
- Center for Stroke Research Berlin (CSB), Berlin, Germany.,Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Cluster of Excellence and Charité Core Facility 7T Experimental MRIs, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Melina Nieminen-Kelhä
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Berlin, Germany
| | - Lars Wessels
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Berlin, Germany
| | - Susanne Mueller
- Center for Stroke Research Berlin (CSB), Berlin, Germany.,Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Cluster of Excellence and Charité Core Facility 7T Experimental MRIs, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Giovanna D Ielacqua
- Institute for Biomedical Engineering, University of Zurich and ETH Zürich, Zurich, Switzerland
| | - Jan Klohs
- Institute for Biomedical Engineering, University of Zurich and ETH Zürich, Zurich, Switzerland
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Berlin, Germany
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24
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Ohara J, Fujimoto M, Tani S, Ogata H, Shimizu K, Taguchi T, Itani M, Akiyama Y. 3D Turbo Spin-echo MRI-based Mechanical Thrombectomy at Middle Cerebral Artery Bifurcations. Neurol Med Chir (Tokyo) 2021; 62:149-155. [PMID: 34880196 PMCID: PMC8918366 DOI: 10.2176/nmc.tn.2021-0179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We describe three cases with acute middle cerebral artery (MCA) occlusion. From the pre-operative MRI, including three-dimensional turbo spin-echo sequences using T1WI and T2WI, we assessed both thrombus configuration and arterial anatomy at the MCA bifurcations. For efficient endovascular thrombectomy, we identified the applied MCA segment 2 (M2) branch, in which the main thrombus was buried. Sufficient recanalization after a single pass was achieved and the patients made a marked recovery. Although mechanical thrombectomy for M2 occlusion has not been of proven benefit, the endovascular procedure based on three-dimensional turbo spin-echo imaging is useful for more complete thrombus removal at MCA bifurcations.
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Affiliation(s)
- Jiro Ohara
- Department of Neurosurgery, Tenri Hospital
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25
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Li H, Yang S, Zhong Y, Wang J, Li X, Gao H, Chen G. Mechanical Thrombectomy with or without Intravenous Thrombolysis in Acute Ischemic Stroke: A Meta-Analysis for Randomized Controlled Trials. Eur Neurol 2021; 85:85-94. [PMID: 34818658 DOI: 10.1159/000520085] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 10/04/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The combination of mechanical thrombectomy (MT) and intravenous thrombolysis (IVT) is more effective than IVT alone in patients with large vessel occlusion, which has been proven in recent studies. However, there are still debates over whether IVT benefits patients treated with only direct mechanical thrombectomy (dMT). METHODS PubMed, Embase, and Cochrane Library were searched on June 15, 2021, for randomized controlled trials (RCTs). Seven RCTs with 2,143 patients were enrolled in our study. RESULTS MT combined with IVT had comparable efficacy and safety outcome compared with dMT in proximal anterior circulation occlusion at 90 days. For the primary outcome, pooled data showed no significant difference in the modified Rankin Scale (mRS) 0-2 at 90 days between the dMT and MT+IVT groups (pooled odds ratio 0.96, 95% confidence interval, 0.79, 1.17, p = 0.39). As for the mRS score 0-1 at 90 days, the degree of benefit conferred by dMT was substantial: for every 100 patients treated, the number of patients which had an excellent outcome in the dMT group was 10 higher than that of the MT+IVT group. CONCLUSION In this meta-analysis including 7 RCTs, MT had comparable consequences to bridging treatment in efficacy and safety outcomes for patients with ischemic stroke caused by the occlusion of proximal anterior circulation, irrespective of geographical location. These findings support the adoption of dMT in acute ischemic stroke treatments and have higher cost-effectiveness in global applications.
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Affiliation(s)
- Hang Li
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Siyuan Yang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yi Zhong
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jiahe Wang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiang Li
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Heng Gao
- Department of Neurosurgery, The Affiliated Jiangyin Hospital, School of Medicine, Southeast University, Jiangyin, China
| | - Gang Chen
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
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26
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McDonough R, Cimflova P, Kashani N, Ospel JM, Kappelhof M, Singh N, Sehgal A, Sakai N, Fiehler J, Chen M, Goyal M. Patient-Relevant Deficits Dictate Endovascular Thrombectomy Decision-Making in Patients with Low NIHSS Scores with Medium-Vessel Occlusion Stroke. AJNR Am J Neuroradiol 2021; 42:1834-1838. [PMID: 34413064 DOI: 10.3174/ajnr.a7253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/27/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE There is a paucity of evidence regarding the safety of endovascular treatment for patients with acute ischemic stroke due to primary medium-vessel occlusion. The aim of this study was to examine the willingness among stroke physicians to perform endovascular treatment in patients with mild-yet-disabling deficits due to medium-vessel occlusion. MATERIALS AND METHODS In an international cross-sectional survey consisting of 7 primary medium-vessel occlusion case scenarios, participants were asked whether the presence of personally disabling deficits would influence their decision-making for endovascular treatment despite the patients having low NIHSS scores (<6). Decision rates were calculated on the basis of physician characteristics. Univariable logistic regression clustered by respondent and scenario identity was performed. RESULTS Three hundred sixty-six participants from 44 countries provided 2562 answers to the 7 medium-vessel occlusion scenarios included in this study. In scenarios in which the deficit was relevant to the patient's profession, 56.9% of respondents opted to perform immediate endovascular treatment compared with 41.0% when no information regarding the patient's profession was provided (risk ratio = 1.39, P < .001). The largest effect sizes were seen for female participants (risk ratio = 1.68; 95% CI, 1.35-2.09), participants older than 60 years of age (risk ratio = 1.61; 95% CI, 1.23-2.10), those with more experience in neurointervention (risk ratio = 1.60; 95% CI, 1.24-2.06), and those who personally performed >100 endovascular treatments per year (risk ratio = 1.63; 95% CI, 1.22-2.17). CONCLUSIONS The presence of a patient-relevant deficit in low-NIHSS acute ischemic stroke due to medium-vessel occlusion is an important factor for endovascular treatment decision-making. This may have relevance for the conduct and interpretation of low-NIHSS endovascular treatment in randomized trials.
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Affiliation(s)
- R McDonough
- From the Department of Diagnostic and Interventional Neuroradiology (R.M., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Diagnostic Imaging (R.M., N.K., M.K., A.S., M.G.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - P Cimflova
- Department of Medical Imaging (P.C., M.G.), St. Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Clinical Neurosciences (P.C., N.S.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - N Kashani
- Department of Diagnostic Imaging (R.M., N.K., M.K., A.S., M.G.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - J M Ospel
- Division of Neuroradiology (J.M.O.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - M Kappelhof
- Department of Diagnostic Imaging (R.M., N.K., M.K., A.S., M.G.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology and Nuclear Medicine (M.K.), University of Amsterdam, Amsterdam, the Netherlands
| | - N Singh
- Department of Clinical Neurosciences (P.C., N.S.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - A Sehgal
- Department of Diagnostic Imaging (R.M., N.K., M.K., A.S., M.G.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - N Sakai
- Department of Neurosurgery (N.S.), Kobe City Medical Centre General Hospital, Kobe, Japan
| | - J Fiehler
- From the Department of Diagnostic and Interventional Neuroradiology (R.M., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M Chen
- Department of Neurological Sciences (M.C.), Rush University Medical Center, Chicago, Illinois
| | - M Goyal
- Department of Diagnostic Imaging (R.M., N.K., M.K., A.S., M.G.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
- Department of Medical Imaging (P.C., M.G.), St. Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
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27
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Cho YH, Choi JH. Mechanical thrombectomy for acute ischemic stroke with occlusion of the M2 segment of the middle cerebral artery: A literature review. J Cerebrovasc Endovasc Neurosurg 2021; 23:193-200. [PMID: 34492752 PMCID: PMC8497726 DOI: 10.7461/jcen.2021.e2020.11.002] [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] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/21/2021] [Indexed: 11/29/2022] Open
Abstract
Thanks to new generation devices, mechanical thrombectomy (MT) has substantially evolved and become the standard treatment for patients with acute occlusion of the internal carotid artery or proximal middle cerebral artery (MCA) (M1 segment). However, the role and benefit of MT in patients with distal MCA (M2 segment) occlusion remain unclear. Therefore, there is a need for further studies. To evaluate the efficacy and safety of MT for M2 occlusion, this article reviews the natural course of M2 occlusion, the evidence regarding MT for M2 segment occlusion, clinical outcomes of MT for M2 occlusion, and treatment outcomes according to device type.
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Affiliation(s)
- Yong-Hwan Cho
- Busan Regional Cerebrovascular Center, Dong-A University Hospital, Busan, Korea.,Department of Neurosurgery, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Jae Hyung Choi
- Busan Regional Cerebrovascular Center, Dong-A University Hospital, Busan, Korea.,Department of Neurosurgery, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
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28
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Khunte M, Wu X, Payabvash S, Zhu C, Matouk C, Schindler J, Sanelli P, Gandhi D, Malhotra A. Cost-effectiveness of endovascular thrombectomy in patients with acute stroke and M2 occlusion. J Neurointerv Surg 2021; 13:784-789. [PMID: 33077578 DOI: 10.1136/neurintsurg-2020-016765] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND The cost-effectiveness of endovascular thrombectomy (EVT) in patients with acute ischemic stroke due to M2 branch occlusion remains uncertain. OBJECTIVE To evaluate the cost-effectiveness of EVT compared with medical management in patients with acute stroke presenting with M2 occlusion using a decision-analytic model. METHODS A decision-analytic study was performed with Markov modeling to estimate the lifetime quality-adjusted life years and associated costs of EVT-treated patients compared with no-EVT/medical management. The study was performed over a lifetime horizon with a societal perspective in the Unites States setting. Base case, one-way, two-way, and probabilistic sensitivity analyses were performed. RESULTS EVT was the long-term cost-effective strategy in 93.37% of the iterations in the probabilistic sensitivity analysis, and resulted in difference in health benefit of 1.66 QALYs in the 65-year-old age groups, equivalent to 606 days in perfect health. Varying the outcomes after both strategies shows that EVT was more cost-effective when the probability of good outcome after EVT was only 4-6% higher relative to medical management in clinically likely scenarios. EVT remained cost-effective even when its cost exceeded US$200 000 (threshold was US$209 111). EVT was even more cost-effective for 55-year-olds than for 65-year-old patients. CONCLUSION Our study suggests that EVT is cost-effective for treatment of acute M2 branch occlusions. Faster and improved reperfusion techniques would increase the relative cost-effectiveness of EVT even further in these patients.
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Affiliation(s)
- Mihir Khunte
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Xiao Wu
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sam Payabvash
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Chengcheng Zhu
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Joseph Schindler
- Department of Neurology, Yale University, New Haven, Connecticut, USA
| | - Pina Sanelli
- Hofstra Northwell School of Medicine at Hofstra University, Hempstead, New York, USA
| | - Dheeraj Gandhi
- Department of Interventional Neuroradiology, University of Maryland, Baltimore, Maryland, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
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29
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Guisado-Alonso D, Martínez-Domeño A, Prats-Sánchez L, Delgado-Mederos R, Camps-Renom P, Abilleira S, de la Ossa NP, Ramos-Pachón A, Cardona P, Rodríguez-Campello A, Molina CA, Rudilosso S, Martí-Fàbregas J. Reasons for Not Performing Mechanical Thrombectomy: A Population-Based Study of Stroke Codes. Stroke 2021; 52:2746-2753. [PMID: 34289711 DOI: 10.1161/strokeaha.120.032648] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Daniel Guisado-Alonso
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona (Department of Medicine), Spain (D.G.-A., A.M.-D., L.P.-S., R.D.-M., P.C.-R., J.M.-F.)
| | - Alejandro Martínez-Domeño
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona (Department of Medicine), Spain (D.G.-A., A.M.-D., L.P.-S., R.D.-M., P.C.-R., J.M.-F.)
| | - Luis Prats-Sánchez
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona (Department of Medicine), Spain (D.G.-A., A.M.-D., L.P.-S., R.D.-M., P.C.-R., J.M.-F.)
| | - Raquel Delgado-Mederos
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona (Department of Medicine), Spain (D.G.-A., A.M.-D., L.P.-S., R.D.-M., P.C.-R., J.M.-F.)
| | - Pol Camps-Renom
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona (Department of Medicine), Spain (D.G.-A., A.M.-D., L.P.-S., R.D.-M., P.C.-R., J.M.-F.)
| | - Sònia Abilleira
- Stroke Programme, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain (S.A., N.P.d.l.O.)
| | - Natalia Pérez de la Ossa
- Stroke Programme, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain (S.A., N.P.d.l.O.)
| | - Anna Ramos-Pachón
- Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Badalona, Spain (A.R.-P)
| | - Pere Cardona
- Department of Neurology, Hospital de Bellvitge, Hospitalet de Llobregat, Spain (P.C.)
| | | | - Carlos A Molina
- Department of Neurology, Hospital Vall d'Hebrón, Barcelona, Spain (C.A.M.)
| | | | - Joan Martí-Fàbregas
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona (Department of Medicine), Spain (D.G.-A., A.M.-D., L.P.-S., R.D.-M., P.C.-R., J.M.-F.)
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30
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Tran QK, Yarbrough KL, Capobianco P, Chang WTW, Jindal G, Medic A, Menaker J, Rehan MA, Swafford I, Traynor T, Phipps MS. Comparison of Outcomes After Treatment of Large Vessel Occlusion in a Critical Care Resuscitation Unit or a Neurocritical Care Unit. Neurocrit Care 2021; 32:725-733. [PMID: 31452015 DOI: 10.1007/s12028-019-00825-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Mechanical thrombectomy (MT) has become first-line treatment for patients with acute ischemic stroke caused by large vessel occlusion (AIS-LVO). Delay in the interhospital transfer (IHT) of patients from referral hospitals to a comprehensive stroke center is associated with worse outcomes. At our academic tertiary care facility in an urban setting, a neurocritical care and emergency neurology unit (NCCU) receives patients with AIS-LVO from outlying medical facilities. When the NCCU is full, patients with AIS-LVO are initially transferred to a critical care resuscitation unit (CCRU). We were interested in quantifying the numbers of AIS-LVO patients treated in those two units and assessing their outcomes. We hypothesized that the CCRU would facilitate an increase in IHTs and provide care comparable to that delivered by the subspecialty NCCU. METHODS We conducted a retrospective study of the medical center's prospective stroke registry for adult IHT patients undergoing MT between 01/01/2015 and 12/31/2017. Primary outcome was time from consultation and request for transfer to arrival (Consult-Arrival). Other outcomes of interest were functional independence, defined as 90-day modified Rankin Scale (mRS) score ≤ 2, and 90-day all-cause mortality. Multivariable logistic regression was performed to assess association between clinical factors, mortality, and functional independence. RESULTS We analyzed the records of 128 IHT patients: 87 (68%) were admitted to the CCRU, and 41 (32%) to the NCCU. The two groups had similar baseline characteristics (age, National Institutes of Health Stroke Scale score, Alberta Stroke Program Early Computed Tomography scores [ASPECTS]). The median Consult-Arrival time was shorter for CCRU patients than for the NCCU patients (86 [88‒109] vs 100 [77‒127] [p = 0.031]). The 90-day mortality rates (16 vs 30% [p = 0.052]) and the rates having a mRS score ≤ 2 (31 vs 36% [p = 0.59]) were not statistically different. Multivariable logistic regression showed that each minute of delay in the Consult-Arrival time was associated with 2.3% increase in the likelihood of death (OR 1.023; 95% CI 1.003‒1.04 [p = 0.026]), while high thrombolysis in cerebral infarction score was the only factor that was significantly associated with functional independence at 90 days (OR 2.9; 95% CI 1.4‒6.4 [p = 0.006]). CONCLUSION The CCRU increased AIS-LVO patients' access to definitive care and reduced their transfer time from outlying medical facilities while achieving outcomes similar to those attained by patients treated in the subspecialty NCCU. We conclude that a resuscitation unit can complement the NCCU to care for patients in the hyperacute phase of AIS-LVO.
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Affiliation(s)
- Quincy K Tran
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA. .,The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Karen L Yarbrough
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Paul Capobianco
- University of Maryland at College Park, College Park, MD, USA
| | - Wan-Tsu W Chang
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.,The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gaurav Jindal
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Neuroradiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Amir Medic
- University of Maryland at College Park, College Park, MD, USA
| | - Jay Menaker
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.,The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mehboob A Rehan
- Department of Medicine, Eastern Idaho Regional Medical Center, Idaho Falls, ID, USA
| | | | - Timothy Traynor
- University of Maryland at College Park, College Park, MD, USA
| | - Michael S Phipps
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
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31
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Shek K, Alcock S, Ghrooda E, Trivedi A, McEachern J, Kaderali Z, Shankar J. Effectiveness and safety of endovascular thrombectomy for large versus medium vessel occlusions: a single-center experience. J Neurointerv Surg 2021; 14:neurintsurg-2021-017502. [PMID: 34035151 DOI: 10.1136/neurintsurg-2021-017502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/19/2021] [Accepted: 04/25/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The effectiveness and safety of endovascular thrombectomy (EVT) for medium vessel occlusions (MeVO) in the anterior intracranial circulation for patients with acute ischemic stroke (AIS) has yet to be definitively established. We compared outcomes in patients undergoing EVT for large vessel occlusion (LVO) versus those with MeVO. METHODS This retrospective cohort study, using an intention to treat design, compared the 90-day modified Rankin Scale (mRS) score between 43 patients with MeVO and 199 with LVO in the anterior intracranial circulation. Secondary outcome measures included vessel recanalization using the Thrombolysis in Cerebral Infarction (TICI) score, procedural complications, post-EVT intracranial hemorrhage (ICH), and infarct size. RESULTS The rate of good functional outcome (90-day mRS 0-2) was higher in patients with LVO than in those with MeVO (32.9% vs 27%), but this was not statistically significant (p=0.19). The rate of EVT procedural complications was also not significantly different between the groups (p=0.10), nor was the rate of ICH (p=0.30). There was also no significant difference in TICI scores between groups (p=0.12). Infarct size was larger in the LVO group (p<0.01). Multivariate analysis showed older age, not receiving recombinant tissue plasminogen activator (r-tPA), and larger infarct size were independent predictors of poor functional outcome at 90 days. CONCLUSION The 90-day mRS and rate of periprocedural complications were not significantly different between patients treated for LVO and those treated for MeVO with EVT. Older age, not receiving r-tPA, and larger infarct size were independent predictors of poor outcome at 90 days.
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Affiliation(s)
- Kevin Shek
- Radiology, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Susan Alcock
- Radiology, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Esseddeeg Ghrooda
- Internal Medicine, Section of Neurology, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Anurag Trivedi
- Internal Medicine, Section of Neurology, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - James McEachern
- Radiology, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Zul Kaderali
- Surgery, Section of Neurosurgery, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Jai Shankar
- Radiology, University of Manitoba Faculty of Health Sciences, Winnipeg, Manitoba, Canada
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32
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The Natural History and Reperfusion Therapy Outcomes of Acute Ischemic Stroke due to Isolated M2 Occlusions. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6626604. [PMID: 33997031 PMCID: PMC8096556 DOI: 10.1155/2021/6626604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 04/01/2021] [Accepted: 04/16/2021] [Indexed: 11/17/2022]
Abstract
Objective Currently, the standard treatment modality for patients with acute ischemic stroke (AIS) presenting with isolated M2 occlusions is not specific. We therefore assessed the difference in treatment outcomes for patients with isolated M2 occlusions. Methods We retrospectively analyzed consecutive patients with AIS presenting with isolated M2 occlusions from October 1, 2018, to June 30, 2020. Patients were divided into 3 groups based on the treatments they received: no reperfusion therapy (NRT), intravenous thrombolysis treatment (IVT), and endovascular intervention (EVT), which comprised IVT in conjunction with EVT or EVT alone. The primary outcomes were improvements in modified Rankin Scale (mRS) scores at 90 days and National Institutes of Health Stroke Scale (NIHSS) scores at 24 hours after treatment compared with the baseline. The secondary efficacy outcome comprised a good outcome rate defined as a 90 − day mRS score ≤ 2, final infarct volume (FIV), 90-day mortality rate, and successful recanalization rate, which was defined as a modified thrombolysis in cerebral infarction score ≥ 2b. Safety outcomes included symptomatic intracerebral hemorrhage and procedure-related complications. Results Seventy patients were enrolled and divided into 3 groups: the NRT group (n = 25), IVT group (n = 27), and EVT group (n = 18). Twenty-four-hour posttreatment NIHSS scores were substantially decreased by EVT compared with NRT (adjusted β -4.01, 95% confidence interval [CI] -6.60 to -1.43; P = 0.003) or IVT (adjusted β, -3.61 [95% CI, -6.45 to -0.77]; P = 0.013). Compared with the outcomes observed after NRT, patients who received EVT were more likely to achieve lower 90-day mRS scores (adjusted β, -1.42 [95% CI, -2.66 to -0.63]; P = 0.007), higher good outcome rates (adjusted odds ratio, 8.73 [95% CI, 1.43-53.24]; P = 0.019), and smaller FIVs (adjusted β, -29.66 [95% CI, -59.73 to 0.42]; P = 0.048). The recanalization rate of EVT was high (88.89%), and procedure-related complications were rare (5.56%). Conclusions For acute, isolated M2 occlusions, EVT could dramatically and rapidly improve neurological deficits with high safety and effectiveness. These changes were observed at 24 hours after treatment and were maintained over the long term.
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Wu X, Wira CR, Matouk CC, Forman HP, Gandhi D, Sanelli P, Schindler J, Malhotra A. Drip-and-ship versus mothership for endovascular treatment of acute stroke: A comparative effectiveness analysis. Int J Stroke 2021; 17:315-322. [PMID: 33759645 DOI: 10.1177/17474930211008701] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Triage for suspected acute stroke has two main options: (1) transport to the closest primary stroke center (PSC) and then to the nearest comprehensive stroke center (CSC) (Drip-and-Ship) or (2) transport the patient to the nearest CSC, bypassing a closer PSC (mothership). The purpose was to evaluate the effectiveness of drip-and-ship versus mothership models for acute stroke patients. METHODS A Markov decision-analytic model was constructed. All model parameters were derived from recent medical literature. Our target population was adult patient with sudden onset of acute stroke within 8 h of onset over a one-year horizon. The primary outcome was quantified in terms of quality-adjusted-life-years (QALYs). RESULTS The base case scenario show that the drip-and-ship strategy has a slightly higher expected health benefit, 0.591 QALY, as compared to 0.586 QALY in the mothership strategy when the time to PSC is 30 min and to CSC is 65 min, although the difference in health benefit becomes minimal as the time to PSC increases towards 60 min. Multiple sensitivity analyses show that when both PSC and CSC are far from place of onset (>1.5 h away), drip-and-ship becomes the better strategy. Mothership strategy is favored by smaller difference between distances to PSC and CSC, shorter transfer time from PSC to CSC, and longer delay in reperfusion in CSC for transferred patients. Drip-and-ship is favored by the reverse. CONCLUSION Drip-and-ship has a slightly higher utility than mothership. This study assesses the complex issue of prehospital triage of acute stroke patients and can provide a framework for real-world data input.
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Affiliation(s)
- Xiao Wu
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA
| | - Charles R Wira
- Department of Emergency Medicine, 12228Yale University School of Medicine, New Haven, CT, USA
| | - Charles C Matouk
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA
| | - Howard P Forman
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA
| | - Dheeraj Gandhi
- Radiology, Neurology and Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Pina Sanelli
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Joseph Schindler
- Department of Neurology, 12228Yale School of Medicine, New Haven, CT, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA
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Dobrocky T, Piechowiak EI, Volbers B, Slavova N, Kaesmacher J, Meinel TR, Arnold M, Fischer U, Jung S, Gralla J, Mordasini P, Heldner MR. Treatment and Outcome in Stroke Patients With Acute M2 Occlusion and Minor Neurological Deficits. Stroke 2021; 52:802-810. [PMID: 33494637 DOI: 10.1161/strokeaha.120.031672] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Treatment in stroke patients with M2 segment occlusion of the middle cerebral artery presenting with mild neurological deficits is a matter of debate. The main purpose was to compare the outcome in patients with a minor stroke and a M2 occlusion. METHODS Consecutive intravenous thrombolysis (IVT) eligible patients admitted to the Bernese stroke center between January 2005 and January 2020 with acute occlusion of the M2 segment and National Institutes of Health Stroke Scale score ≤5 were included. Outcome was compared between IVT only versus endovascular therapy (EVT) including intra-arterial thrombolysis and mechanical thrombectomy (MT; ±IVT) and between IVT only versus MT only. RESULTS Among 169 patients (38.5% women, median age 70.2 years), 84 (49.7%) received IVT only and 85 (50.3%) EVT (±IVT), the latter including 39 (45.9%) treated with MT only. Groups were similar in sex, age, vascular risk factors, event cause, or preevent independency. Compared with IVT only, there was no difference in favorable outcome (modified Rankin Scale score, 0-2) for EVT (adjusted odds ratio, 0.96; adjusted P=0.935) or for MT only (adjusted odds ratio, 1.12; adjusted P=0.547) groups. Considering only patients treated after 2015, there was a significantly better 3-month modified Rankin Scale shift (adjusted P=0.032) in the EVT compared with the IVT only group. CONCLUSIONS Our study demonstrates similar effectiveness of IVT only versus EVT (±IVT), and of IVT only versus MT only in patients with peripheral middle cerebral artery occlusions and minor neurological deficits and indicates a possible benefit of EVT considering only patients treated after 2015. There is an unmet need for randomized controlled trials in this stroke field, including imaging parameters, and more sophisticated evaluation of National Institutes of Health Stroke Scale score subitems, neurocognition, and quality of life neglected by the standard outcome scales such as modified Rankin Scale and National Institutes of Health Stroke Scale score.
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Affiliation(s)
- Tomas Dobrocky
- Institute of Diagnostic and Interventional Neuroradiology (T.D., E.I.P., N.S., J.K., J.G., P.M.), Inselspital, University Hospital of Bern, Switzerland
| | - Eike I Piechowiak
- Institute of Diagnostic and Interventional Neuroradiology (T.D., E.I.P., N.S., J.K., J.G., P.M.), Inselspital, University Hospital of Bern, Switzerland
| | - Bastian Volbers
- Department of Neurology (B.V., T.R.M., M.A., U.F., S.J., M.R.H), Inselspital, University Hospital of Bern, Switzerland.,Department of Neurology, University of Erlangen-Nuremberg, Germany (B.V.)
| | - Nedelina Slavova
- Institute of Diagnostic and Interventional Neuroradiology (T.D., E.I.P., N.S., J.K., J.G., P.M.), Inselspital, University Hospital of Bern, Switzerland.,Department of Interventional, Pediatric and Diagnostic Radiology (N.S., J.K.), Inselspital, University Hospital of Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology (T.D., E.I.P., N.S., J.K., J.G., P.M.), Inselspital, University Hospital of Bern, Switzerland.,Department of Interventional, Pediatric and Diagnostic Radiology (N.S., J.K.), Inselspital, University Hospital of Bern, Switzerland
| | - Thomas R Meinel
- Department of Neurology (B.V., T.R.M., M.A., U.F., S.J., M.R.H), Inselspital, University Hospital of Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology (B.V., T.R.M., M.A., U.F., S.J., M.R.H), Inselspital, University Hospital of Bern, Switzerland
| | - Urs Fischer
- Department of Neurology (B.V., T.R.M., M.A., U.F., S.J., M.R.H), Inselspital, University Hospital of Bern, Switzerland
| | - Simon Jung
- Department of Neurology (B.V., T.R.M., M.A., U.F., S.J., M.R.H), Inselspital, University Hospital of Bern, Switzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology (T.D., E.I.P., N.S., J.K., J.G., P.M.), Inselspital, University Hospital of Bern, Switzerland
| | - Pasquale Mordasini
- Institute of Diagnostic and Interventional Neuroradiology (T.D., E.I.P., N.S., J.K., J.G., P.M.), Inselspital, University Hospital of Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology (B.V., T.R.M., M.A., U.F., S.J., M.R.H), Inselspital, University Hospital of Bern, Switzerland
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35
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Goyal M, Kappelhof M, McDonough R, Ospel JM. Secondary Medium Vessel Occlusions: When Clots Move North. Stroke 2021; 52:1147-1153. [PMID: 33467882 DOI: 10.1161/strokeaha.120.032799] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Medium vessel occlusions (MeVOs, ie, M2, M3, A2, A3, P2, and P3 segment occlusions) are increasingly recognized as a target for endovascular treatment in acute ischemic stroke. It is important to note that not all MeVOs are equal. Primary MeVOs occur de novo with the underlying mechanisms being very similar to large vessel occlusion strokes. Secondary MeVOs arise from large vessel occlusions through clot migration or fragmentation, either spontaneously or following treatment with intravenous thrombolysis or endovascular treatment. Currently, there are little data on the prevalence, management, and prognosis of acute ischemic stroke due to secondary MeVOs. This type of stroke is, however, likely to become more relevant in the future as indications for endovascular treatment continue to broaden. In this article, we describe different types of secondary MeVOs, imaging findings associated with them, challenges related to the diagnosis of secondary MeVOs, and their potential implications for treatment strategies and clinical outcomes.
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Affiliation(s)
- Mayank Goyal
- Department of Clinical Neurosciences (M.G., M.K., J.M.O.), University of Calgary, Canada.,Department of Radiology (M.G.), University of Calgary, Canada
| | - Manon Kappelhof
- Department of Clinical Neurosciences (M.G., M.K., J.M.O.), University of Calgary, Canada.,University Medical Center Amsterdam, the Netherlands (M.K.)
| | - Rosalie McDonough
- Department of Neuroradiology, University Hospital Hamburg Eppendorf, Germany (R.M.)
| | - Johanna Maria Ospel
- Department of Clinical Neurosciences (M.G., M.K., J.M.O.), University of Calgary, Canada.,Department of Neuroradiology, University Hospital Basel, Switzerland (J.M.O.)
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Abstract
Endovascular therapy (EVT) has become the standard treatment for large-vessel occlusion (LVO) acute ischemic stroke (AIS). EVT is now indicated in patients up to 24h from their last known well, provided that the patient meets specific clinical and imaging criteria. Improvements in thrombectomy devices, techniques, and operator experience have allowed successful EVT of ICA terminus, M1-MCA occlusions as well as proximal M2-MCA, basilar artery occlusions, and revascularization of tandem lesions. Mechanical thrombectomy failures still occur due to several factors, however, highlighting the need for further device and technical improvements. An ongoing debate exists regarding the need for pre-EVT thrombolytic agents, thrombectomy techniques, distal occlusions, anesthesia methods, the role of advanced neuroimaging, the treatment of patients with larger infarct core, and those presenting with milder stroke symptoms. Many of these questions are the subject of current or upcoming clinical trials. This review aims to provide an outline and discussion about the established recommendations and emerging topics regarding EVT for LVO AIS.
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Affiliation(s)
- Fabio Settecase
- Neuroradiology Division, Department of Radiology, University of British Columbia, Vancouver, BC, Canada; Diagnostic and Interventional Neuroradiology Division, Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada; Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, United States.
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37
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Gao L, Tan E, Moodie M, Parsons M, Spratt NJ, Levi C, Butcher K, Kleinig T, Yan B, Chen C, Lin L, Choi P, Bivard A. Reduced Impact of Endovascular Thrombectomy on Disability in Real-World Practice, Relative to Randomized Controlled Trial Evidence in Australia. Front Neurol 2020; 11:593238. [PMID: 33363508 PMCID: PMC7753020 DOI: 10.3389/fneur.2020.593238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/09/2020] [Indexed: 11/17/2022] Open
Abstract
Background and Aims: Disability-adjusted life years (DALYs) are an important measure of the global burden of disease that informs patient outcomes and policy decision-making. Our study aimed to compare the DALYs saved by endovascular thrombectomy (EVT) in the Australasian-based EXTEND-IA trial vs. clinical registry data from EVT in Australian routine clinical practice. Methods: The 3-month modified Rankin scale (mRS) outcome and treatment status of consecutively enrolled Australian patients with large vessel occlusion (LVO) stroke were taken from the International Stroke Perfusion Imaging Registry (INSPIRE). DALYs were calculated as the summation of years of life lost (YLL) due to premature death and years lived with a disability (YLD). A generalized linear model (GLM) with gamma family and log link was used to compare the difference in DALYs for patients receiving/not receiving EVT while controlling for key covariates. Ordered logit regression model was utilized to compare the difference in functional outcome at 3 months between the treatment groups. Cox regression analysis was undertaken to compare the difference in survival over an 18-year time horizon. Estimated long-term DALYs saved based on the EXTEND-IA randomized controlled trial (RCT) results were used as the comparator. Results: INSPIRE patients who received EVT treatment only achieved nominally better functional outcomes than the non-EVT group (p = 0.181) at 3 months. There was no significant survival gain from EVT over the first 3 months of stroke in both INSPIRE and EXTEND-IA patients. However, measured against no EVT in the long-term, EVT in INSPIRE was associated with no significant survival gain [hazard ratio (HR): 0.92, 95% confidence interval (CI): 0.78–1.08, p = 0.287] compared with the survival benefit extrapolated from the EXTEND-IA trial (HR: 0.42, 95% CI: 0.22–0.82, p = 0.01]. Offering EVT to patients with LVO stroke was also associated with fewer DALYs lost (11.04, 95% CI: 10.45–11.62) than those not receiving EVT in INSPIRE (12.13, 95% CI: 11.75–12.51), a reduction of −1.09 DALY (95% CI: −1.76 to −0.43, p = 0.002). The absolute magnitude of the treatment effect was lower than that seen in EXTEND-IA (−2.72 DALY reduction in EVT vs non-EVT patients). Conclusions: EVT for the treatment of LVO in a registry of routine care was associated with significantly lower DALYs lost than medical care alone, but the saved DALYs are less than those reported in clinical trials, as there were major differences in the baseline characteristics of the patients.
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Affiliation(s)
- Lan Gao
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
| | - Elise Tan
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
| | - Marj Moodie
- Deakin Health Economics, Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
| | - Mark Parsons
- Department of Neurology, University of New South Wales (UNSW) South Western Clinical School, Liverpool Hospital, University of New South Wales, Liverpool, NSW, Australia.,Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia.,Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Neil J Spratt
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Christopher Levi
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Kenneth Butcher
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Bernard Yan
- Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Chushuang Chen
- Departments of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Longting Lin
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Philip Choi
- Department Neuroscience, Eastern Health, Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - Andrew Bivard
- Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia
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Abstract
PURPOSE OF REVIEW This article reviews the actual indications for mechanical thrombectomy in patients with acute ischemic stroke and how the opportunities for endovascular therapy can be expanded by using the concept of clinical-imaging or perfusion-imaging mismatch (as a surrogate for salvageable tissue) rather than time of ischemia. RECENT FINDINGS Six randomized controlled trials undoubtedly confirmed the benefits of using endovascular thrombectomy on the clinical outcome of patients with stroke with large vessel occlusion within 6 hours from symptom onset compared with those receiving only standard medical care. In a meta-analysis of individual patient data, the number needed to treat with endovascular thrombectomy to reduce disability by at least one level on the modified Rankin Scale for one patient was 2.6. Recently, the concept of "tissue window" versus time window has proved useful for selecting patients for mechanical thrombectomy up to 24 hours from symptom onset. The DAWN (DWI or CTP Assessment With Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention) trial included patients at a median of 12.5 hours from onset and showed the largest effect in functional outcome ever described in any acute stroke treatment trial (35.5% increase in functional independence). In DEFUSE 3 (Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution 3), patients treated with mechanical thrombectomy at a median of 11 hours after onset had a 28% increase in functional independence and an additional 20% absolute reduction in death or severe disability. SUMMARY For patients with acute ischemic stroke and a large vessel occlusion in the proximal anterior circulation who can be treated within 6 hours of stroke symptom onset, mechanical thrombectomy with a second-generation stent retriever or a catheter aspiration device should be indicated regardless of whether the patient received treatment with intravenous (IV) recombinant tissue plasminogen activator (rtPA) in patients with limited signs of early ischemic changes on neuroimaging. Two clinical trials completely disrupted the time window concept in acute ischemic stroke, showing excellent clinical outcomes in patients treated up to 24 hours from symptom onset. Time of ischemia is, on average, a good biomarker for tissue viability; however, the window of opportunity for treatment varies across different individuals because of a range of compensatory mechanisms. Adjusting time to the adequacy of collateral flow leads to the concept of tissue window, a paradigm shift in stroke reperfusion therapy.
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Nogueira RG, Mohammaden MH, Haussen DC, Budzik RF, Gupta R, Krajina A, English JD, Malek AR, Sarraj A, Narata AP, Taqi MA, Frankel MR, Miller TR, Grobelny T, Baxter BW, Bartolini BM, Jenkins P, Estrade L, Liebeskind D, Veznedaroglu E. Endovascular therapy in the distal neurovascular territory: results of a large prospective registry. J Neurointerv Surg 2020; 13:979-984. [PMID: 33323503 DOI: 10.1136/neurintsurg-2020-016851] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/13/2020] [Accepted: 11/13/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND There is a paucity of data regarding mechanical thrombectomy (MT) in distal arterial occlusions (DAO). We aim to evaluate the safety and efficacy of MT in patients with DAO and compare their outcomes with proximal arterial occlusion (PAO) strokes. METHODS The Trevo Registry was a prospective open-label MT registry including 2008 patients from 76 sites across 12 countries. Patients were categorized into: PAO: intracranial ICA, and MCA-M1; and DAO: MCA-M2, MCA-M3, ACA, and PCA. Baseline and outcome variables were compared across the PAO vs DAO patients with pre-morbid mRS 0-2. RESULTS Among 407 DAOs including 350 (86.0%) M2, 25 (6.1%) M3, 10 (2.5%) ACA, and 22 (5.4%) PCA occlusions, there were 376 DAO with pre-morbid mRS 0-2 which were compared with 1268 PAO patients. The median baseline NIHSS score was lower in DAO (13 [8-18] vs 16 [12-20], P<0.001). There were no differences in terms of age, sex, IV-tPA use, co-morbidities, or time to treatment across DAO vs PAO. The rates of post-procedure reperfusion, symptomatic intracranial hemorrhage (sICH), and 90-mortality were comparable between both groups. DAO showed significantly higher rates of 90-day mRS 0-2 (68.3% vs 56.5%, P<0.001). After adjustment for potential confounders, the level of arterial occlusion was not associated with the chances of excellent outcome (DAO for 90-day mRS 0-1: OR; 1.18, 95% CI [0.90 to 1.54], P=0.225), successful reperfusion or SICH. However, DAO patients were more likely to be functionally independent (mRS 0-2: OR; 1.45, 95% CI [1,09 to 1.92], P=0.01) or dead (OR; 1.54, 95% CI [1.06 to 2.27], P=0.02) at 90 days. CONCLUSION Endovascular therapy in DAO appears to result in a comparable safety and technical success profile as in PAO. The potential benefits of DAO thrombectomy should be investigated in future randomized trials.
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Affiliation(s)
- Raul G Nogueira
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mahmoud H Mohammaden
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Diogo C Haussen
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ronald F Budzik
- Department of Neuroradiology, Riverside Methodist Hospital, Columbus, Ohio, USA
| | - Rishi Gupta
- Department of Neurosciences, WellStar Health System, Atlanta, Georgia, USA
| | - Antonin Krajina
- Department of Neuroradiology, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Joey D English
- Department of Neurology, California Pacific Medical Center, San Francisco, California, USA
| | - Ali R Malek
- Neurointerventional & Comprehensive Stroke Program, Saint Mary Medical Center, Long Beach, California, USA
| | - Amrou Sarraj
- Neurology, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Ana Paula Narata
- Department of Radiology, Diagnostic and Interventional Neuroradiology Section, Regional University Hospital Centre Tours, Tours, Centre, France
| | - Muhammad Asif Taqi
- Department of Neurology, Vascular Neurology of Southern California, Thousand Oaks, California, USA
| | - Michael R Frankel
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Timothy Ryan Miller
- Department of Radiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Thomas Grobelny
- Advocate Neurovascular Center, Advocate Health Care Library Network, Park Ridge, Illinois, USA
| | - Blaise W Baxter
- Department of Radiology, University of Tennessee, Chattanooga, TN, USA
| | | | - Paul Jenkins
- Division of Biostatistics, Stryker Neurovascular, Fremont, California, USA
| | - Laurent Estrade
- Department of Interventional Neuroradiology, Centre Hospitalier Regional Universitaire de Lille, Lille, France
| | | | - Erol Veznedaroglu
- Department of Neurosciences, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
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Beretta S, Versace A, Martini B, Viganò M, Diamanti S, Pini C, Paternò G, Carone D, Mariani J, Monza L, Riva M, Padovano G, Rossi E, Citerio G, Castoldi G, Padelli F, Giachetti I, Aquino D, Giussani C, Sganzerla EP, Ferrarese C. Head down tilt 15° in experimental intracerebral hemorrhage: a randomized noninferiority safety trial. Eur J Neurol 2020; 28:525-531. [PMID: 32986293 DOI: 10.1111/ene.14560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/19/2020] [Accepted: 09/22/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Head down tilt 15° (HDT15°), applied before recanalization, increases collateral flow and improves outcome in experimental ischemic stroke. For its simplicity and low cost, HDT15° holds considerable potential to be developed as an emergency treatment of acute stroke in the prehospital setting, where hemorrhagic stroke is the major mimic of ischemic stroke. In this study, we assessed safety of HDT15° in the acute phase of experimental intracerebral hemorrhage. METHODS Intracerebral hemorrhage was produced by stereotaxic injection of collagenase in Wistar rats. A randomized noninferiority trial design was used to assign rats to HDT15° or flat position (n = 64). HDT15° was applied for 1 h during the time window of hematoma expansion. The primary outcome was hematoma volume at 24 h. Secondary outcomes were mass effect, mortality, and functional deficit in the main study and acute changes of intracranial pressure, hematoma growth, and cardiorespiratory parameters in separate sets of randomized animals (n = 32). RESULTS HDT15° achieved the specified criteria of noninferiority for hematoma volume at 24 h. Mass effect, mortality, and functional deficit at 24 h showed no difference in the two groups. HDT15° induced a mild increase in intracranial pressure with respect to the pretreatment values (+2.91 ± 1.76 mmHg). HDT15° had a neutral effect on MRI-based analysis of hematoma growth and cardiorespiratory parameters. CONCLUSIONS Application of HDT15° in the hyperacute phase of experimental intracerebral hemorrhage does not worsen early outcome. Further research is needed to implement HDT15° as an emergency collateral therapeutic for acute stroke.
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Affiliation(s)
- S Beretta
- Laboratory of Experimental Stroke Research, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Neuroscience, ASST Monza, San Gerardo Hospital, Monza, Italy
| | - A Versace
- Laboratory of Experimental Stroke Research, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - B Martini
- Laboratory of Experimental Stroke Research, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - M Viganò
- Laboratory of Experimental Stroke Research, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - S Diamanti
- Laboratory of Experimental Stroke Research, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - C Pini
- Laboratory of Experimental Stroke Research, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - G Paternò
- Laboratory of Experimental Stroke Research, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - D Carone
- Laboratory of Experimental Stroke Research, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - J Mariani
- Laboratory of Experimental Stroke Research, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - L Monza
- Laboratory of Experimental Stroke Research, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - M Riva
- Laboratory of Experimental Stroke Research, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - G Padovano
- Laboratory of Experimental Stroke Research, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - E Rossi
- Center of Biostatistics, Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy
| | - G Citerio
- Department of Intensive Care, ASST Monza, San Gerardo Hospital, Monza, Italy
| | - G Castoldi
- Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy
| | - F Padelli
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - I Giachetti
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - D Aquino
- Neuroradiology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - C Giussani
- Laboratory of Experimental Stroke Research, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Neuroscience, ASST Monza, San Gerardo Hospital, Monza, Italy
| | - E P Sganzerla
- Laboratory of Experimental Stroke Research, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Neuroscience, ASST Monza, San Gerardo Hospital, Monza, Italy
| | - C Ferrarese
- Laboratory of Experimental Stroke Research, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Neuroscience, ASST Monza, San Gerardo Hospital, Monza, Italy
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Ospel JM, Menon BK, Demchuk AM, Almekhlafi MA, Kashani N, Mayank A, Fainardi E, Rubiera M, Khaw A, Shankar JJ, Dowlatshahi D, Puig J, Sohn SI, Ahn SH, Poppe A, Calleja A, Hill MD, Goyal M. Clinical Course of Acute Ischemic Stroke Due to Medium Vessel Occlusion With and Without Intravenous Alteplase Treatment. Stroke 2020; 51:3232-3240. [PMID: 33070714 DOI: 10.1161/strokeaha.120.030227] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Available data on the clinical course of patients with acute ischemic stroke due to medium vessel occlusion (MeVO) are mostly limited to those with M2 segment occlusions. Outcomes are generally better compared with more proximal occlusions, but many patients will still suffer from severe morbidity. We aimed to determine the clinical course of acute ischemic stroke due to MeVO with and without intravenous alteplase treatment. METHODS Patients with MeVO (M2/M3/A2/A3/P2/P3 occlusion) from the INTERRSeCT (The Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography) and PRoveIT (Precise and Rapid Assessment of Collaterals Using Multi-Phase CTA in the Triage of Patients With Acute Ischemic Stroke for IA Therapy) studies were included. Baseline characteristics and clinical outcomes were summarized using descriptive statistics. The primary outcome was a modified Rankin Scale score of 0 to 1 at 90 days, describing excellent functional outcome. Secondary outcomes were the common odds ratio for a 1-point shift across the modified Rankin Scale and functional independence, defined as modified Rankin Scale score of 0 to 2. We compared outcomes between patients with versus without intravenous alteplase treatment and between patients who did and did not show recanalization on follow-up computed tomography angiography. Logistic regression was used to provide adjusted effect-size estimates. RESULTS Among 258 patients with MeVO, the median baseline National Institutes of Health Stroke Scale score was 7 (interquartile range: 5-12). A total of 72.1% (186/258) patients were treated with intravenous alteplase and in 41.8% (84/201), recanalization of the occlusion (revised arterial occlusive lesion score 2b/3) was seen on follow-up computed tomography angiography. Excellent functional outcome was achieved by 50.0% (129/258), and 67.4% (174/258) patients gained functional independence, while 8.9% (23/258) patients died within 90 days. Recanalization was observed in 21.4% (9/42) patients who were not treated with alteplase and 47.2% (75/159) patients treated with alteplase (P=0.003). Early recanalization (adjusted odds ratio, 2.29 [95% CI, 1.23-4.28]) was significantly associated with excellent functional outcome, while intravenous alteplase was not (adjusted odds ratio, 1.70 [95% CI, 0.88-3.25]). CONCLUSIONS One of every 2 patients with MeVO did not achieve excellent clinical outcome at 90 days with best medical management. Early recanalization was strongly associated with excellent outcome but occurred in <50% of patients despite intravenous alteplase treatment.
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Affiliation(s)
- Johanna M Ospel
- Department of Clinical Neurosciences (J.M.O., B.K.M., A.M.D., M.A.A., N.K., A.M., M.D.H., M.G.), University of Calgary, Canada.,Department of Radiology, University Hospital of Basel, Switzerland (J.M.O.)
| | - Bijoy K Menon
- Department of Clinical Neurosciences (J.M.O., B.K.M., A.M.D., M.A.A., N.K., A.M., M.D.H., M.G.), University of Calgary, Canada.,Department of Radiology (B.K.M., A.M.D., M.A.A., N.K., M.D.H., M.G.), University of Calgary, Canada.,Community Health Sciences (B.K.M., M.A.A., M.D.H.), University of Calgary, Canada.,Hotchkiss Brain Institute, Calgary, Canada (B.K.M., A.M.D., M.A.A., M.D.H., M.G.)
| | - Andrew M Demchuk
- Department of Clinical Neurosciences (J.M.O., B.K.M., A.M.D., M.A.A., N.K., A.M., M.D.H., M.G.), University of Calgary, Canada.,Department of Radiology (B.K.M., A.M.D., M.A.A., N.K., M.D.H., M.G.), University of Calgary, Canada.,Hotchkiss Brain Institute, Calgary, Canada (B.K.M., A.M.D., M.A.A., M.D.H., M.G.)
| | - Mohammed A Almekhlafi
- Department of Clinical Neurosciences (J.M.O., B.K.M., A.M.D., M.A.A., N.K., A.M., M.D.H., M.G.), University of Calgary, Canada.,Department of Radiology (B.K.M., A.M.D., M.A.A., N.K., M.D.H., M.G.), University of Calgary, Canada.,Community Health Sciences (B.K.M., M.A.A., M.D.H.), University of Calgary, Canada.,Hotchkiss Brain Institute, Calgary, Canada (B.K.M., A.M.D., M.A.A., M.D.H., M.G.)
| | - Nima Kashani
- Department of Clinical Neurosciences (J.M.O., B.K.M., A.M.D., M.A.A., N.K., A.M., M.D.H., M.G.), University of Calgary, Canada.,Department of Radiology (B.K.M., A.M.D., M.A.A., N.K., M.D.H., M.G.), University of Calgary, Canada
| | - Arnuv Mayank
- Department of Clinical Neurosciences (J.M.O., B.K.M., A.M.D., M.A.A., N.K., A.M., M.D.H., M.G.), University of Calgary, Canada
| | - Enrico Fainardi
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Italy (E.F.)
| | | | - Alexander Khaw
- Department of Clinical Neurosciences, University of Western Ontario, London Health Sciences Centre, Canada (A.K.)
| | - Jai J Shankar
- Department of Radiology, University of Manitoba, Winnipeg, Canada (J.J.S.)
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), University of Ottawa Brain and Mind Institute & Ottawa Hospital Research Institute (D.D.)
| | - Josep Puig
- Department of Radiology, Biomedical Research Institute Imaging Research Unit, Diagnostic Imaging Institute, Dr Josep Trueta University Hospital, Girona, Spain (J.P.)
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea (S.-I.S.)
| | - Seong H Ahn
- Department of Neurology, Chosun University Hospital, Chosun University College of Medicine, Gwangju, South Korea (S.H.A.)
| | - Alexandre Poppe
- Department of Neurosciences, Université de Montréal, Canada (A.P.)
| | - Ana Calleja
- Department of Neurology, Hospital Clínico Universitario de Valladolid, University of Valladolid, Spain (A.C.)
| | - Michael D Hill
- Department of Clinical Neurosciences (J.M.O., B.K.M., A.M.D., M.A.A., N.K., A.M., M.D.H., M.G.), University of Calgary, Canada.,Department of Radiology (B.K.M., A.M.D., M.A.A., N.K., M.D.H., M.G.), University of Calgary, Canada.,Community Health Sciences (B.K.M., M.A.A., M.D.H.), University of Calgary, Canada.,Hotchkiss Brain Institute, Calgary, Canada (B.K.M., A.M.D., M.A.A., M.D.H., M.G.)
| | - Mayank Goyal
- Department of Clinical Neurosciences (J.M.O., B.K.M., A.M.D., M.A.A., N.K., A.M., M.D.H., M.G.), University of Calgary, Canada.,Department of Radiology (B.K.M., A.M.D., M.A.A., N.K., M.D.H., M.G.), University of Calgary, Canada.,Hotchkiss Brain Institute, Calgary, Canada (B.K.M., A.M.D., M.A.A., M.D.H., M.G.)
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McCarthy DJ, Tonetti DA, Stone J, Starke RM, Narayanan S, Lang MJ, Jadhav AP, Gross BA. More expansive horizons: a review of endovascular therapy for patients with low NIHSS scores. J Neurointerv Surg 2020; 13:146-151. [PMID: 33028674 DOI: 10.1136/neurintsurg-2020-016583] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/08/2020] [Accepted: 09/13/2020] [Indexed: 11/03/2022]
Abstract
While the landmark 2015 stroke trials demonstrated that endovascular therapy (EVT) was superior to medical management for the treatment of acute ischemic stroke due to large vessel occlusion, the efficacy of EVT for patients presenting with a low NIHSS score remains undetermined. We conducted a review of the EVT low National Institutes of Health Stroke Scale (NIHSS) stroke literature, identifying 24 quantitative and six qualitative publications. Details of study designs and outcome were extracted and critically discussed.All identified qualitative studies were retrospective. There was significant study design heterogeneity, with 18 unique study designs between the 24 identified quantitative manuscripts. Study investigations included low NIHSS EVT feasibility (n=6), EVT versus best medical management (BMM; n=10), EVT versus intravenous therapy (IVT, n=3), and low NIHSS score versus high NIHSS score (n=3). From single-arm EVT feasibility studies, the reported ranges of modified Thrombolysis in Cerebral Infarction and symptomatic intracranial hemorrhage were 78-97% and 0-10%, respectively. The EVT versus BMM literature had heterogeneous results with 40% reporting benefit with EVT and 60% reporting neutral findings. None of the studies comparing EVT with IVT reported a difference between the two revascularization therapies. The four identified meta-analyses had incongruent inclusion criteria and conflicting results. Two randomized trials are currently investigating EVT in patients with a low NIHSS score. Selected meta-analyses do suggest a potential benefit of EVT over BMM; however, current and future randomized clinical trials will better elucidate the efficacy of EVT in this patient population.
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Affiliation(s)
- David J McCarthy
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Daniel A Tonetti
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeremy Stone
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami MILLER School of Medicine, Miami Beach, Florida, USA.,Department of Neurosurgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Sandra Narayanan
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael J Lang
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ashutosh P Jadhav
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Stib MT, Vasquez J, Dong MP, Kim YH, Subzwari SS, Triedman HJ, Wang A, Wang HLC, Yao AD, Jayaraman M, Boxerman JL, Eickhoff C, Cetintemel U, Baird GL, McTaggart RA. Detecting Large Vessel Occlusion at Multiphase CT Angiography by Using a Deep Convolutional Neural Network. Radiology 2020; 297:640-649. [PMID: 32990513 DOI: 10.1148/radiol.2020200334] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Large vessel occlusion (LVO) stroke is one of the most time-sensitive diagnoses in medicine and requires emergent endovascular therapy to reduce morbidity and mortality. Leveraging recent advances in deep learning may facilitate rapid detection and reduce time to treatment. Purpose To develop a convolutional neural network to detect LVOs at multiphase CT angiography. Materials and Methods This multicenter retrospective study evaluated 540 adults with CT angiography examinations for suspected acute ischemic stroke from February 2017 to June 2018. Examinations positive for LVO (n = 270) were confirmed by catheter angiography and LVO-negative examinations (n = 270) were confirmed through review of clinical and radiology reports. Preprocessing of the CT angiography examinations included vasculature segmentation and the creation of maximum intensity projection images to emphasize the contrast agent-enhanced vasculature. Seven experiments were performed by using combinations of the three phases (arterial, phase 1; peak venous, phase 2; and late venous, phase 3) of the CT angiography. Model performance was evaluated on the held-out test set. Metrics included area under the receiver operating characteristic curve (AUC), sensitivity, and specificity. Results The test set included 62 patients (mean age, 69.5 years; 48% women). Single-phase CT angiography achieved an AUC of 0.74 (95% confidence interval [CI]: 0.63, 0.85) with sensitivity of 77% (24 of 31; 95% CI: 59%, 89%) and specificity of 71% (22 of 31; 95% CI: 53%, 84%). Phases 1, 2, and 3 together achieved an AUC of 0.89 (95% CI: 0.81, 0.96), sensitivity of 100% (31 of 31; 95% CI: 99%, 100%), and specificity of 77% (24 of 31; 95% CI: 59%, 89%), a statistically significant improvement relative to single-phase CT angiography (P = .01). Likewise, phases 1 and 3 and phases 2 and 3 also demonstrated improved fit relative to single phase (P = .03). Conclusion This deep learning model was able to detect the presence of large vessel occlusion and its diagnostic performance was enhanced by using delayed phases at multiphase CT angiography examinations. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Ospel and Goyal in this issue.
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Affiliation(s)
- Matthew T Stib
- From the Departments of Diagnostic Imaging (M.T.S., M.J., J.L.B., G.L.B., R.A.M.), Diagnostic Imaging (A.D.Y.), and Neurosurgery (M.J., R.A.M.), Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, 593 Eddy St, APC 701, Providence, RI 02903; Department of Computer Science, Brown University, Providence, RI (J.V., M.P.D., Y.H.K., S.S.S., H.J.T., A.W., H.L.C.W., C.E., U.C.); and the Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (M.J., R.A.M.)
| | - Justin Vasquez
- From the Departments of Diagnostic Imaging (M.T.S., M.J., J.L.B., G.L.B., R.A.M.), Diagnostic Imaging (A.D.Y.), and Neurosurgery (M.J., R.A.M.), Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, 593 Eddy St, APC 701, Providence, RI 02903; Department of Computer Science, Brown University, Providence, RI (J.V., M.P.D., Y.H.K., S.S.S., H.J.T., A.W., H.L.C.W., C.E., U.C.); and the Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (M.J., R.A.M.)
| | - Mary P Dong
- From the Departments of Diagnostic Imaging (M.T.S., M.J., J.L.B., G.L.B., R.A.M.), Diagnostic Imaging (A.D.Y.), and Neurosurgery (M.J., R.A.M.), Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, 593 Eddy St, APC 701, Providence, RI 02903; Department of Computer Science, Brown University, Providence, RI (J.V., M.P.D., Y.H.K., S.S.S., H.J.T., A.W., H.L.C.W., C.E., U.C.); and the Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (M.J., R.A.M.)
| | - Yun Ho Kim
- From the Departments of Diagnostic Imaging (M.T.S., M.J., J.L.B., G.L.B., R.A.M.), Diagnostic Imaging (A.D.Y.), and Neurosurgery (M.J., R.A.M.), Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, 593 Eddy St, APC 701, Providence, RI 02903; Department of Computer Science, Brown University, Providence, RI (J.V., M.P.D., Y.H.K., S.S.S., H.J.T., A.W., H.L.C.W., C.E., U.C.); and the Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (M.J., R.A.M.)
| | - Sumera S Subzwari
- From the Departments of Diagnostic Imaging (M.T.S., M.J., J.L.B., G.L.B., R.A.M.), Diagnostic Imaging (A.D.Y.), and Neurosurgery (M.J., R.A.M.), Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, 593 Eddy St, APC 701, Providence, RI 02903; Department of Computer Science, Brown University, Providence, RI (J.V., M.P.D., Y.H.K., S.S.S., H.J.T., A.W., H.L.C.W., C.E., U.C.); and the Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (M.J., R.A.M.)
| | - Harold J Triedman
- From the Departments of Diagnostic Imaging (M.T.S., M.J., J.L.B., G.L.B., R.A.M.), Diagnostic Imaging (A.D.Y.), and Neurosurgery (M.J., R.A.M.), Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, 593 Eddy St, APC 701, Providence, RI 02903; Department of Computer Science, Brown University, Providence, RI (J.V., M.P.D., Y.H.K., S.S.S., H.J.T., A.W., H.L.C.W., C.E., U.C.); and the Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (M.J., R.A.M.)
| | - Amy Wang
- From the Departments of Diagnostic Imaging (M.T.S., M.J., J.L.B., G.L.B., R.A.M.), Diagnostic Imaging (A.D.Y.), and Neurosurgery (M.J., R.A.M.), Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, 593 Eddy St, APC 701, Providence, RI 02903; Department of Computer Science, Brown University, Providence, RI (J.V., M.P.D., Y.H.K., S.S.S., H.J.T., A.W., H.L.C.W., C.E., U.C.); and the Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (M.J., R.A.M.)
| | - Hsin-Lei Charlene Wang
- From the Departments of Diagnostic Imaging (M.T.S., M.J., J.L.B., G.L.B., R.A.M.), Diagnostic Imaging (A.D.Y.), and Neurosurgery (M.J., R.A.M.), Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, 593 Eddy St, APC 701, Providence, RI 02903; Department of Computer Science, Brown University, Providence, RI (J.V., M.P.D., Y.H.K., S.S.S., H.J.T., A.W., H.L.C.W., C.E., U.C.); and the Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (M.J., R.A.M.)
| | - Anthony D Yao
- From the Departments of Diagnostic Imaging (M.T.S., M.J., J.L.B., G.L.B., R.A.M.), Diagnostic Imaging (A.D.Y.), and Neurosurgery (M.J., R.A.M.), Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, 593 Eddy St, APC 701, Providence, RI 02903; Department of Computer Science, Brown University, Providence, RI (J.V., M.P.D., Y.H.K., S.S.S., H.J.T., A.W., H.L.C.W., C.E., U.C.); and the Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (M.J., R.A.M.)
| | - Mahesh Jayaraman
- From the Departments of Diagnostic Imaging (M.T.S., M.J., J.L.B., G.L.B., R.A.M.), Diagnostic Imaging (A.D.Y.), and Neurosurgery (M.J., R.A.M.), Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, 593 Eddy St, APC 701, Providence, RI 02903; Department of Computer Science, Brown University, Providence, RI (J.V., M.P.D., Y.H.K., S.S.S., H.J.T., A.W., H.L.C.W., C.E., U.C.); and the Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (M.J., R.A.M.)
| | - Jerrold L Boxerman
- From the Departments of Diagnostic Imaging (M.T.S., M.J., J.L.B., G.L.B., R.A.M.), Diagnostic Imaging (A.D.Y.), and Neurosurgery (M.J., R.A.M.), Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, 593 Eddy St, APC 701, Providence, RI 02903; Department of Computer Science, Brown University, Providence, RI (J.V., M.P.D., Y.H.K., S.S.S., H.J.T., A.W., H.L.C.W., C.E., U.C.); and the Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (M.J., R.A.M.)
| | - Carsten Eickhoff
- From the Departments of Diagnostic Imaging (M.T.S., M.J., J.L.B., G.L.B., R.A.M.), Diagnostic Imaging (A.D.Y.), and Neurosurgery (M.J., R.A.M.), Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, 593 Eddy St, APC 701, Providence, RI 02903; Department of Computer Science, Brown University, Providence, RI (J.V., M.P.D., Y.H.K., S.S.S., H.J.T., A.W., H.L.C.W., C.E., U.C.); and the Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (M.J., R.A.M.)
| | - Ugur Cetintemel
- From the Departments of Diagnostic Imaging (M.T.S., M.J., J.L.B., G.L.B., R.A.M.), Diagnostic Imaging (A.D.Y.), and Neurosurgery (M.J., R.A.M.), Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, 593 Eddy St, APC 701, Providence, RI 02903; Department of Computer Science, Brown University, Providence, RI (J.V., M.P.D., Y.H.K., S.S.S., H.J.T., A.W., H.L.C.W., C.E., U.C.); and the Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (M.J., R.A.M.)
| | - Grayson L Baird
- From the Departments of Diagnostic Imaging (M.T.S., M.J., J.L.B., G.L.B., R.A.M.), Diagnostic Imaging (A.D.Y.), and Neurosurgery (M.J., R.A.M.), Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, 593 Eddy St, APC 701, Providence, RI 02903; Department of Computer Science, Brown University, Providence, RI (J.V., M.P.D., Y.H.K., S.S.S., H.J.T., A.W., H.L.C.W., C.E., U.C.); and the Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (M.J., R.A.M.)
| | - Ryan A McTaggart
- From the Departments of Diagnostic Imaging (M.T.S., M.J., J.L.B., G.L.B., R.A.M.), Diagnostic Imaging (A.D.Y.), and Neurosurgery (M.J., R.A.M.), Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, 593 Eddy St, APC 701, Providence, RI 02903; Department of Computer Science, Brown University, Providence, RI (J.V., M.P.D., Y.H.K., S.S.S., H.J.T., A.W., H.L.C.W., C.E., U.C.); and the Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI (M.J., R.A.M.)
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Ospel JM, Cimflova P, Marko M, Mayank A, Hafeez M, Almekhlafi MA, Hill MD, Demchuk AM, Menon BK, Goyal M. Prevalence and Outcomes of Medium Vessel Occlusions With Discrepant Infarct Patterns. Stroke 2020; 51:2817-2824. [PMID: 32757752 DOI: 10.1161/strokeaha.120.030041] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The prognosis of medium vessel occlusions (MeVOs), that is, M2/3 middle cerebral artery, A2/3 anterior cerebral artery, and P2/3 posterior cerebral artery occlusions, is generally better compared with large vessel occlusions, since brain ischemia is less extensive. However, in some MeVO patients, infarcts are seen outside the territory of the occluded vessel (MeVO with discrepant infarcts). This study aims to determine the prevalence and clinical impact of discrepant infarct patterns in acute ischemic stroke due to MeVO. METHODS We pooled data of MeVO patients from INTERRSeCT (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography) and PRove-IT (Precise and Rapid Assessment of Collaterals Using Multi-Phase CTA in the Triage of Patients With Acute Ischemic Stroke for IA Therapy)-2 prospective cohort studies of patients with acute ischemic stroke. The combination of occlusion location on baseline computed tomography angiography and infarct location on follow-up computed tomography/magnetic resonance imaging was used to identify MeVOs with discrepant infarct patterns. Two definitions for discrepant infarcts were applied; one was more restrictive and purely based on infarct patterns of the basal ganglia, whereas the second one took cortical infarct patterns into account. Clinical outcomes of patients with versus without discrepant infarcts were summarized using descriptive statistics. Logistic regression was performed to obtain adjusted effect size estimates for the association of discrepant infarcts and good outcome, defined as a modified Rankin Scale score of 0 to 2, and excellent outcome (modified Rankin Scale score 0-1). RESULTS Two hundred sixty-two patients with MeVO were included in the analysis. The prevalence of discrepant infarcts was 39.7% (definition 1) and 21.0% (definition 2). Patients with discrepant infarcts were less likely to achieve good outcome (definition 1: adjusted odds ratio, 0.48 [95% CI, 0.25-0.91]; definition 2: adjusted odds ratio, 0.47 [95% CI, 0.22-0.99]). When definition 1 was applied, patients with discrepant infarcts were also less likely to achieve excellent outcome (definition 1: adjusted odds ratio, 0.55 [95% CI, 0.31-0.99]; definition 2: adjusted odds ratio, 0.62 [95% CI, 0.31-1.25]). CONCLUSIONS MeVO patients with discrepant infarcts are common, and they are associated with more severe deficits and poor outcomes.
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Affiliation(s)
- Johanna M Ospel
- Departments of Clinical Neurosciences (J.M.O., P.C., M.M., A.M., M.H., M.A.A., M.D.H., A.M.D., B.K.M., M.G.), University of Calgary, Canada.,Department of Radiology, University Hospital of Basel, Switzerland (J.M.O.)
| | - Petra Cimflova
- Departments of Clinical Neurosciences (J.M.O., P.C., M.M., A.M., M.H., M.A.A., M.D.H., A.M.D., B.K.M., M.G.), University of Calgary, Canada.,Department of Medical Imaging (P.C.), St. Anne's University Hospital Brno, Czech Republic.,International Clinical Research Center (P.C.), St. Anne's University Hospital Brno, Czech Republic.,Faculty of Medicine, Masaryk University, Brno, Czech Republic (P.C.)
| | - Martha Marko
- Departments of Clinical Neurosciences (J.M.O., P.C., M.M., A.M., M.H., M.A.A., M.D.H., A.M.D., B.K.M., M.G.), University of Calgary, Canada
| | - Arnuv Mayank
- Departments of Clinical Neurosciences (J.M.O., P.C., M.M., A.M., M.H., M.A.A., M.D.H., A.M.D., B.K.M., M.G.), University of Calgary, Canada
| | - Moiz Hafeez
- Departments of Clinical Neurosciences (J.M.O., P.C., M.M., A.M., M.H., M.A.A., M.D.H., A.M.D., B.K.M., M.G.), University of Calgary, Canada
| | - Mohammed A Almekhlafi
- Departments of Clinical Neurosciences (J.M.O., P.C., M.M., A.M., M.H., M.A.A., M.D.H., A.M.D., B.K.M., M.G.), University of Calgary, Canada.,Radiology (M.A.A., M.D.H., A.M.D., B.K.M., M.G.), University of Calgary, Canada
| | - Michael D Hill
- Departments of Clinical Neurosciences (J.M.O., P.C., M.M., A.M., M.H., M.A.A., M.D.H., A.M.D., B.K.M., M.G.), University of Calgary, Canada.,Radiology (M.A.A., M.D.H., A.M.D., B.K.M., M.G.), University of Calgary, Canada
| | - Andrew M Demchuk
- Departments of Clinical Neurosciences (J.M.O., P.C., M.M., A.M., M.H., M.A.A., M.D.H., A.M.D., B.K.M., M.G.), University of Calgary, Canada.,Radiology (M.A.A., M.D.H., A.M.D., B.K.M., M.G.), University of Calgary, Canada
| | - Bijoy K Menon
- Departments of Clinical Neurosciences (J.M.O., P.C., M.M., A.M., M.H., M.A.A., M.D.H., A.M.D., B.K.M., M.G.), University of Calgary, Canada.,Radiology (M.A.A., M.D.H., A.M.D., B.K.M., M.G.), University of Calgary, Canada
| | - Mayank Goyal
- Departments of Clinical Neurosciences (J.M.O., P.C., M.M., A.M., M.H., M.A.A., M.D.H., A.M.D., B.K.M., M.G.), University of Calgary, Canada.,Radiology (M.A.A., M.D.H., A.M.D., B.K.M., M.G.), University of Calgary, Canada
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Al Khathaami AM, Aldriweesh MA, Al Bdah BA, Alhasson MA, Alsaif SA, Alluhidan WA, Almutairi FM, Alskaini MA, Alotaibi N, Alghamdi SAM. Anterior circulation large vessel occlusion stroke in Saudi Arabia: Prevalence, predictors, and outcome. J Stroke Cerebrovasc Dis 2020; 29:105080. [PMID: 32807477 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 05/31/2020] [Accepted: 06/18/2020] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Anterior circulation Large Vessel Occlusion (LVO) stroke comes with significant morbidity and mortality. With the advent of endovascular interventions, its management has revolutionized. For health authorities to build systems and allocate resources, its burden, predictors, and outcome must be determined. METHODS In a single tertiary care center, we retrospectively collected data from 1495 ischemic stroke patients to determine anterior circulation LVO prevalence, predictors, and outcome. Patients must have radiologically proven ischemic stroke within 24 hours before arrival at the emergency department. Anterior circulation LVO related stroke was defined as evidence of new anterior circulation infarct detected on neuroimaging, and vascular imaging confirming anterior circulation Large Vessel Occlusion. Data on demographics, vascular risk factors, treatment with reperfusion therapy, modified Rankin Scale (mRS) at admission, National Institute of Health Stroke Scale (NIHSS) at admission, length of stay (LOS) in days, and in-hospital comorbidities and death were collected. Regression analysis was done to determine the predictors and outcomes of anterior circulation LVO ischemic strokes. RESULTS We found anterior circulation LVO in 27.8% (95 % CI 25.5-30.0) of all ischemic stroke patients. Atrial fibrillation and admission National Institute of Health Stroke Scale (NIHSS) were the strongest predictors of LVO [OR 2.33, P = 0.0011 and OR 1.17, P < 0.0001] respectively. Occurrence of LVO was associated with worse disability score (mRS ≥ 3) [47.22 vs. 19.81% (P = 0.0073)], longer hospitalization in days [Median 9.0 vs. 3.0, IQR (14.0 vs. 5.0) P = 0.0432)], and was more likely to results in patient admission to intensive care unit [Mean 17.59 vs. 3.70 % (P = 0.0002)]. CONCLUSION Stroke with large vessel occlusion in Saudi Arabia is not uncommon. Its burden and outcome deserve national attention, as effective treatment is now readily available.
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Affiliation(s)
- Ali M Al Khathaami
- King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia; College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Mohammed A Aldriweesh
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Bayan A Al Bdah
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Muath A Alhasson
- Unaizah College of Medicine, Qassim University, Qassim, Saudi Arabia
| | - Sultan A Alsaif
- College of Medicine, Almaarefa University, Riyadh, Saudi Arabia
| | - Waleed A Alluhidan
- College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Faisal M Almutairi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Mohammed A Alskaini
- King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Nasser Alotaibi
- King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia; College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Saeed A M Alghamdi
- King Abdulaziz Medical City, National Guard Health Affairs, Jeddah, Saudi Arabia; College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
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Findakly S, Maingard J, Phan K, Barras CD, Jhamb A, Chandra R, Thijs V, Brooks M, Asadi H. Endovascular clot retrieval for M2 segment middle cerebral artery occlusion: a systematic review and meta‐analysis. Intern Med J 2020; 50:530-541. [DOI: 10.1111/imj.14333] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/17/2019] [Accepted: 04/22/2019] [Indexed: 11/28/2022]
Affiliation(s)
| | - Julian Maingard
- Interventional Neuroradiology ServiceAustin Health Melbourne Victoria Australia
- School of MedicineDeakin University Geelong Victoria Australia
- Interventional Neuroradiology UnitMonash Imaging, Monash Health Melbourne Victoria Australia
| | - Kevin Phan
- NeuroSpine Surgery Research GroupPrince of Wales Private Hospital Sydney New South Wales Australia
| | - Christen D. Barras
- South Australian Health and Medical Research Institute Adelaide South Australia Australia
- The University of Adelaide Adelaide South Australia Australia
| | - Ashu Jhamb
- Interventional Neuroradiology ServiceAustin Health Melbourne Victoria Australia
| | - Ronil Chandra
- Interventional Neuroradiology UnitMonash Imaging, Monash Health Melbourne Victoria Australia
- Department of ImagingMonash University Melbourne Victoria Australia
| | - Vincent Thijs
- Stroke DivisionFlorey Institute of Neuroscience and Mental Health, University of Melbourne Melbourne Victoria Australia
- The University of Melbourne Melbourne Victoria Australia
- Department of NeurologyAustin Health Melbourne Victoria Australia
| | - Mark Brooks
- Interventional Neuroradiology ServiceAustin Health Melbourne Victoria Australia
- School of MedicineDeakin University Geelong Victoria Australia
| | - Hamed Asadi
- Interventional Neuroradiology ServiceAustin Health Melbourne Victoria Australia
- School of MedicineDeakin University Geelong Victoria Australia
- Interventional Neuroradiology UnitMonash Imaging, Monash Health Melbourne Victoria Australia
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Bulwa Z, Del Brutto VJ, Loggini A, Ammar FE, Martinez RC, Christoforidis G, Brorson JR, Ardelt AA, Goldenberg FD. Mechanical Thrombectomy for Patients with In-Hospital Ischemic Stroke: A Case-Control Study. J Stroke Cerebrovasc Dis 2020; 29:104692. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.104692] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 01/12/2020] [Accepted: 01/23/2020] [Indexed: 10/25/2022] Open
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Shriki J, Johnson L, Patel P, McGann M, Lurie T, Phipps MS, Yarbrough K, Jindal G, Mubariz H, Galvagno SM, Thom SR, Tran QK. Transport Blood Pressures and Outcomes in Stroke Patients Requiring Thrombectomy. Air Med J 2020; 39:166-172. [PMID: 32540106 DOI: 10.1016/j.amj.2020.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 01/09/2020] [Accepted: 03/01/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Mechanical thrombectomy is the treatment of choice for acute ischemic strokes from large vessel occlusions. Absolute blood pressure and blood pressure variability (BPV) may affect patients' outcome. We hypothesized that patients' outcomes were not associated with BPV during transport between hospitals in the era of effective thrombectomy. METHODS We performed a retrospective observational review of adult patients admitted to our comprehensive stroke center who underwent mechanical thrombectomy between January 1, 2015, and December 31, 2018. Data were collected from our stroke registry and transportation records. Outcomes were defined as 90-day modified Rankin Scale (mRS) ≤2 and any acute kidney injury (AKI) during hospitalization. RESULTS We analyzed 134 eligible patients. The mean age was 66 years (standard deviation = 14 years). Forty percent achieved mRS ≤2, and 16% had an AKI. BPV and maximum systolic blood pressures during transport were examined as variables to determine outcome. We found BPV was similar between patients with good and bad functional independence. Furthermore, the maximum systolic blood pressure during transport (odds ratio = 0.98; 95% confidence interval, 0.96-0.99; P = .038), not BPV, was associated with a lower likelihood of mRS ≤2. No similar correlation of analyzed blood pressure variables could be found for AKI as an outcome. CONCLUSION The maximum systolic blood pressure was associated with worse functional outcomes in stroke patients transported for thrombectomy. Prehospital clinicians should be cognizant of high blood pressure among patients with acute ischemic stroke from large vessel occlusion during transport and treat accordingly.
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Affiliation(s)
- Jesse Shriki
- University of Maryland Medical Center, Baltimore, MD.
| | | | - Priya Patel
- University of Maryland at College Park, College Park, MD
| | - Madison McGann
- University of Maryland Department of Emergency Medicine, Baltimore, MD
| | - Tucker Lurie
- University of Maryland School of Medicine, Baltimore, MD
| | - Michael S Phipps
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Karen Yarbrough
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Gaurav Jindal
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD; Department of Neuroradiology, University of Maryland School of Medicine, Baltimore, MD
| | | | - Samuel M Galvagno
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Stephen R Thom
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD; Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Quincy K Tran
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD; Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
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Goyal M, Ospel JM, Menon BK, Hill MD. MeVO: the next frontier? J Neurointerv Surg 2020; 12:545-547. [DOI: 10.1136/neurintsurg-2020-015807] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2020] [Indexed: 11/04/2022]
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Navia P, Schramm P, Fiehler J. ADAPT technique in ischemic stroke treatment of M2 middle cerebral artery occlusions in comparison to M1 occlusions: Post hoc analysis of the PROMISE study. Interv Neuroradiol 2019; 26:178-186. [PMID: 31847643 PMCID: PMC7507234 DOI: 10.1177/1591019919894800] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background/purpose The benefit of endovascular thrombectomy in acute ischemic stroke (AIS)
therapy of proximal large vessel occlusions (LVO) is established. However,
there are few prospective studies evaluating the use of a direct aspiration
first pass technique in distal vessel occlusions. This post hoc analysis of
the PROMISE study examines the safety and effectiveness of the Penumbra
System with the ACE68 and ACE64 Reperfusion Catheters for aspiration
thrombectomy in the M1 and M2 segments of the middle cerebral artery. Methods PROMISE is a prospective, multicenter study that enrolled 204 patients with
anterior circulation LVO AIS-treated frontline with ACE68/ACE64 catheters.
We compared clinical and angiographic outcomes, complications, and mortality
in patients with M1 and M2 occlusions. The association of M1 and M2 location
and functional independence or mTICI 2b-3 reperfusion was described in
univariable and multivariable analyses. Results One hundred sixty-one patients (124 M1 and 37 M2 locations) met the study
criteria. Post procedure mTICI 2b-3 reperfusion (93% vs. 92%,
p = 1.00), functional independence (57% vs. 70%,
p = 0.18), symptomatic intracranial hemorrhage (1.6%
vs. 2.7%, p = 0.55), device- or procedure-related serious
adverse events at 30 days (4.0% vs. 8.1%, p = 0.39), and
mortality at 90 days (6.6% vs. 2.7%, p = 0.69) were
comparable between M1 and M2 occlusions. In multivariable analysis, lower
age, lower baseline NIHSS, and shorter time from onset to admission were
independent predictors of functional independence. Conclusions For frontline aspiration thrombectomy of stroke, use of large-bore
ACE68/ACE64 catheters for treatment of M2 occlusions appeared as safe and
effective as for M1 occlusions.
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Affiliation(s)
- Pedro Navia
- Hospital Universitario La Paz, Madrid, Spain
| | - Peter Schramm
- Department of Neuroradiology, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Jens Fiehler
- Department of Neuroradiology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
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