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Collateral-Core Ratio as a Novel Predictor of Clinical Outcomes in Acute Ischemic Stroke. Transl Stroke Res 2023; 14:73-82. [PMID: 35877061 DOI: 10.1007/s12975-022-01066-9] [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: 03/16/2022] [Revised: 06/26/2022] [Accepted: 07/13/2022] [Indexed: 01/31/2023]
Abstract
The interaction effect between collateral circulation and ischemic core size on stroke outcomes has been highlighted in acute ischemic stroke (AIS). However, biomarkers that assess the magnitude of this interaction are still lacking. We aimed to present a new imaging marker, the collateral-core ratio (CCR), to quantify the interaction effect between these factors and evaluate its ability to predict functional outcomes using machine learning (ML) in AIS. Patients with AIS caused by anterior circulation large vessel occlusion (LVO) were recruited from a prospective multicenter study. CCR was calculated as collateral perfusion volume/ischemic core volume. Functional outcomes were assessed using the modified Rankin Scale (mRS) at 90 days. An ML model was built and tested with a tenfold cross-validation using nine clinical and four imaging variables with mRS score 3-6 as unfavorable outcomes. Among 129 patients, CCR was identified as the most important variable. The prediction model incorporating clinical factors, ischemic core volume, collateral perfusion volume, and CCR showed better discriminatory power in predicting unfavorable outcomes than the model without CCR (mean C index 0.853 ± 0.108 versus 0.793 ± 0.133, P = 0.70; mean net reclassification index 52.7% ± 32.7%, P < 0.05). When patients were divided into two groups based on their CCR value with a threshold of 0.73, unfavorable outcomes were significantly more prevalent in patients with CCR ≤ 0.73 than in those with CCR > 0.73. CCR is a robust predictor of functional outcomes, as identified by ML, in patients with acute LVO. The prediction model that incorporated CCR improved the model's ability to identify unfavorable outcomes. ClinicalTrials.gov Identifier: NCT02580097.
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Arora K, Gaekwad A, Evans J, O'Brien W, Ang T, Garcia-Esperon C, Blair C, Edwards LS, Chew BLA, Delcourt C, Spratt NJ, Parsons MW, Butcher KS. Diagnostic Utility of Computed Tomography Perfusion in the Telestroke Setting. Stroke 2022; 53:2917-2925. [PMID: 35652343 DOI: 10.1161/strokeaha.122.038798] [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 Definitive diagnosis of acute ischemic stroke is challenging, particularly in telestroke settings. Although the prognostic utility of CT perfusion (CTP) has been questioned, its diagnostic value remains under-appreciated, especially in cases without an easily visible intracranial occlusion. We assessed the diagnostic accuracy of routine CTP in the acute telestroke setting. METHODS Acute and follow-up data collected prospectively from consecutive suspected patients with stroke assessed by a state-wide telestroke service between March 2020 and August 2021 at 12 sites in Australia were analyzed. All patients in the final analysis had been assessed with multimodal CT, including CTP, which was post-processed with automated volumetric software. Diagnostic sensitivity and specificity were calculated for multimodal CT and each individual component (noncontrast CT [NCCT], CT angiogram [CTA], and CTP). Final diagnosis determined by consensus review of follow-up imaging and clinical data was used as the reference standard. RESULTS During the study period, complete multimodal CT examination was obtained in 831 patients, 457 of whom were diagnosed with stroke. Diagnostic sensitivity for ischemic stroke increased by 19.5 percentage points when CTP was included with NCCT and CTA compared with NCCT and CTA alone (73.1% positive with NCCT+CTA+CTP [95% CI, 68.8-77.1] versus 53.6% positive with NCCT+CTA alone [95% CI, 48.9-58.3], P<0.001). No difference was observed between specificities of NCCT+CTA and NCCT+CTA+CTP (98.7% [95% CI, 98.5-100] versus 98.7% [95% CI, 96.9-99.6], P=0.13). Multimodal CT, including CTP, demonstrated the highest negative predictive value (75.0% [95% CI, 72.1-77.7]). Patients with stroke not evident on CTP had small volume infarcts on follow-up (1.2 mL, interquartile range 0.5-2.7mL). CONCLUSIONS Acquisition of CTP as part of a telestroke imaging protocol permits definitive diagnosis of cerebral ischemia in 1 in 5 patients with normal NCCT and CTA.
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Affiliation(s)
- Kshitij Arora
- Prince of Wales Clinical School, University of New South Wales, Clinical Neurosciences, Randwick, Australia (K.A., A.G., K.S.B.)
| | - Aaron Gaekwad
- Prince of Wales Clinical School, University of New South Wales, Clinical Neurosciences, Randwick, Australia (K.A., A.G., K.S.B.)
| | - James Evans
- Gosford Hospital, Department of Neurosciences, Australia (J.E., W.O.B., L.S.E.)
| | - William O'Brien
- Gosford Hospital, Department of Neurosciences, Australia (J.E., W.O.B., L.S.E.)
| | - Timothy Ang
- Departments of Neurology and Radiology, Royal Prince Alfred Hospital, Camperdown, Australia (T.A.)
| | - Carlos Garcia-Esperon
- John Hunter Hospital, Department of Neurology, and Hunter Medical Research Institute, New Lambton Heights, Australia (C.G.-E., B.L.A.C., N.J.S.).,The University of Newcastle, School of Biomedical Sciences and Pharmacy, Callaghan, Australia (C.G.-E., B.L.A.C., N.J.S.)
| | - Christopher Blair
- Sydney Brain Centre, Ingham Institute for Applied Medical Research, Liverpool, Australia (C.B., L.S.E.)
| | - Leon S Edwards
- Gosford Hospital, Department of Neurosciences, Australia (J.E., W.O.B., L.S.E.).,Sydney Brain Centre, Ingham Institute for Applied Medical Research, Liverpool, Australia (C.B., L.S.E.).,South Western Sydney Clinical School, University of New South Wales, Department of Neurology and Neurophysiology, Liverpool, Australia (L.S.E., M.W.P.)
| | - Beng L A Chew
- John Hunter Hospital, Department of Neurology, and Hunter Medical Research Institute, New Lambton Heights, Australia (C.G.-E., B.L.A.C., N.J.S.).,The University of Newcastle, School of Biomedical Sciences and Pharmacy, Callaghan, Australia (C.G.-E., B.L.A.C., N.J.S.)
| | - Candice Delcourt
- The George Institute for Global Health, University of New South Wales, Neurological and Mental Health Division, Newtown, Australia (C.D.).,Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia (C.D.)
| | - Neil J Spratt
- John Hunter Hospital, Department of Neurology, and Hunter Medical Research Institute, New Lambton Heights, Australia (C.G.-E., B.L.A.C., N.J.S.).,The University of Newcastle, School of Biomedical Sciences and Pharmacy, Callaghan, Australia (C.G.-E., B.L.A.C., N.J.S.)
| | - Mark W Parsons
- South Western Sydney Clinical School, University of New South Wales, Department of Neurology and Neurophysiology, Liverpool, Australia (L.S.E., M.W.P.)
| | - Ken S Butcher
- Prince of Wales Clinical School, University of New South Wales, Clinical Neurosciences, Randwick, Australia (K.A., A.G., K.S.B.)
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3
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Bivard A, Churilov L, Ma H, Levi C, Campbell B, Yassi N, Meretoja A, Zhao H, Sharma G, Chen C, Davis S, Donnan G, Yan B, Parsons M. Does variability in automated perfusion software outputs for acute ischemic stroke matter? Reanalysis of EXTEND perfusion imaging. CNS Neurosci Ther 2021; 28:139-144. [PMID: 34786868 PMCID: PMC8673699 DOI: 10.1111/cns.13756] [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: 08/21/2021] [Revised: 10/05/2021] [Accepted: 10/21/2021] [Indexed: 11/28/2022] Open
Abstract
Aims We reprocessed the Extending the time for Thrombolysis in Emergency Neurological Deficits (EXTEND) perfusion imaging with a different automated software with the aim of comparing mismatch eligibility and outcomes. Methods EXTEND baseline perfusion imaging data were reprocessed using autoMIStar software to identify patients who were eligible based on the same target mismatch criteria as per the original trial. Results From the 225 patients fulfilling RAPID‐based mismatch criteria randomized in the EXTEND study, 196 (87%) patients met the revised mismatch criteria. Most common reasons for not meeting revised criteria were core >70 ml (n = 9), and no perfusion lesion/lack of penumbral tissue (n = 20). The revised perfusion lesion volumes were significantly smaller compared to the original RAPID volumes (median 68 ml IQR 34–102 ml vs. 42 ml 16–92 ml, p = 0.036). Of the patients who met the revised mismatch criteria, 40% receiving alteplase had modified Rankin Scale (mRS) 0–1 at 3‐month compared to 28% with placebo (Adjusted Odds Ratio (OR) = 2.23, CI 1.08–4.58, p = 0.028). In contrast, in the original mismatch cohort, 35% receiving alteplase had mRS 0–1 at 3‐month compared to 30% with placebo (adjusted OR = 1.88, p = 0.056). Conclusions These data reinforce the benefit of alteplase in the later time window, and suggest that differences in automated perfusion imaging software outputs may be clinically relevant.
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Affiliation(s)
- Andrew Bivard
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Henry Ma
- Department of Medicine, School of Clinical Science, Monash University, Clayton, VIC, Australia
| | - Christopher Levi
- Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Bruce Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Atte Meretoja
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia.,Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Henry Zhao
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Gagan Sharma
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Chushuang Chen
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Stephen Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Geoffrey Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Mark Parsons
- Department of Neurology Liverpool Hospital, Ingham Institute of Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Liverpool, NSW, Australia
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4
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Psychogios K, Safouris A, Kargiotis O, Magoufis G, Andrikopoulou A, Papageorgiou E, Chondrogianni M, Papadimitropoulos G, Polyzogopoulou E, Spiliopoulos S, Brountzos E, Stamboulis E, Giannopoulos S, Tsivgoulis G. Advanced Neuroimaging Preceding Intravenous Thrombolysis in Acute Ischemic Stroke Patients Is Safe and Effective. J Clin Med 2021; 10:jcm10132819. [PMID: 34206790 PMCID: PMC8268827 DOI: 10.3390/jcm10132819] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/24/2021] [Accepted: 06/24/2021] [Indexed: 02/05/2023] Open
Abstract
Advanced neuroimaging is one of the most important means that we have in the attempt to overcome time constraints and expand the use of intravenous thrombolysis (IVT). We assessed whether, and how, the prior use of advanced neuroimaging (AN), and more specifically CT/MR perfusion post-processed with RAPID software, regardless of time from symptoms onset, affected the outcomes of acute ischemic stroke (AIS) patients who received IVT. Methods. We retrospectively evaluated consecutive AIS patients who received intravenous thrombolysis monotherapy (without endovascular reperfusion) during a six-year period. The study population was divided into two groups according to the neuroimaging protocol used prior to IVT administration in AIS patients (AN+ vs. AN-). Safety outcomes included any intracranial hemorrhage (ICH) and 3-month mortality. Effectiveness outcomes included door-to-needle time, neurological status (NIHSS-score) on discharge, and functional status at three months assessed by the modified Rankin Scale (mRS). Results. The rate of IVT monotherapy increased from ten patients per year (n = 29) in the AN- to fifteen patients per year (n = 47) in the AN+ group. Although the onset-to-treatment time was longer in the AN+ cohort, the two groups did not differ in door-to-needle time, discharge NIHSS-score, symptomatic ICH, any ICH, 3-month favorable functional outcome (mRS-scores of 0-1), 3-month functional independence (mRS-scores of 0-2), distribution of 3-month mRS-scores, or 3-month mortality. Conclusion. Our pilot observational study showed that the incorporation of advanced neuroimaging in the acute stroke chain pathway in AIS patients increases the yield of IVT administration without affecting the effectiveness and safety of the treatment.
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Affiliation(s)
- Klearchos Psychogios
- Acute Stroke Unit, Metropolitan Hospital, Ethnarhou Makariou 9, 18547 Piraeus, Greece; (A.S.); (O.K.); (G.M.); (A.A.); (E.P.); (M.C.); (G.P.); (E.S.)
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, 12462 Athens, Greece; (S.G.); (G.T.)
- Correspondence: ; Tel.: +30-(210)480-9788 or +30-(697)340-7804
| | - Apostolos Safouris
- Acute Stroke Unit, Metropolitan Hospital, Ethnarhou Makariou 9, 18547 Piraeus, Greece; (A.S.); (O.K.); (G.M.); (A.A.); (E.P.); (M.C.); (G.P.); (E.S.)
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, 12462 Athens, Greece; (S.G.); (G.T.)
| | - Odysseas Kargiotis
- Acute Stroke Unit, Metropolitan Hospital, Ethnarhou Makariou 9, 18547 Piraeus, Greece; (A.S.); (O.K.); (G.M.); (A.A.); (E.P.); (M.C.); (G.P.); (E.S.)
| | - Georgios Magoufis
- Acute Stroke Unit, Metropolitan Hospital, Ethnarhou Makariou 9, 18547 Piraeus, Greece; (A.S.); (O.K.); (G.M.); (A.A.); (E.P.); (M.C.); (G.P.); (E.S.)
| | - Athina Andrikopoulou
- Acute Stroke Unit, Metropolitan Hospital, Ethnarhou Makariou 9, 18547 Piraeus, Greece; (A.S.); (O.K.); (G.M.); (A.A.); (E.P.); (M.C.); (G.P.); (E.S.)
| | - Ermioni Papageorgiou
- Acute Stroke Unit, Metropolitan Hospital, Ethnarhou Makariou 9, 18547 Piraeus, Greece; (A.S.); (O.K.); (G.M.); (A.A.); (E.P.); (M.C.); (G.P.); (E.S.)
| | - Maria Chondrogianni
- Acute Stroke Unit, Metropolitan Hospital, Ethnarhou Makariou 9, 18547 Piraeus, Greece; (A.S.); (O.K.); (G.M.); (A.A.); (E.P.); (M.C.); (G.P.); (E.S.)
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, 12462 Athens, Greece; (S.G.); (G.T.)
| | - Georgios Papadimitropoulos
- Acute Stroke Unit, Metropolitan Hospital, Ethnarhou Makariou 9, 18547 Piraeus, Greece; (A.S.); (O.K.); (G.M.); (A.A.); (E.P.); (M.C.); (G.P.); (E.S.)
| | - Eftihia Polyzogopoulou
- Emergency Medicine Clinic, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, 12462 Athens, Greece;
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, 12462 Athens, Greece; (S.S.); (E.B.)
| | - Elias Brountzos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, 12462 Athens, Greece; (S.S.); (E.B.)
| | - Elefterios Stamboulis
- Acute Stroke Unit, Metropolitan Hospital, Ethnarhou Makariou 9, 18547 Piraeus, Greece; (A.S.); (O.K.); (G.M.); (A.A.); (E.P.); (M.C.); (G.P.); (E.S.)
| | - Sotirios Giannopoulos
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, 12462 Athens, Greece; (S.G.); (G.T.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, 12462 Athens, Greece; (S.G.); (G.T.)
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5
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Chen C, Parsons MW, Levi CR, Spratt NJ, Lin L, Kleinig T, Butcher K, Cheng X, Dong Q, O'Brien B, Avivi RI, Krause M, Sylaja PN, Choi P, Bhuta S, Yin C, Yang J, Wang P, Qiu W, Bivard A. What Is the "Optimal" Target Mismatch Criteria for Acute Ischemic Stroke? Front Neurol 2021; 11:590766. [PMID: 33584495 PMCID: PMC7874100 DOI: 10.3389/fneur.2020.590766] [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: 08/02/2020] [Accepted: 12/11/2020] [Indexed: 11/27/2022] Open
Abstract
We aimed to compare Perfusion Imaging Mismatch (PIM) and Clinical Core Mismatch (CCM) criteria in ischemic stroke patients to identify the effect of these criteria on selected patient population characteristics and clinical outcomes. Patients from the INternational Stroke Perfusion Imaging REgistry (INSPIRE) who received reperfusion therapy, had pre-treatment multimodal CT, 24-h imaging, and 3 month outcomes were analyzed. Patients were divided into 3 cohorts: endovascular thrombectomy (EVT), intravenous thrombolysis alone with large vessel occlusion (IVT-LVO), and intravenous thrombolysis alone without LVO (IVT-nonLVO). Patients were classified using 6 separate mismatch criteria: PIM-using 3 different measures to define the perfusion deficit (Delay Time, Tmax, or Mean Transit Time); or CCM-mismatch between age-adjusted National Institutes of Health Stroke Scale and CT Perfusion core, defined as relative cerebral blood flow <30% within the perfusion deficit defined in three ways (as above). We assessed the eligibility rate for each mismatch criterion and its ability to identify patients likely to respond to treatment. There were 994 patients eligible for this study. PIM with delay time (PIM-DT) had the highest inclusion rate for both EVT (82.7%) and IVT-LVO (79.5%) cohorts. In PIM positive patients who received EVT, recanalization was strongly associated with achieving an excellent outcome at 90-days (e.g., PIM-DT: mRS 0-1, adjusted OR 4.27, P = 0.005), whereas there was no such association between reperfusion and an excellent outcome with any of the CCM criteria (all p > 0.05). Notably, in IVT-LVO cohort, 58.2% of the PIM-DT positive patients achieved an excellent outcome compared with 31.0% in non-mismatch patients following successful recanalization (P = 0.006). Conclusion: PIM-DT was the optimal mismatch criterion in large vessel occlusion patients, combining a high eligibility rate with better clinical response to reperfusion. No mismatch criterion was useful to identify patients who are most likely response to reperfusion in non-large vessel occlusion patients.
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Affiliation(s)
- Chushuang Chen
- Melbourne Brain Centre, University of Melbourne, Parkville, VIC, Australia
| | - Mark W Parsons
- Department of Neurology, Liverpool Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Christopher R Levi
- Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Neil J Spratt
- Department of Neurology, John Hunter Hospital, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Longting Lin
- Department of Neurology, Liverpool Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Kenneth Butcher
- Prince of Wales Medical School, University of New South Wales, Sydney, NSW, Australia
| | - Xin Cheng
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Billy O'Brien
- Department of Neurology, Gosford Hospital, Gosford, NSW, Australia
| | - Richard I Avivi
- Division of Neuroradiology, Department of Medical Imaging, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Martin Krause
- Department of Neurology, Kolling Institute, Royal North Shore Hospital, University of Sydney, Sydney, NSW, Australia
| | - P N Sylaja
- Department of Neurology, Sri Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Philip Choi
- Department of Neurology, Box Hill Hospital, Melbourne, VIC, Australia
| | - Sandeep Bhuta
- Department of Medical Imaging, Gold Coast University Hospital, Southport, QLD, Australia
| | - Congguo Yin
- Department of Neurology, Hangzhou First Hospital, Zhejiang, China
| | - Jianhong Yang
- Department of Neurology, Ningbo First Hospital, Zhejiang, China
| | - Peng Wang
- Department of Neurology, Taizhou First People's Hospital, Zhejiang, China
| | - Weiwen Qiu
- Department of Neurology, Lishui People's Hospital, Zhejiang, China
| | - Andrew Bivard
- Melbourne Brain Centre, University of Melbourne, Parkville, VIC, Australia
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6
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Bivard A, Churilov L, Parsons M. Artificial intelligence for decision support in acute stroke - current roles and potential. Nat Rev Neurol 2020; 16:575-585. [PMID: 32839584 DOI: 10.1038/s41582-020-0390-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2020] [Indexed: 12/13/2022]
Abstract
The identification and treatment of patients with stroke is becoming increasingly complex as more treatment options become available and new relationships between disease features and treatment response are continually discovered. Consequently, clinicians must constantly learn new skills (such as clinical evaluations or image interpretation), stay up to date with the literature and incorporate advances into everyday practice. The use of artificial intelligence (AI) to support clinical decision making could reduce inter-rater variation in routine clinical practice and facilitate the extraction of vital information that could improve identification of patients with stroke, prediction of treatment responses and patient outcomes. Such support systems would be ideal for centres that deal with few patients with stroke or for regional hubs, and could assist informed discussions with the patients and their families. Moreover, the use of AI for image processing and interpretation in stroke could provide any clinician with an imaging assessment equivalent to that of an expert. However, any AI-based decision support system should allow for expert clinician interaction to enable identification of errors (for example, in automated image processing). In this Review, we discuss the increasing importance of imaging in stroke management before exploring the potential and pitfalls of AI-assisted treatment decision support in acute stroke.
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Affiliation(s)
- Andrew Bivard
- Department of Medicine and Public Health, University of Melbourne, Melbourne, VIC, Australia.,Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Leonid Churilov
- Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Mark Parsons
- Department of Medicine and Public Health, University of Melbourne, Melbourne, VIC, Australia. .,Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia.
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7
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Tsivgoulis G, Goyal N, Katsanos AH, Malhotra K, Ishfaq MF, Pandhi A, Frohler MT, Spiotta AM, Anadani M, Psychogios M, Maus V, Siddiqui A, Waqas M, Schellinger PD, Groen M, Krogias C, Richter D, Saqqur M, Garcia-Bermejo P, Mokin M, Leker R, Cohen JE, Magoufis G, Psychogios K, Lioutas VA, Van Nostrand M, Sharma VK, Paciaroni M, Rentzos A, Shoirah H, Mocco J, Nickele C, Mitsias PD, Inoa V, Hoit D, Elijovich L, Arthur AS, Alexandrov AV. Intravenous thrombolysis for large vessel or distal occlusions presenting with mild stroke severity. Eur J Neurol 2020; 27:1039-1047. [PMID: 32149450 DOI: 10.1111/ene.14199] [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: 12/27/2019] [Accepted: 02/29/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE We investigated the effectiveness of intravenous thrombolysis (IVT) in acute ischaemic stroke (AIS) patients with large vessel or distal occlusions and mild neurological deficits, defined as National Institutes of Health Stroke Scale scores < 6 points. METHODS The primary efficacy outcome was 3-month functional independence (FI) [modified Rankin Scale (mRS) scores 0-2] that was compared between patients with and without IVT treatment. Other efficacy outcomes of interest included 3-month favorable functional outcome (mRS scores 0-1) and mRS score distribution at discharge and at 3 months. The safety outcomes comprised all-cause 3-month mortality, symptomatic intracranial hemorrhage (ICH), asymptomatic ICH and severe systemic bleeding. RESULTS We evaluated 336 AIS patients with large vessel or distal occlusions and mild stroke severity (mean age 63 ± 15 years, 45% women). Patients treated with IVT (n = 162) had higher FI (85.6% vs. 74.8%, P = 0.027) with lower mRS scores at hospital discharge (P = 0.034) compared with the remaining patients. No differences were detected in any of the safety outcomes including symptomatic ICH, asymptomatic ICH, severe systemic bleeding and 3-month mortality. IVT was associated with higher likelihood of 3-month FI [odds ratio (OR), 2.19; 95% confidence intervals (CI), 1.09-4.42], 3-month favorable functional outcome (OR, 1.99; 95% CI, 1.10-3.57), functional improvement at discharge [common OR (per 1-point decrease in mRS score), 2.94; 95% CI, 1.67-5.26)] and at 3 months (common OR, 1.72; 95% CI, 1.06-2.86) on multivariable logistic regression models adjusting for potential confounders, including mechanical thrombectomy. CONCLUSIONS Intravenous thrombolysis is independently associated with higher odds of improved discharge and 3-month functional outcomes in AIS patients with large vessel or distal occlusions and mild stroke severity. IVT appears not to increase the risk of systemic or symptomatic intracranial bleeding.
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Affiliation(s)
- G Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Second Department of Neurology, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - N Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - A H Katsanos
- Second Department of Neurology, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - K Malhotra
- Charleston Division, Department of Neurology, West Virginia University, Charleston, WV, USA
| | - M F Ishfaq
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - A Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - M T Frohler
- Cerebrovascular Program, Vanderbilt University, Nashville, TN, USA
| | - A M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - M Anadani
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - M Psychogios
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - V Maus
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - A Siddiqui
- Departments of Neurosurgery and Radiology, University at Buffalo, Buffalo, NY, USA
| | - M Waqas
- Departments of Neurosurgery and Radiology, University at Buffalo, Buffalo, NY, USA
| | - P D Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Clinic RUB, Minden, Germany
| | - M Groen
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Clinic RUB, Minden, Germany
| | - C Krogias
- Department of Neurology, St Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - D Richter
- Department of Neurology, St Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - M Saqqur
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Neurology, Hamad General Hospital, Doha, Qatar
| | - P Garcia-Bermejo
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - M Mokin
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - J E Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - G Magoufis
- Acute Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | - K Psychogios
- Acute Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | - V A Lioutas
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - M Van Nostrand
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - V K Sharma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, National University Hospital, Singapore, Singapore
| | - M Paciaroni
- Stroke Unit, Divisione di Medicina Cardiovascolare, Università di Perugia, Perugia, Italy
| | - A Rentzos
- Department of Interventional and Diagnostic Neuroradiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - H Shoirah
- Department of Neurosurgery, Mount Sinai Medical Center, New York, NY, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Medical Center, New York, NY, USA
| | - C Nickele
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - P D Mitsias
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA.,Department of Neurology, School of Medicine, University of Crete, Herakleion, Greece
| | - V Inoa
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - D Hoit
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - L Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - A S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - A V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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8
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Seners P, Turc G, Lion S, Cottier JP, Cho TH, Arquizan C, Bracard S, Ozsancak C, Legrand L, Naggara O, Debiais S, Berthezene Y, Costalat V, Richard S, Magni C, Nighoghossian N, Narata AP, Dargazanli C, Gory B, Mas JL, Oppenheim C, Baron JC. Relationships between brain perfusion and early recanalization after intravenous thrombolysis for acute stroke with large vessel occlusion. J Cereb Blood Flow Metab 2020; 40:667-677. [PMID: 30890074 PMCID: PMC7026851 DOI: 10.1177/0271678x19836288] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
In large vessel occlusion (LVO) stroke, it is unclear whether severity of ischemia is involved in early post-thrombolysis recanalization over and above thrombus site and length. Here we assessed the relationships between perfusion parameters and early recanalization following intravenous thrombolysis administration in LVO patients. From a multicenter registry, we identified 218 thrombolysed LVO patients referred for thrombectomy with both (i) pre-thrombolysis MRI, including diffusion-weighted imaging (DWI), T2*-imaging, MR-angiography and dynamic susceptibility-contrast perfusion-weighted imaging (PWI); and (ii) evaluation of recanalization on first angiographic run or non-invasive imaging ≤ 3 h from thrombolysis start. Infarct core volume on DWI, PWI-DWI mismatch volume and hypoperfusion intensity ratio (HIR; defined as Tmax ≥ 10 s volume/ Tmax ≥ 6 s volume, low HIR indicating milder hypoperfusion) were determined using a commercially available software. Early recanalization occurred in 34 (16%) patients, and multivariable analysis was associated with lower HIR (P = 0.006), shorter thrombus on T2*-imaging (P < 0.001) and more distal occlusion (P = 0.006). However, the relationship between HIR and early recanalization was robust only for thrombus length <14 mm. In summary, the present study disclosed an association between lower HIR and early post-thrombolysis recanalization. Early post-thrombolysis recanalization is therefore determined not only by thrombus site and length but also by severity of ischemia.
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Affiliation(s)
- Pierre Seners
- Neurology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
| | - Guillaume Turc
- Neurology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
| | - Stéphanie Lion
- Radiology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
| | - Jean-Philippe Cottier
- Department of Neuroradiology, Bretonneau Hospital, University of Tours, Tours, France
| | - Tae-Hee Cho
- Department of Stroke Medicine, Hospices Civils de Lyon, Université Lyon 1, CREATIS, CNRS UMR 5220-INSERM U1044, INSALyon, Lyon, France
| | | | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, INSERM U 947, Nancy, France
| | | | - Laurence Legrand
- Radiology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
| | - Olivier Naggara
- Radiology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
| | - Séverine Debiais
- Department of Neurology, Bretonneau Hospital, University of Tours, Tours, France
| | - Yves Berthezene
- Neuroradiology Department, Hospices Civils de Lyon, Lyon, France
| | - Vincent Costalat
- Department of Interventional Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | | | | | - Norbert Nighoghossian
- Department of Stroke Medicine, Hospices Civils de Lyon, Université Lyon 1, CREATIS, CNRS UMR 5220-INSERM U1044, INSALyon, Lyon, France
| | - Ana-Paula Narata
- Department of Neuroradiology, Bretonneau Hospital, University of Tours, Tours, France
| | - Cyril Dargazanli
- Department of Interventional Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, INSERM U 947, Nancy, France
| | - Jean-Louis Mas
- Neurology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
| | - Catherine Oppenheim
- Radiology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
| | - Jean-Claude Baron
- Neurology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
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9
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Lillicrap T, Pinheiro A, Miteff F, Garcia-Bermejo P, Gangadharan S, Wellings T, O'Brien B, Evans J, Alanati K, Bivard A, Parsons M, Levi C, Garcia-Esperon C, Spratt N. No Evidence of the "Weekend Effect" in the Northern New South Wales Telestroke Network. Front Neurol 2020; 11:130. [PMID: 32174885 PMCID: PMC7057236 DOI: 10.3389/fneur.2020.00130] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 02/05/2020] [Indexed: 01/01/2023] Open
Abstract
Background: Admission outside normal business hours has been associated with prolonged door-to-treatment times and poorer patient outcomes, the so called "weekend effect. " This is the first examination of the weekend effect in a telestroke service that uses multi-modal computed tomography. Aims: To examine differences in workflow and triage between in-hours and out-of-hours calls to a telestroke service. Methods: All patients assessed using the Northern New South Wales (N-NSW) telestroke service from April 2013 to January 2019 were eligible for inclusion (674 in total; 539 with complete data). The primary outcomes measured were differences between in-hours and out-of-hours in door-to-call-to-decision-to-needle times, differences in the proportion of patients confirmed to have strokes or of patients selected for reperfusion therapies or patients with a modified Rankin Score (mRS ≤ 2) at 90 days. Results: There were no significant differences between in-hours and out-of-hours in any of the measured times, nor in the proportions of patients confirmed to have strokes (67.6 and 69.6%, respectively, p = 0.93); selected for reperfusion therapies (22.7 and 22.6%, respectively, p = 0.56); or independent at 3 months (34.8 and 33.6%, respectively, p = 0.770). There were significant differences in times between individual hospitals, and patient presentation more than 4.5 h after symptom onset was associated with slower times (21 minute delay in door-to-call, p = 0.002 and 22 min delay in door-to-image, p = 0.001). Conclusions: The weekend effect is not evident in the Northern NSW telestroke network experience, though this study did identify some opportunities for improvement in the delivery of acute stroke therapies.
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Affiliation(s)
- Thomas Lillicrap
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Alex Pinheiro
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Ferdinand Miteff
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | | | - Shyam Gangadharan
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Thomas Wellings
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Billy O'Brien
- Department of Neurology, Gosford Hospital, Gosford, NSW, Australia
| | - James Evans
- Department of Neurology, Gosford Hospital, Gosford, NSW, Australia
| | - Khaled Alanati
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Andrew Bivard
- Department of Neurology, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Mark Parsons
- Department of Neurology, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Christopher Levi
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia.,SPHERE, Sydney, NSW, Australia
| | - Carlos Garcia-Esperon
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Neil Spratt
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
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10
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Garcia-Esperon C, Soderhjelm Dinkelspiel F, Miteff F, Gangadharan S, Wellings T, O Brien B, Evans J, Lillicrap T, Demeestere J, Bivard A, Parsons M, Levi C, Spratt NJ. Implementation of multimodal computed tomography in a telestroke network: Five-year experience. CNS Neurosci Ther 2019; 26:367-373. [PMID: 31568661 PMCID: PMC7052799 DOI: 10.1111/cns.13224] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 08/27/2019] [Accepted: 09/04/2019] [Indexed: 12/18/2022] Open
Abstract
AIMS Penumbral selection is best-evidence practice for thrombectomy in the 6-24 hour window. Moreover, it helps to identify the best responders to thrombolysis. Multimodal computed tomography (mCT) at the primary centre-including noncontrast CT, CT perfusion, and CT angiography-may enhance reperfusion therapy decision-making. We developed a network with five spoke primary stroke sites and assessed safety, feasibility, and influence of mCT in rural hospitals on decision-making for thrombolysis. METHODS Consecutive patients assessed via telemedicine from April 2013 to June 2018. Clinical outcomes were measured, and decision-making compared using theoretical models for reperfusion therapy applied without mCT guidance. Symptomatic intracranial hemorrhage (sICH) was assessed according to Safe Implementation of Treatments in Stroke Thrombolysis Registry criteria. RESULTS A total of 334 patients were assessed, 240 received mCT, 58 were thrombolysed (24.2%). The mean age of thrombolysed patients was 70 years, median baseline National Institutes of Health Stroke Scale was 10 (IQR 7-18) and 23 (39.7%) had a large vessel occlusion. 1.7% had sICH and 3.5% parenchymal hematoma. Three months poststroke, 55% were independent, compared with 70% in the non-thrombolysed group. CONCLUSION Implementation of CTP in rural centers was feasible and led to high thrombolysis rates with low rates of sICH.
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Affiliation(s)
- Carlos Garcia-Esperon
- Department of Neurology, John Hunter Hospital, Hunter New England Local Health District, Newcastle, NSW, Australia.,Hunter Medical Research Institute and University of Newcastle, Newcastle, NSW, Australia
| | | | - Ferdi Miteff
- Department of Neurology, John Hunter Hospital, Hunter New England Local Health District, Newcastle, NSW, Australia.,Hunter Medical Research Institute and University of Newcastle, Newcastle, NSW, Australia
| | - Shyam Gangadharan
- Department of Neurology, John Hunter Hospital, Hunter New England Local Health District, Newcastle, NSW, Australia.,Hunter Medical Research Institute and University of Newcastle, Newcastle, NSW, Australia
| | - Tom Wellings
- Department of Neurology, John Hunter Hospital, Hunter New England Local Health District, Newcastle, NSW, Australia.,Hunter Medical Research Institute and University of Newcastle, Newcastle, NSW, Australia
| | - Bill O Brien
- Neurosciences Department, Gosford Hospital, Central Coast Local Health District, Gosford, NSW, Australia
| | - James Evans
- Neurosciences Department, Gosford Hospital, Central Coast Local Health District, Gosford, NSW, Australia
| | - Tom Lillicrap
- Department of Neurology, John Hunter Hospital, Hunter New England Local Health District, Newcastle, NSW, Australia.,Hunter Medical Research Institute and University of Newcastle, Newcastle, NSW, Australia
| | - Jelle Demeestere
- Neurology Department, Leuven University Hospital, Leuven, Belgium
| | - Andrew Bivard
- Department of Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Mark Parsons
- Hunter Medical Research Institute and University of Newcastle, Newcastle, NSW, Australia.,Department of Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | | | - Neil James Spratt
- Department of Neurology, John Hunter Hospital, Hunter New England Local Health District, Newcastle, NSW, Australia.,Hunter Medical Research Institute and University of Newcastle, Newcastle, NSW, Australia
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11
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Zhou Y, Zhang R, Yan S, Zhang M, Chen Z, Hu H, Zhang M, Bivard A, Lin L, Parsons MW, Lou M. Identification of Corticospinal Tract Lesion for Predicting Outcome in Small Perfusion Stroke. Stroke 2019; 49:2683-2691. [PMID: 30355191 DOI: 10.1161/strokeaha.118.021426] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Whether patients with small perfusion lesions benefit from thrombolysis remains an uncertainty. We assessed acute ischemic stroke patients with a total perfusion lesion of <15 mL and tested the hypothesis the pattern of corticospinal tract (CST) involvement might predict outcome in thrombolysis-eligible patients. Methods- We used a prospectively collected cohort of acute ischemic stroke patients being assessed for thrombolysis at 7 centers. Three neurologists categorized the presence of hypoperfusion and infarction within CST. Excellent outcome was defined as 90-day modified Rankin Scale score 0 to 1. Results- Of 2654 patients, 407 had a perfusion lesion <15 mL and were clinically eligible for thrombolysis (243 being treated). Median National Institutes of Health Stroke Scale was 5.0, and 312 (76.7%) patients achieved excellent outcome. Alteplase treatment was an independent unfavorable factor for excellent outcome (alteplase-treated 72.0% versus untreated 83.5%; odds ratio, 0.541; P=0.025). For patients with CST hypoperfusion without CST infarction, alteplase treatment was an independent favorable factor for excellent outcome (alteplase-treated 75.6% versus untreated 47.1%; odds ratio, 4.096; P=0.045). Among patients with CST infarction, alteplase treatment was an independent unfavorable factor for excellent outcome (alteplase-treated 30.6% versus untreated 88.9%; odds ratio, 0.002; P=0.003). Among patients without either CST hypoperfusion or CST infarction, alteplase treatment was not an independent influencing factor for excellent outcome (alteplase-treated 80.1% versus untreated 87.7%; P=0.258). Conclusions- Only patients with CST hypoperfusion without CST infarction among eligible acute ischemic stroke patients with small perfusion lesions could benefit from thrombolysis, which needs to be confirmed in future prospective studies. Patient selection, including an assessment of lesion location rather than purely lesion volume, may be ideal.
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Affiliation(s)
- Ying Zhou
- From the Department of Neurology (Y.Z., R.Z., S.Y., Meixia Zhang, Z.C., H.H., M.L.), the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Ruiting Zhang
- From the Department of Neurology (Y.Z., R.Z., S.Y., Meixia Zhang, Z.C., H.H., M.L.), the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Shenqiang Yan
- From the Department of Neurology (Y.Z., R.Z., S.Y., Meixia Zhang, Z.C., H.H., M.L.), the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Meixia Zhang
- From the Department of Neurology (Y.Z., R.Z., S.Y., Meixia Zhang, Z.C., H.H., M.L.), the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Zhicai Chen
- From the Department of Neurology (Y.Z., R.Z., S.Y., Meixia Zhang, Z.C., H.H., M.L.), the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Haitao Hu
- From the Department of Neurology (Y.Z., R.Z., S.Y., Meixia Zhang, Z.C., H.H., M.L.), the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Minming Zhang
- Department of Radiology (Minming Zhang), the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Andrew Bivard
- Department of Neurology, John Hunter Hospital, University of Newcastle, Australia (A.B., L.L., M.W.P.)
| | - Longting Lin
- Department of Neurology, John Hunter Hospital, University of Newcastle, Australia (A.B., L.L., M.W.P.)
| | - Mark W Parsons
- Department of Neurology, John Hunter Hospital, University of Newcastle, Australia (A.B., L.L., M.W.P.)
| | - Min Lou
- From the Department of Neurology (Y.Z., R.Z., S.Y., Meixia Zhang, Z.C., H.H., M.L.), the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
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12
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Haeberlin MI, Held U, Baumgartner RW, Georgiadis D, Valko PO. Impact of intravenous thrombolysis on functional outcome in patients with mild ischemic stroke without large vessel occlusion or rapidly improving symptoms. Int J Stroke 2019; 15:429-437. [PMID: 31514684 DOI: 10.1177/1747493019874719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Optimal treatment strategy in patients with mild ischemic stroke remains uncertain. While functional dependency or death has been reported in up to one-third of non-thrombolyzed mild ischemic stroke patients, intravenous thrombolysis is currently not recommended in this patient group. Emerging evidence suggests two risk factors-rapid early improvement and large vessel occlusion-as main associates of unfavorable outcome in mild ischemic stroke patients not undergoing intravenous thrombolysis. AIMS To analyze natural course as well as safety and three-month outcome of intravenous thrombolysis in mild ischemic stroke without rapid early improvement or large vessel occlusion. METHODS Mild ischemic stroke was defined by a National Institute of Health Stroke Scale score ≤6. We used the modified Rankin Scale (mRS) to compare three-month functional outcome in 370 consecutive mild ischemic stroke patients without early rapid improvement and without large vessel occlusion, who either underwent intravenous thrombolysis (n = 108) or received best medical treatment (n = 262). RESULTS Favorable outcome (mRS ≤ 1) was common in both groups (intravenous thrombolysis: 91%; no intravenous thrombolysis: 90%). Although intravenous thrombolysis use was independently associated with a higher risk of asymptomatic hemorrhagic transformation (OR = 4.62, p = 0.002), intravenous thrombolysis appeared as an independent predictor of mRS = 0 at three months (OR = 3.33, p < 0.0001). CONCLUSIONS Mild ischemic stroke patients without rapidly improving symptoms and without large vessel occlusion have a high chance of favorable three-month outcome, irrespective of treatment type. Patients receiving intravenous thrombolysis, however, more often achieved complete remission of symptoms, which particularly in mild ischemic stroke may constitute a meaningful endpoint.
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Affiliation(s)
- Marcellina Isabelle Haeberlin
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Ulrike Held
- Horten Center for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Ralf W Baumgartner
- NeuroCenter, Swiss Neuro Institute, Clinic Hirslanden, Zurich, Switzerland
| | - Dimitrios Georgiadis
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Philipp O Valko
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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13
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Tian H, Parsons MW, Levi CR, Lin L, Aviv RI, Spratt NJ, Butcher KS, Lou M, Kleinig TJ, Bivard A. Influence of occlusion site and baseline ischemic core on outcome in patients with ischemic stroke. Neurology 2019; 92:e2626-e2643. [PMID: 31043475 DOI: 10.1212/wnl.0000000000007553] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 01/29/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We assessed patient clinical outcomes based on occlusion location, focusing on distal occlusions to understand if occlusion location was an independent predictor of outcome, and tested the relationship between occlusion location and baseline ischemic core, a known predictor of modified Rankin Scale (mRS) score at 90 days. METHODS We analyzed a prospectively collected cohort of thrombolysis-eligible ischemic stroke patients from the International Stroke Perfusion Imaging Registry who underwent multimodal CT pretreatment. For the primary analysis, logistic regression was used to predict the effect of occlusion location and ischemic core on the likelihood of excellent (mRS 0-1) and favorable (mRS 0-2) 90-day outcomes. RESULTS This study included 945 patients. The rates of excellent and favorable outcome in patients with distal occlusion (M2, M3 segment of middle cerebral artery, anterior cerebral artery, and posterior cerebral artery) were higher than M1 occlusions (mRS 0%-1%, 55% vs 37%; mRS 0%-2%, 73% vs 50%, p < 0.001). Vessel occlusion location was not a strong predictor of outcomes compared to baseline ischemic core (area under the curve, mRS 0-1, 0.64 vs 0.83; mRS 0-2, 0.70 vs 0.86, p < 0.001). There was no interaction between occlusion location and ischemic core (interaction coefficient 1.00, p = 0.798). CONCLUSIONS Ischemic stroke patients with a distal occlusion have higher rate of excellent and favorable outcome than patients with an M1 occlusion. The baseline ischemic core was shown to be a more powerful predictor of functional outcome than the occlusion location, but the relationship between ischemic core and outcome does not different by occlusion locations.
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Affiliation(s)
- Huiqiao Tian
- From the Department of Neurology (H.T., M.W.P., C.R.L., L.L., N.J.S., A.B.), John Hunter Hospital, University of Newcastle, Australia; Department of Medical Imaging, Division of Neuroradiology (R.I.A.), Sunnybrook Health Sciences Center and University of Toronto; Division of Neurology, Department of Medicine (K.S.B.), University of Alberta, Edmonton, Canada; Department of Neurology (M.L.), the Second Affiliated Hospital of Zhejiang University, Hangzhou, China; and Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia.
| | - Mark W Parsons
- From the Department of Neurology (H.T., M.W.P., C.R.L., L.L., N.J.S., A.B.), John Hunter Hospital, University of Newcastle, Australia; Department of Medical Imaging, Division of Neuroradiology (R.I.A.), Sunnybrook Health Sciences Center and University of Toronto; Division of Neurology, Department of Medicine (K.S.B.), University of Alberta, Edmonton, Canada; Department of Neurology (M.L.), the Second Affiliated Hospital of Zhejiang University, Hangzhou, China; and Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia
| | - Christopher R Levi
- From the Department of Neurology (H.T., M.W.P., C.R.L., L.L., N.J.S., A.B.), John Hunter Hospital, University of Newcastle, Australia; Department of Medical Imaging, Division of Neuroradiology (R.I.A.), Sunnybrook Health Sciences Center and University of Toronto; Division of Neurology, Department of Medicine (K.S.B.), University of Alberta, Edmonton, Canada; Department of Neurology (M.L.), the Second Affiliated Hospital of Zhejiang University, Hangzhou, China; and Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia
| | - Longting Lin
- From the Department of Neurology (H.T., M.W.P., C.R.L., L.L., N.J.S., A.B.), John Hunter Hospital, University of Newcastle, Australia; Department of Medical Imaging, Division of Neuroradiology (R.I.A.), Sunnybrook Health Sciences Center and University of Toronto; Division of Neurology, Department of Medicine (K.S.B.), University of Alberta, Edmonton, Canada; Department of Neurology (M.L.), the Second Affiliated Hospital of Zhejiang University, Hangzhou, China; and Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia
| | - Richard I Aviv
- From the Department of Neurology (H.T., M.W.P., C.R.L., L.L., N.J.S., A.B.), John Hunter Hospital, University of Newcastle, Australia; Department of Medical Imaging, Division of Neuroradiology (R.I.A.), Sunnybrook Health Sciences Center and University of Toronto; Division of Neurology, Department of Medicine (K.S.B.), University of Alberta, Edmonton, Canada; Department of Neurology (M.L.), the Second Affiliated Hospital of Zhejiang University, Hangzhou, China; and Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia
| | - Neil J Spratt
- From the Department of Neurology (H.T., M.W.P., C.R.L., L.L., N.J.S., A.B.), John Hunter Hospital, University of Newcastle, Australia; Department of Medical Imaging, Division of Neuroradiology (R.I.A.), Sunnybrook Health Sciences Center and University of Toronto; Division of Neurology, Department of Medicine (K.S.B.), University of Alberta, Edmonton, Canada; Department of Neurology (M.L.), the Second Affiliated Hospital of Zhejiang University, Hangzhou, China; and Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia
| | - Kenneth S Butcher
- From the Department of Neurology (H.T., M.W.P., C.R.L., L.L., N.J.S., A.B.), John Hunter Hospital, University of Newcastle, Australia; Department of Medical Imaging, Division of Neuroradiology (R.I.A.), Sunnybrook Health Sciences Center and University of Toronto; Division of Neurology, Department of Medicine (K.S.B.), University of Alberta, Edmonton, Canada; Department of Neurology (M.L.), the Second Affiliated Hospital of Zhejiang University, Hangzhou, China; and Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia
| | - Min Lou
- From the Department of Neurology (H.T., M.W.P., C.R.L., L.L., N.J.S., A.B.), John Hunter Hospital, University of Newcastle, Australia; Department of Medical Imaging, Division of Neuroradiology (R.I.A.), Sunnybrook Health Sciences Center and University of Toronto; Division of Neurology, Department of Medicine (K.S.B.), University of Alberta, Edmonton, Canada; Department of Neurology (M.L.), the Second Affiliated Hospital of Zhejiang University, Hangzhou, China; and Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia
| | - Timothy J Kleinig
- From the Department of Neurology (H.T., M.W.P., C.R.L., L.L., N.J.S., A.B.), John Hunter Hospital, University of Newcastle, Australia; Department of Medical Imaging, Division of Neuroradiology (R.I.A.), Sunnybrook Health Sciences Center and University of Toronto; Division of Neurology, Department of Medicine (K.S.B.), University of Alberta, Edmonton, Canada; Department of Neurology (M.L.), the Second Affiliated Hospital of Zhejiang University, Hangzhou, China; and Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia
| | - Andrew Bivard
- From the Department of Neurology (H.T., M.W.P., C.R.L., L.L., N.J.S., A.B.), John Hunter Hospital, University of Newcastle, Australia; Department of Medical Imaging, Division of Neuroradiology (R.I.A.), Sunnybrook Health Sciences Center and University of Toronto; Division of Neurology, Department of Medicine (K.S.B.), University of Alberta, Edmonton, Canada; Department of Neurology (M.L.), the Second Affiliated Hospital of Zhejiang University, Hangzhou, China; and Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia
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14
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Kaesmacher J, Chaloulos-Iakovidis P, Panos L, Mordasini P, Heldner MR, Kurmann CC, Michel P, Hajdu SD, Ribo M, Requena M, Maegerlein C, Friedrich B, Costalat V, Benali A, Pierot L, Gawlitza M, Schaafsma J, Pereira VM, Gralla J, Fischer U. Clinical effect of successful reperfusion in patients presenting with NIHSS < 8: data from the BEYOND-SWIFT registry. J Neurol 2019; 266:598-608. [PMID: 30617997 PMCID: PMC6394689 DOI: 10.1007/s00415-018-09172-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/22/2018] [Accepted: 12/25/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE If patients presenting with large vessel occlusions (LVO) and mild symptoms should be treated with endvoascular treatment (EVT) remains unclear. Aims of this study were (1) assessing the safety and technical efficacy of EVT in patients with NIHSS < 8 as opposed to a comparison group of patients presenting with NIHSS ≥ 8 and (2) evaluation of the clinical effect of reperfusion in patients with NIHSS < 8. METHODS Patients included into the retrospective multicenter BEYOND-SWIFT registry (NCT03496064) were analyzed. Clinical effect of achieving successful reperfusion (defined as modified Thrombolysis in Cerebral Infarction grade 2b/3) in patients presenting with NIHSS < 8 (N = 193) was evaluated using multivariable logistic regression analyses (displayed as adjusted Odds Ratios, aOR and 95% confidence intervals, 95%-CI). Primary outcome was excellent functional outcome (modified Rankin Scale, mRS 0-1) at day 90. Safety and efficacy of mechanical thrombectomy in patients with NIHSS < 8 was compared to patients presenting with NIHSS ≥ 8 (N = 1423). RESULTS Among patients with NIHSS < 8 (N = 193, 77/193, 39.9% receiving pre-interventional IV-tPA), successful reperfusion was significantly related to mRS 0-1 (aOR 3.217, 95%-CI 1.174-8.816) and reduced the chances of non-hemorrhagic neurological worsening (aOR 0.194, 95%-CI 0.050-0.756) after adjusting for prespecified confounders. In interaction analyses, the relative merits of achieving successful reperfusion were mostly comparable between patients presenting with NIHSS < 8 and NIHSS ≥ 8 as evidenced by non-significantly different aOR. Interventional safety and efficacy metrics were similar between patients with NIHSS < 8 and NIHSS ≥ 8. CONCLUSIONS Achieving successful reperfusion is beneficial in patients with persisting LVO presenting with NIHSS < 8 and reduces the risk of non-hemorrhagic neurological worsening.
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Affiliation(s)
- Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Panagiotis Chaloulos-Iakovidis
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Leonidas Panos
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Christoph C Kurmann
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Patrik Michel
- Department of Neurology, CHUV Lausanne, Lausanne, Switzerland
| | - Steven D Hajdu
- Department of Radiology, CHUV Lausanne, Lausanne, Switzerland
| | - Marc Ribo
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Manuel Requena
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Vincent Costalat
- Department of Neuroradiology, CHU Montpellier, Montpellier, France
| | - Amel Benali
- Department of Neuroradiology, CHU Montpellier, Montpellier, France
| | | | | | - Joanna Schaafsma
- Department of Neurology, Toronto Western Hospital, Toronto, ON, Canada
| | - Vitor Mendes Pereira
- Joint Department of Medical Imaging, Toronto Western Hospital, Toronto, ON, Canada
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland.
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15
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Reeves P, Edmunds K, Levi C, Lin L, Cheng X, Aviv R, Kleinig T, Butcher K, Zhang J, Parsons M, Bivard A. Cost-effectiveness of targeted thrombolytic therapy for stroke patients using multi-modal CT compared to usual practice. PLoS One 2018; 13:e0206203. [PMID: 30352076 PMCID: PMC6198974 DOI: 10.1371/journal.pone.0206203] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 10/09/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction The use of multimodal computed tomography imaging (MMCT) in routine clinical assessment of stroke patients improves the identification of patients with large regions of salvageable brain tissue, lower risk for haemorrhagic transformation, or a large vessel occlusion requiring endovascular therapy. Aim To evaluate the cost-effectiveness of using MMCT compared to usual practice for determining eligibility for reperfusion therapy with alteplase using real world data from the International Stroke Perfusion Imaging Registry (INSPIRE). Methods We performed a cost-utility analysis. Mean costs and quality-adjusted life years (QALYs) per patient for two alternative screening protocols were calculated. Protocol 1 represented usual practice, while Protocol 2 reflected treatment targeting using multimodal imaging. Cost-effectiveness was assessed using the net-benefit framework. Results Protocol 1 had a total mean per patient cost of $2,013 USD and 0.148 QALYs. Protocol 2 had a total mean per patient cost of $1,519 USD and 0.153 QALYs. For a range of willingness-to-pay values, representing implicit thresholds of cost-effectiveness, the lower bound of the incremental net monetary benefit statistic was consistently greater than zero, indicating that MMCT is cost- effective compared to usual practice. The results were most sensitive to variation in the mean number of alteplase vials administered. Conclusion In a healthcare setting where multimodal imaging technologies are available and reimbursed, their use in screening patients presenting with acute stroke to determine eligibility for alteplase treatment is cost-effective given a range of willingness-to-pay thresholds and warrants consideration as an alternative to routine practice.
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Affiliation(s)
- Penny Reeves
- Health Research Economics, Hunter Medical Research Institute (HMRI), Newcastle, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Kim Edmunds
- Health Research Economics, Hunter Medical Research Institute (HMRI), Newcastle, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
- * E-mail:
| | - Christopher Levi
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Longting Lin
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Xin Cheng
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Richard Aviv
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, and University of Toronto, Toronto, Canada
| | - Tim Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Kenneth Butcher
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Jingfen Zhang
- Department of Neurology, Baotou Central Hospital, Baotou, China
| | - Mark Parsons
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Andrew Bivard
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
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16
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Bisson DA, Mahmoudian D, Shatil AS, Waggass G, Zhang L, Levi C, Spratt NJ, Lin L, Liebeskind D, Parsons M, Bivard A, Aviv RI. Single-phase CT angiography: collateral grade is independent of scan weighting. Neuroradiology 2018; 61:19-28. [PMID: 30288551 DOI: 10.1007/s00234-018-2105-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 09/19/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE Collateral grading may vary on single-phase CTA (sCTA) depending on whether the CTA is arterial (A), arteriovenous (AV), or venous (V) weighted. We studied the impact of sCTA weighting on collateral grading using the Tan, MAAS, and Menon methods, and their ability to predict infarct and clinical outcome hypothesizing that AV-weighted sCTA should better predict these outcomes. METHODS Multicenter retrospective analysis of 212 patients undergoing baseline CTP/sCTA. sCTA weighting was determined by comparing ICA to torcula AV ratios with those from concomitant CTP time-density curves at peak arterial or venous contrast attenuation. A generalized linear mixed model investigated the predictive value for infarct volume or 90-day mRS of the three collateral scores stratified by sCTA weighting and adjusting for age, sex, clot burden score (CBS), and NIHSS. Bayesian information criterion (BIC) differences were calculated between the null and fitted models. RESULTS Mean age, baseline median NIHSS, ASPECTS, and onset to treatment time were 69.89 ± 14.45, 13 (6-18), 10 (8-10), and 128 (66-181) minutes. sCTA scans were AV-weighted in 137/212 (65%) and A-weighted in 73 (34%). No association was demonstrated between sCTA weighting, hospital site, and sCTA technique. All collateral scores were related to infarct volume irrespective of sCTA weighting, with greatest fit with the regional leptomeningeal score (BIC 18.29, p = 0.0001). No association was shown between sCTA weighting, collateral grade, and clinical outcome. CONCLUSION sCTA weighting did not significantly impact collateral grade using three common collateral scores or their ability to predict final infarct.
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Affiliation(s)
- Daniel-Alexandre Bisson
- Department of Medical Imaging, Division of Neuroradiology, Sunnybrook Health Sciences Centre, AG31e, 2075 Bayview Avenue, Toronto, M4N3M5, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - David Mahmoudian
- Department of Medical Imaging, Division of Neuroradiology, Sunnybrook Health Sciences Centre, AG31e, 2075 Bayview Avenue, Toronto, M4N3M5, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Anwar S Shatil
- Department of Medical Imaging, Division of Neuroradiology, Sunnybrook Health Sciences Centre, AG31e, 2075 Bayview Avenue, Toronto, M4N3M5, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Ghouth Waggass
- Department of Medical Imaging, Division of Neuroradiology, Sunnybrook Health Sciences Centre, AG31e, 2075 Bayview Avenue, Toronto, M4N3M5, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Liying Zhang
- Department of Medical Imaging, Division of Neuroradiology, Sunnybrook Health Sciences Centre, AG31e, 2075 Bayview Avenue, Toronto, M4N3M5, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Christopher Levi
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - Neil J Spratt
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - Longting Lin
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - David Liebeskind
- UCLA Stroke Center, UCLA Neuroscience Research Building, 635 Charles E Young Drive South, Suite 225, Los Angeles, CA, 90095-7334, USA
| | - Mark Parsons
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - Andrew Bivard
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - Richard I Aviv
- Department of Medical Imaging, Division of Neuroradiology, Sunnybrook Health Sciences Centre, AG31e, 2075 Bayview Avenue, Toronto, M4N3M5, Canada. .,Department of Medical Imaging, University of Toronto, Toronto, Canada.
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17
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Coutts SB, Berge E, Campbell BCV, Muir KW, Parsons MW. Tenecteplase for the treatment of acute ischemic stroke: A review of completed and ongoing randomized controlled trials. Int J Stroke 2018; 13:885-892. [DOI: 10.1177/1747493018790024] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Alteplase has been the mainstay of thrombolytic treatment since the National Institutes of Neurological Disorders and Stroke trial was published in 1995. Over recent years, several trials have investigated alternative thrombolytic agents. Tenecteplase, a genetically engineered mutant tissue plasminogen activator, has a longer half-life, allowing single intravenous bolus administration without infusion, is more fibrin specific, produces less systemic depletion of circulating fibrinogen, and is more resistant to plasminogen activator inhibitor compared to alteplase. Tenecteplase is established as the first-line intravenous thrombolytic drug for myocardial infarction, where it has been shown to achieve comparable reperfusion with reduced risk of systemic bleeding in comparison to alteplase. We review the literature on tenecteplase for the treatment of acute ischemic stroke, with a focus on the major completed and ongoing trials. Overall, tenecteplase shows promise for treatment of acute ischemic stroke, both in populations currently eligible for alteplase and also in groups not currently treated with thrombolysis.
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Affiliation(s)
- Shelagh B Coutts
- Department of Clinical Neurosciences, Radiology, Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Eivind Berge
- Department of Internal Medicine, Oslo University Hospital, Oslo, and Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
| | - Bruce CV Campbell
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - Mark W Parsons
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
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18
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Tian H, Parsons MW, Levi CR, Cheng X, Aviv RI, Spratt NJ, Kleinig TJ, O'Brien B, Butcher KS, Lin L, Zhang J, Dong Q, Chen C, Bivard A. Intravenous Thrombolysis May Not Improve Clinical Outcome of Acute Ischemic Stroke Patients Without a Baseline Vessel Occlusion. Front Neurol 2018; 9:405. [PMID: 29928251 PMCID: PMC5997810 DOI: 10.3389/fneur.2018.00405] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/17/2018] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: The benefit of thrombolysis in ischemic stroke patients without a visible vessel occlusion still requires investigation. This study tested the hypothesis that non-lacunar stroke patients with no visible vessel occlusion on baseline imaging would have a favorable outcome regardless of treatment with alteplase. Methods: We utilized a prospectively collected registry of ischemic stroke patients [the International Stroke Perfusion Imaging Registry (INSPIRE)] who had baseline computed tomographic perfusion and computed tomographic angiography. The rates of patients achieving modified Rankin Scale (mRS) 0-1 were compared between alteplase treated and untreated patients using logistic regression to generate odds ratios. Results: Of 1569 patients in the INSPIRE registry, 1,277 were eligible for inclusion. Of these, 306 (24%) had no identifiable occlusion and were eligible for alteplase, with 141 (46%) of these patients receiving thrombolysis. The treated and untreated groups had significantly different median baseline National Institutes of Health Stroke Scale (NIHSS) [alteplase 8, interquartile range (IQR) 5-10, untreated 6, IQR 4-8, P < 0.001] and median volume of baseline perfusion lesion [alteplase 5.6 mL, IQR 1.3-17.7 mL, untreated 2.6 mL, IQR 0-6.7 mL, P < 0.001]. After propensity analysis, alteplase treated patients without a vessel occlusion were less likely to have an excellent outcome (mRS 0-1; 56%) than untreated (78.8%, OR, 0.42, 95% confidence interval, 0.24-0.75, P = 0.003). Conclusions: In this non-randomized comparison, alteplase treatment in patients without an identifiable vessel occlusion did not result in higher rates of favorable outcome compared to untreated. However, treated patients displayed less favorable baseline prognostic factors than the untreated group. Further studies may be required to confirm this data.
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Affiliation(s)
- Huiqiao Tian
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Mark W Parsons
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Christopher R Levi
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Xin Cheng
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Richard I Aviv
- Division of Neuroradiology, Department of Medical Imaging, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Neil J Spratt
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Billy O'Brien
- Department of Neurology, Gosford Hospital, Gosford, NSW, Australia
| | - Kenneth S Butcher
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Longting Lin
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Jingfen Zhang
- Department of Neurology, Baotou Central Hospital, Baotou, China
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Chushuang Chen
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Andrew Bivard
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
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19
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Kunz WG, Fabritius MP, Sommer WH, Höhne C, Scheffler P, Rotkopf LT, Fendler WP, Sabel BO, Meinel FG, Dorn F, Ertl-Wagner B, Reiser MF, Thierfelder KM. Effect of stroke thrombolysis predicted by distal vessel occlusion detection. Neurology 2018; 90:e1742-e1750. [PMID: 29678936 DOI: 10.1212/wnl.0000000000005519] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 02/26/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Among ischemic stroke patients with negative CT angiography (CTA), we aimed to determine the predictive value of enhanced distal vessel occlusion detection using CT perfusion postprocessing (waveletCTA) for the treatment effect of IV thrombolysis (IVT). METHODS Patients were selected from 1,851 consecutive patients who had undergone CT perfusion. Inclusion criteria were (1) significant cerebral blood flow (CBF) deficit, (2) no occlusion on CTA, and (3) infarction confirmed on follow-up. Favorable morphologic response was defined as smaller values of final infarction volume divided by initial CBF deficit volume (FIV/CBF). Favorable functional outcome was defined as modified Rankin Scale score of ≤2 after 90 days and decrease in NIH Stroke Scale score of ≥3 from admission to 24 hours (∆NIHSS). RESULTS Among patients with negative CTA (n = 107), 58 (54%) showed a distal occlusion on waveletCTA. There was no difference between patients receiving IVT (n = 57) vs supportive care (n = 50) regarding symptom onset, early ischemic changes, perfusion mismatch, or admission NIHSS score (all p > 0.05). In IVT-treated patients, the presence of an occlusion was an independent predictor of a favorable morphologic response (FIV/CBF: β -1.43; 95% confidence interval [CI] -1.96, -0.83; p = 0.001) and functional outcome (90-day modified Rankin Scale: odds ratio 7.68; 95% CI 4.33-11.51; p = 0.039; ∆NIHSS: odds ratio 5.76; 95% CI 3.98-8.27; p = 0.013), while it did not predict outcome in patients receiving supportive care (all p > 0.05). CONCLUSION In stroke patients with negative CTA, distal vessel occlusions as detected by waveletCTA are an independent predictor of a favorable response to IVT.
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Affiliation(s)
- Wolfgang G Kunz
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany.
| | - Matthias P Fabritius
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
| | - Wieland H Sommer
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
| | - Christopher Höhne
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
| | - Pierre Scheffler
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
| | - Lukas T Rotkopf
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
| | - Wolfgang P Fendler
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
| | - Bastian O Sabel
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
| | - Felix G Meinel
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
| | - Franziska Dorn
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
| | - Birgit Ertl-Wagner
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
| | - Maximilian F Reiser
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
| | - Kolja M Thierfelder
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
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20
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Abstract
This review summarizes the current state of knowledge regarding the use of imaging to guide stroke treatment. Brain imaging plays a central role in the diagnosis of stroke and identification of the mechanism of stroke, which is relevant to acute treatment, prognosis, and secondary prevention. The chief potential modalities are computed tomography (CT) and magnetic resonance imaging (MRI). Currently, most imaging occurs in hospital but mobile stroke units have expanded CT brain imaging into the prehospital field. The proven therapies for ischemic stroke are based on achieving reperfusion and the DAWN and DEFUSE 3 trials have now firmly established a need for imaging selection based on estimated ischemic core volume to guide reperfusion decisions in patients beyond 6 h of stroke onset. However, data also indicate that estimated ischemic core volume, in conjunction with patient factors and expected time delay to reperfusion, forms one of the most useful prognostic assessments that could alter decision-making for patients within 6 h. Current trials are also investigating agents that aim to achieve neuroprotection, reduction in edema or prevention of hemorrhagic transformation. Imaging may play a role in identifying patients likely to benefit from this next generation of interventions for stroke patients.
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Affiliation(s)
- Bruce Cv Campbell
- 1 Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Mark W Parsons
- 1 Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia.,2 Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia
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Bivard A, Spratt N, Miteff F, Levi C, Parsons MW. Tissue Is More Important than Time in Stroke Patients Being Assessed for Thrombolysis. Front Neurol 2018; 9:41. [PMID: 29467716 PMCID: PMC5808281 DOI: 10.3389/fneur.2018.00041] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/17/2018] [Indexed: 11/26/2022] Open
Abstract
Aim The relative prognostic importance of modern imaging profiles compared with standard clinical characteristics is uncertain in acute stroke patients. In this study, we aimed to compare baseline multimodal CT imaging measures with known clinical predictors of patient outcome at 3 months [modified Rankin scale (mRS)]. Methods We collected baseline, 24 h, and day 90 clinical and imaging data from acute ischemic stroke patients being assessed for thrombolytic therapy between 2010 and 2015 at a single center as part of a retrospective analysis. Results 561 patients presenting within 4.5 h of ischemic stroke onset who were eligible for thrombolysis based on standard clinical criteria were assessed. Acute infarct core volume on CTP was the strongest univariate predictor of patient outcome (mRS 0–2, R2 0.497, p < 0.001), followed by collateral grade (mRS 0–2, R2 0.281, p < 0.001). The strongest baseline clinical predictor of outcome was National Institutes of Health Stroke Scale (NIHSS) (mRS 0–2, R2 = 0.203, p < 0.001). Time to treatment (mRS 0–2, R2 0.096, p = 0.01) and age (mRS 0–2, R2 0.027, p = 0.013) were relatively weak univariate baseline clinical predictors of 3-month outcome. In multivariate analysis, acute infarct core volume and collateral grade were the only significant baseline predictors of 3-month disability (both p < 0.001). Conclusion In patients assessed for thrombolysis by combined clinical and multimodal CT criteria within 4.5 h of onset, the size of the CTP infarct core and collateral grade on multimodal CT were highly predictive of patient outcome. Standard clinical variables, including time to treatment and NIHSS, were not as strongly predictive as multimodal CT variables.
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Affiliation(s)
- Andrew Bivard
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Neil Spratt
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Ferdinand Miteff
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Christopher Levi
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Mark William Parsons
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
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Bivard A, Parsons M. Tissue is more important than time: insights into acute ischemic stroke from modern brain imaging. Curr Opin Neurol 2018; 31:23-27. [DOI: 10.1097/wco.0000000000000520] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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El-Tawil S, Wardlaw J, Ford I, Mair G, Robinson T, Kalra L, Muir KW. Penumbra and re-canalization acute computed tomography in ischemic stroke evaluation: PRACTISE study protocol. Int J Stroke 2017; 12:671-678. [PMID: 28730951 DOI: 10.1177/1747493017696099] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Rationale Multimodal imaging, including computed tomography angiography and computed tomography perfusion imaging, yields additional information on intracranial vessels and brain perfusion and can differentiate between ischemic core and penumbra which may affect patient selection for intravenous thrombolysis. Hypothesis The use of multimodal imaging will increase the number of patients receiving intravenous thrombolysis and lead to better treatment outcomes. Sample size 400 patients. Methods and design PRACTISE is a prospective, multicenter, randomized, controlled trial in which patients presenting within 4.5 h of symptom onset are randomized to either the current evidence-based imaging (NCCT alone) or additional multimodal computed tomography imaging (NCCT + computed tomography angiography + computed tomography perfusion). Clinical decisions on intravenous recombinant tissue plasminogen activator are documented. Total imaging time in both arms and time to initiation of treatment delivery in those treated with intravenous recombinant tissue plasminogen activator, is recorded. Follow-up will include brain imaging at 24 h to document infarct size, the presence of edema and the presence of intra-cerebral hemorrhage. Clinical evaluations include NIHSS score at baseline, 24 h and day 7 ± 2, and mRS at day 90 to define functional outcomes. Study outcomes The primary outcome is the proportion of patients receiving intravenous recombinant tissue plasminogen activator. Secondary end-points evaluate times to decision-making, comparison of different image processing software and clinical outcomes at three months. Discussion Multimodal computed tomography is a widely available tool for patient selection for revascularization therapy, but it is currently unknown whether the use of additional imaging in all stroke patients is beneficial. The study opened for recruitment in March 2015 and will provide data on the value of multimodal imaging in treatment decisions for acute stroke.
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Affiliation(s)
- Salwa El-Tawil
- 1 Institute of Neuroscience & Psychology, Queen Elizabeth University Hospital, University of Glasgow, Glasgow, UK
| | - Joanna Wardlaw
- 2 Division of Neuroimaging Sciences, Western General Hospital, Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Ian Ford
- 3 Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Grant Mair
- 2 Division of Neuroimaging Sciences, Western General Hospital, Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Tom Robinson
- 4 Department of Cardiovascular Sciences, Ageing and Stroke Medicine Group, University of Leicester, Leicester, UK
| | - Lalit Kalra
- 5 Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neurosciences, King's College London, London, UK
| | - Keith W Muir
- 1 Institute of Neuroscience & Psychology, Queen Elizabeth University Hospital, University of Glasgow, Glasgow, UK
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