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Rex NB, McDonough RV, Ospel JM, Kashani N, Sehgal A, Fladt JC, McTaggart RA, Nogueira R, Menon B, Demchuk AM, Tymianski M, Hill MD, Goyal M. CT Perfusion Does Not Modify the Effect of Reperfusion in Patients with Acute Ischemic Stroke Undergoing Endovascular Treatment in the ESCAPE-NA1 Trial. AJNR Am J Neuroradiol 2023; 44:1045-1049. [PMID: 37620153 PMCID: PMC10494951 DOI: 10.3174/ajnr.a7954] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/27/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND AND PURPOSE Although reperfusion is associated with improved outcomes in patients with acute ischemic stroke undergoing endovascular treatment, many patients still do poorly. We investigated whether CTP modifies the effect of near-complete reperfusion on clinical outcomes, ie, whether poor clinical outcomes despite near-complete reperfusion can be partly or fully explained by CTP findings. MATERIALS AND METHODS Data are from the Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) trial. Admission CTP was processed using RAPID software, generating relative CBF and CBV volume maps at standard thresholds. CTP lesion volumes were compared in patients with-versus-without near-complete reperfusion. Associations between each CTP metric and clinical outcome (90-day mRS) were tested using multivariable logistic regression, adjusted for baseline imaging and clinical variables. Treatment-effect modification was assessed by introducing CTP lesion volume × reperfusion interaction terms in the models. RESULTS CTP lesion volumes and reperfusion status were available in 410/1105 patients. CTP lesion volumes were overall larger in patients without near-complete reperfusion, albeit not always statistically significant. Increased CBF <34%, CBV <34%, CBV <38%, and CBV <42% lesion volumes were associated with worse clinical outcome (ordinal mRS) at 90 days. CTP core lesion volumes did not modify the treatment effect of near-complete recanalization on clinical outcome. CONCLUSIONS CTP did not modify the effect of near-complete reperfusion on clinical outcomes. Thus, CTP cannot explain why some patients with near-complete reperfusion have poor clinical outcomes.
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Affiliation(s)
- N B Rex
- From the Department of Diagnostic Imaging (N.B.R., R.A.M.), Brown University, Providence, Rhode Island
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - R V McDonough
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - J M Ospel
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - N Kashani
- Department of Neurosurgery (N.K.), University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - A Sehgal
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - J C Fladt
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Neurology and Stroke Center (J.C.F.), University Hospital Basel, Basel, Switzerland
| | - R A McTaggart
- From the Department of Diagnostic Imaging (N.B.R., R.A.M.), Brown University, Providence, Rhode Island
| | - R Nogueira
- Department of Neurology and Neurosurgery (R.N.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - B Menon
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - A M Demchuk
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | | | - M D Hill
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
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Abdalkader M, Siegler JE, Lee JS, Yaghi S, Qiu Z, Huo X, Miao Z, Campbell BC, Nguyen TN. Neuroimaging of Acute Ischemic Stroke: Multimodal Imaging Approach for Acute Endovascular Therapy. J Stroke 2023; 25:55-71. [PMID: 36746380 PMCID: PMC9911849 DOI: 10.5853/jos.2022.03286] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 12/19/2022] [Accepted: 01/04/2023] [Indexed: 02/04/2023] Open
Abstract
Advances in acute ischemic stroke (AIS) treatment have been contingent on innovations in neuroimaging. Neuroimaging plays a pivotal role in the diagnosis and prognosis of ischemic stroke and large vessel occlusion, enabling triage decisions in the emergent care of the stroke patient. Current imaging protocols for acute stroke are dependent on the available resources and clinicians' preferences and experiences. In addition, differential application of neuroimaging in medical decision-making, and the rapidly growing evidence to support varying paradigms have outpaced guideline-based recommendations for selecting patients to receive intravenous or endovascular treatment. In this review, we aimed to discuss the various imaging modalities and approaches used in the diagnosis and treatment of AIS.
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Affiliation(s)
| | - James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - Jin Soo Lee
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, RI, USA
| | - Zhongming Qiu
- Department of Neurology, The 903rd Hospital of The Chinese People’s Liberation Army, Hangzhou, China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bruce C.V. Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Thanh N. Nguyen
- Department of Radiology, Boston Medical Center, Boston, MA, USA
- Department of Neurology, Boston Medical Center, Boston, MA, USA
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Fischer U, Branca M, Bonati LH, Carrera E, Vargas MI, Platon A, Kulcsar Z, Wegener S, Luft A, Seiffge DJ, Arnold M, Michel P, Strambo D, Dunet V, De Marchis GM, Schelosky L, Andreisek G, Barinka F, Peters N, Fisch L, Nedeltchev K, Cereda CW, Kägi G, Bolognese M, Salmen S, Sturzenegger R, Medlin F, Berger C, Renaud S, Bonvin C, Schaerer M, Mono ML, Rodic B, Psychogios M, Mordasini P, Gralla J, Kaesmacher J, Meinel TR. MRI or CT for Suspected Acute Stroke: Association of Admission Image Modality with Acute Recanalization Therapies, Workflow Metrics and Outcomes. Ann Neurol 2022; 92:184-194. [PMID: 35599442 PMCID: PMC9545922 DOI: 10.1002/ana.26413] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 04/23/2022] [Accepted: 05/13/2022] [Indexed: 11/17/2022]
Abstract
Objective To examine rates of intravenous thrombolysis (IVT), mechanical thrombectomy (MT), door‐to‐needle (DTN) time, door‐to‐puncture (DTP) time, and functional outcome between patients with admission magnetic resonance imaging (MRI) versus computed tomography (CT). Methods An observational cohort study of consecutive patients using a target trial design within the nationwide Swiss‐Stroke‐Registry from January 2014 to August 2020 was carried out. Exclusion criteria included MRI contraindications, transferred patients, and unstable or frail patients. Multilevel mixed‐effects logistic regression with multiple imputation was used to calculate adjusted odds ratios with 95% confidence intervals for IVT, MT, DTN, DTP, and good functional outcome (mRS 0–2) at 90 days. Results Of the 11,049 patients included (mean [SD] age, 71 [15] years; 4,811 [44%] women; 69% ischemic stroke, 16% transient ischemic attack, 8% stroke mimics, 6% intracranial hemorrhage), 3,741 (34%) received MRI and 7,308 (66%) CT. Patients undergoing MRI had lower National Institutes of Health Stroke Scale (median [interquartile range] 2 [0–6] vs 4 [1–11]), and presented later after symptom onset (150 vs 123 min, p < 0.001). Admission MRI was associated with: lower adjusted odds of IVT (aOR 0.83, 0.73–0.96), but not with MT (aOR 1.11, 0.93–1.34); longer adjusted DTN (+22 min [13–30]), but not with longer DTP times; and higher adjusted odds of favorable outcome (aOR 1.54, 1.30–1.81). Interpretation We found an association of MRI with lower rates of IVT and a significant delay in DTN, but not in DTP and rates of MT. Given the delays in workflow metrics, prospective trials are required to show that tissue‐based benefits of baseline MRI compensate for the temporal benefits of CT. ANN NEUROL 2022;92:184–194
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Affiliation(s)
- Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland.,Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland
| | | | | | - Emmanuel Carrera
- Department of Neurology, Neuroradiology, Radiology, HUG, Geneva, Switzerland
| | - Maria I Vargas
- Department of Neurology, Neuroradiology, Radiology, HUG, Geneva, Switzerland
| | - Alexandra Platon
- Department of Neurology, Neuroradiology, Radiology, HUG, Geneva, Switzerland
| | - Zsolt Kulcsar
- Department of Neurology, Neuroradiology, University Hospital Zurich, Switzerland & Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Susanne Wegener
- Department of Neurology, Neuroradiology, University Hospital Zurich, Switzerland & Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Andreas Luft
- Department of Neurology, Neuroradiology, University Hospital Zurich, Switzerland & Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - David J Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Davide Strambo
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Vincent Dunet
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Ludwig Schelosky
- Department of Neurology, Institute for Radiology, Cantonal Hospital Muensterlingen, Switzerland
| | - Gustav Andreisek
- Department of Neurology, Institute for Radiology, Cantonal Hospital Muensterlingen, Switzerland
| | - Filip Barinka
- Stroke Center, Hirslanden Hospital Zurich, Switzerland
| | - Nils Peters
- Stroke Center, Hirslanden Hospital Zurich, Switzerland
| | | | | | - Carlo W Cereda
- Stroke Center, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
| | - Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, Switzerland
| | | | - Stephan Salmen
- Department of Neurology, Spitalzentrum Biel, Switzerland
| | | | - Friedrich Medlin
- Stroke and Neurology Unit, Cantonal Hospital Fribourg, Switzerland
| | | | | | | | | | | | | | - Marios Psychogios
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Pasquale Mordasini
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Thomas R Meinel
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
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Jiang L, Zhang C, Wang S, Ai Z, Shen T, Zhang H, Duan S, Yin X, Chen YC. MRI Radiomics Features From Infarction and Cerebrospinal Fluid for Prediction of Cerebral Edema After Acute Ischemic Stroke. Front Aging Neurosci 2022; 14:782036. [PMID: 35309889 PMCID: PMC8929352 DOI: 10.3389/fnagi.2022.782036] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 02/11/2022] [Indexed: 12/17/2022] Open
Abstract
Neuroimaging biomarkers that predict the edema after acute stroke may help clinicians provide targeted therapies and minimize the risk of secondary injury. In this study, we applied pretherapy MRI radiomics features from infarction and cerebrospinal fluid (CSF) to predict edema after acute ischemic stroke. MRI data were obtained from a prospective, endovascular thrombectomy (EVT) cohort that included 389 patients with acute stroke from two centers (dataset 1, n = 292; dataset 2, n = 97), respectively. Patients were divided into edema group (brain swelling and midline shift) and non-edema group according to CT within 36 h after therapy. We extracted the imaging features of infarct area on diffusion weighted imaging (DWI) (abbreviated as DWI), CSF on fluid-attenuated inversion recovery (FLAIR) (CSFFLAIR) and CSF on DWI (CSFDWI), and selected the optimum features associated with edema for developing models in two forms of feature sets (DWI + CSFFLAIR and DWI + CSFDWI) respectively. We developed seven ML models based on dataset 1 and identified the most stable model. External validations (dataset 2) of the developed stable model were performed. Prediction model performance was assessed using the area under the receiver operating characteristic curve (AUC). The Bayes model based on DWI + CSFFLAIR and the RF model based on DWI + CSFDWI had the best performances (DWI + CSFFLAIR: AUC, 0.86; accuracy, 0.85; recall, 0.88; DWI + CSFDWI: AUC, 0.86; accuracy, 0.84; recall, 0.84) and the most stability (RSD% in DWI + CSFFLAIR AUC: 0.07, RSD% in DWI + CSFDWI AUC: 0.09), respectively. External validation showed that the AUC of the Bayes model based on DWI + CSFFLAIR was 0.84 with accuracy of 0.77 and area under precision-recall curve (auPRC) of 0.75, and the AUC of the RF model based on DWI + CSFDWI was 0.83 with accuracy of 0.81 and the auPRC of 0.76. The MRI radiomics features from infarction and CSF may offer an effective imaging biomarker for predicting edema.
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Affiliation(s)
- Liang Jiang
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Chuanyang Zhang
- Department of Radiology, Nanjing Gaochun People’s Hospital, Nanjing, China
| | - Siyu Wang
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zhongping Ai
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Tingwen Shen
- Department of Radiology, Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
| | - Hong Zhang
- Department of Radiology, Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
| | - Shaofeng Duan
- GE Healthcare, Precision Health Institution, Shanghai, China
| | - Xindao Yin
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- *Correspondence: Xindao Yin,
| | - Yu-Chen Chen
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Yu-Chen Chen,
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Grøan M, Ospel J, Ajmi S, Sandset EC, Kurz MW, Skjelland M, Advani R. Time-Based Decision Making for Reperfusion in Acute Ischemic Stroke. Front Neurol 2021; 12:728012. [PMID: 34790159 PMCID: PMC8591257 DOI: 10.3389/fneur.2021.728012] [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: 06/20/2021] [Accepted: 09/16/2021] [Indexed: 11/13/2022] Open
Abstract
Decision making in the extended time windows for acute ischemic stroke can be a complex and time-consuming process. The process of making the clinical decision to treat has been compounded by the availability of different imaging modalities. In the setting of acute ischemic stroke, time is of the essence and chances of a good outcome diminish by each passing minute. Navigating the plethora of advanced imaging modalities means that treatment in some cases can be inefficaciously delayed. Time delays and individually based non-programmed decision making can prove challenging for clinicians. Visual aids can assist such decision making aimed at simplifying the use of advanced imaging. Flow charts are one such visual tool that can expedite treatment in this setting. A systematic review of existing literature around imaging modalities based on site of occlusion and time from onset can be used to aid decision making; a more program-based thought process. The use of an acute reperfusion flow chart helping navigate the myriad of imaging modalities can aid the effective treatment of patients.
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Affiliation(s)
- Mathias Grøan
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Johanna Ospel
- Department of Radiology, Basel University Hospital, Basel, Switzerland.,Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Soffien Ajmi
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway.,University of Stavanger, Stavanger, Norway
| | - Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway.,Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Martin W Kurz
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway.,Neuroscience Research Group, Stavanger University Hospital, Stavanger, Norway
| | - Mona Skjelland
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Rajiv Advani
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway.,Neuroscience Research Group, Stavanger University Hospital, Stavanger, Norway
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Ma G, Cao YZ, Xu XQ, Lu SS, Liu QH, Shi HB, Liu S, Wu FY. Incremental value of Alberta Stroke Program Early CT Score to collateral score for predicting target mismatch in stroke patients with extended time window or unknown onset time. Neurol Sci 2021; 43:1097-1104. [PMID: 34128149 DOI: 10.1007/s10072-021-05387-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 06/07/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To evaluate whether Alberta Stroke Program Early CT Score (ASPECTS) could provide incremental value to collateral score, and their integration could be an effective surrogate of CTP in predicting target mismatch. MATERIAL AND METHODS One hundred and fifty-nine stroke patients (onset time 6-16 h or with unknown onset time) with MCA and/or ICA occlusion underwent non-contrast computed tomography (NCCT) and CT perfusion (CTP) scan for initial assessment. Simulated single-phase CT angiography (sCTA, peak arterial phase) and multiphase CTA (mCTA) were reconstructed from CTP. ASPECTS was assessed on NCCT and sCTA. Collateral score was evaluated on mCTA. Target mismatch was defined as infarct core volume < 70 mL, the mismatch ratio ≥ 1.8, and the absolute mismatch volume ≥ 15 mL. Pearson correlation analysis, Mann-Whitney U test, chi-square test, and receiver operating characteristic curve analyses were performed. RESULTS Median CTA source image (CTA-SI) ASPECTS was significantly lower than NCCT ASPECTS (p = 0.001). NCCT ASPECTS, CTA-SI ASPECTS, and mCTA collateral score correlated significantly with infarct core volume and mismatch ratio (all p < 0.05). Mismatch group showed significantly higher NCCT ASPECTS, CTA-SI ASPECTS, and mCTA collateral score than non-mismatch group (all p < 0.001). NCCT ASPECTS and CTA-SI ASPECTS showed comparable predicting performance with mCTA collateral score (p > 0.05). Adding CTA-SI ASPECTS to mCTA collateral score improved the performance of mCTA in predicting target mismatch (area under curve, 0.905 vs. 0.804, p = 0.003). CONCLUSION ASPECTS can provide incremental information to collateral score in predicting target mismatch. If CTP scan fails, clinical decision based on ASPECTS and collateral score might be reasonable.
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Affiliation(s)
- Gao Ma
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd., Nanjing, China
| | - Yue-Zhou Cao
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd., Nanjing, China
| | - Xiao-Quan Xu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd., Nanjing, China
| | - Shan-Shan Lu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd., Nanjing, China
| | - Qiang-Hui Liu
- Department of Emergency, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hai-Bin Shi
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd., Nanjing, China
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd., Nanjing, China.
| | - Fei-Yun Wu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Rd., Nanjing, China.
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Magoufis G, Safouris A, Raphaeli G, Kargiotis O, Psychogios K, Krogias C, Palaiodimou L, Spiliopoulos S, Polizogopoulou E, Mantatzis M, Finitsis S, Karapanayiotides T, Ellul J, Bakola E, Brountzos E, Mitsias P, Giannopoulos S, Tsivgoulis G. Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach. Ther Adv Neurol Disord 2021; 14:17562864211021182. [PMID: 34122624 PMCID: PMC8175833 DOI: 10.1177/17562864211021182] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/10/2021] [Indexed: 02/05/2023] Open
Abstract
Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.
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Affiliation(s)
- Georgios Magoufis
- Interventional Neuroradiology Unit, Metropolitan Hospital, Piraeus, Greece
| | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Guy Raphaeli
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | | | - Klearchos Psychogios
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Lina Palaiodimou
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Eftihia Polizogopoulou
- Emergency Medicine Clinic, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Michael Mantatzis
- Department of Radiology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Stephanos Finitsis
- Department of Interventional Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, Aristotle University of Thessaloniki, School of Medicine, Faculty of Health Sciences, AHEPA University Hospital, Thessaloniki, Greece
| | - John Ellul
- Department of Neurology, University Hospital of Patras, School of Medicine, University of Patras, Patras, Greece
| | - Eleni Bakola
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Elias Brountzos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Panayiotis Mitsias
- Department of Neurology Medical School, University of Crete, Heraklion, Crete, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian, University of Athens, School of Medicine, “Attikon” University Hospital, Iras 39, Gerakas Attikis, Athens, 15344, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
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Meinel TR, Kaesmacher J, Mosimann PJ, Seiffge D, Jung S, Mordasini P, Arnold M, Goeldlin M, Hajdu SD, Olivé-Gadea M, Maegerlein C, Costalat V, Pierot L, Schaafsma JD, Fischer U, Gralla J. Association of initial imaging modality and futile recanalization after thrombectomy. Neurology 2020; 95:e2331-e2342. [PMID: 32847948 PMCID: PMC7682915 DOI: 10.1212/wnl.0000000000010614] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 05/18/2020] [Indexed: 12/12/2022] Open
Abstract
Objective To test the hypothesis that selection by initial imaging modality (MRI vs CT) is associated with rate of futile recanalizations (FRs) after mechanical thrombectomy (MT), we assessed this association in a multicenter, retrospective observational registry (BEYOND-SWIFT [Registry for Evaluating Outcome of Acute Ischemic Stroke Patients Treated With Mechanical Thrombectomy], NCT03496064). Methods In 2,011 patients (49.7% female, median age 73 years [61–81]) included between 2009 and 2017, we performed univariate and multivariate analyses regarding the occurrence of FR. FRs were defined as 90-day modified Rankin Scale (mRS) score 4–6 despite successful recanalization in patients selected by MRI (n = 690) and CT (n = 1,321) with a sensitivity analysis considering only patients with mRS 5–6 as futile. Results MRI as compared to CT resulted in similar rates of subsequent MT (adjusted odds ratio [aOR] 1.048, 95% confidence interval [CI] 0.677–1.624). Rates of FR were as follows: 571/1,489 (38%) FR mRS 4–6 including 393/1,489 (26%) FR mRS 5–6. CT-based selection was associated with increased rates of FRs compared to MRI (44% [41%–47%] vs 29% [25%–32%], p < 0.001; aOR 1.77 [95% CI 1.25–2.51]). These findings were robust in sensitivity analysis. MRI-selected patients had a delay of approximately 30 minutes in workflow metrics in real-world university comprehensive stroke centers. However, functional outcome and mortality were more favorable in patients selected by MRI compared to patients selected with CT. Conclusions CT selection for MT was associated with an increased risk of FRs as compared to MRI selection. Efforts are needed to shorten workflow delays in MRI patients. Further research is needed to clarify the role of the initial imaging modality on FR occurrence and to develop a reliable FR prediction algorithm.
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Affiliation(s)
- Thomas Raphael Meinel
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Johannes Kaesmacher
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Pascal John Mosimann
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - David Seiffge
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Simon Jung
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Pasquale Mordasini
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Marcel Arnold
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Martina Goeldlin
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Steven D Hajdu
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Marta Olivé-Gadea
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Christian Maegerlein
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Vincent Costalat
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Laurent Pierot
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Joanna D Schaafsma
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Urs Fischer
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada.
| | - Jan Gralla
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
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Almekhlafi MA, Kunz WG, McTaggart RA, Jayaraman MV, Najm M, Ahn SH, Fainardi E, Rubiera M, Khaw AV, Zini A, Hill MD, Demchuk AM, Goyal M, Menon BK. Imaging Triage of Patients with Late-Window (6-24 Hours) Acute Ischemic Stroke: A Comparative Study Using Multiphase CT Angiography versus CT Perfusion. AJNR Am J Neuroradiol 2019; 41:129-133. [PMID: 31806593 DOI: 10.3174/ajnr.a6327] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/01/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE The role of collateral imaging in selecting patients for endovascular thrombectomy beyond 6 hours from onset has not been established. To assess the comparative utility of collateral imaging using multiphase CTA in selecting late window patients for EVT. MATERIALS AND METHODS We used data from a prospective multicenter observational study in which all patients underwent imaging with multiphase CT angiography as well as CTP. Two blinded reviewers evaluated patients' eligibility for endovascular thrombectomy using published collateral imaging (multiphase CTA) criteria compared with CTP using the selection criteria of the Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention with Trevo (DAWN) and Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3 (DEFUSE-3) trials. CTP images were processed using automated commercial software. The outcomes of patients eligible for endovascular thrombectomy according to multiphase CTA, DAWN, or DEFUSE-3 criteria were compared using multivariable logistic regression modeling. Model characteristics were compared using the C-statistic for the receiver operating characteristic curve, the Akaike information criterion, and the Bayesian information criterion. RESULTS Eighty-six patients presented beyond 6 hours from onset/last known well (median, 9.6 hours; interquartile range, 4.1 hours). Thirty-five patients (40.7%) received endovascular thrombectomy, of whom good functional outcome (90-day mRS, 0-2) was achieved in 16/35 (47%). Collateral-based imaging paradigms significantly modified the treatment effect of endovascular thrombectomy on 90-day mRS 0-2 (P interaction = .007). The multiphase CTA-based regression model best fit the data for the 90-day outcome (C-statistic, 0.86; 95% CI, 0.77-0.94) and was associated with the least information loss (Akaike information criterion, 95.7; Bayesian information criterion, 114.9) compared with CTP-based models. CONCLUSIONS The collateral-based imaging paradigm using multiphase CTA compares well with CTP in selecting patients for endovascular thrombectomy in the late time window.
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Affiliation(s)
- M A Almekhlafi
- From the Department of Clinical Neurosciences (M.A.A., M.N., M.D.H., A.M.D., M.G., B.K.M.).,Calgary Stroke Program, Department of Radiology (M.A.A., M.D.H., A.M.D., M.G., B.K.M.).,Department of Community Health Sciences (M.A.A., M.D.H., B.K.M.)
| | - W G Kunz
- Department of Radiology (W.G.K.), University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - R A McTaggart
- Departments of Neurology, Diagnostic Imaging, and Neurosurgery (R.A.M., M.V.J.), Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - M V Jayaraman
- Departments of Neurology, Diagnostic Imaging, and Neurosurgery (R.A.M., M.V.J.), Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - M Najm
- From the Department of Clinical Neurosciences (M.A.A., M.N., M.D.H., A.M.D., M.G., B.K.M.)
| | - S H Ahn
- Department of Neurology (S.H.A.), Chosun University School of Medicine, Gwang Ju, South Korea
| | - E Fainardi
- Department of Neurosciences and Rehabilitation (E.F.), University Hospital, Ferrara, Italy
| | - M Rubiera
- Department of Neurology (M.R.), Hospital Vall d'Hebron, Passeig de la Vall d'Hebron, Barcelona, Spain
| | - A V Khaw
- Department of Clinical Neurosciences (A.V.K.), University of Western Ontario, London, Ontario, Canada
| | - A Zini
- Department of Neurology and Stroke Center (A.Z.), Istituto Di Ricovero e Cura a Carattere Scientifico Istituto di Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy
| | - M D Hill
- From the Department of Clinical Neurosciences (M.A.A., M.N., M.D.H., A.M.D., M.G., B.K.M.).,Calgary Stroke Program, Department of Radiology (M.A.A., M.D.H., A.M.D., M.G., B.K.M.).,Department of Community Health Sciences (M.A.A., M.D.H., B.K.M.).,Department of Medicine (M.D.H.), Hotchkiss Brain Institute, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - A M Demchuk
- From the Department of Clinical Neurosciences (M.A.A., M.N., M.D.H., A.M.D., M.G., B.K.M.).,Calgary Stroke Program, Department of Radiology (M.A.A., M.D.H., A.M.D., M.G., B.K.M.)
| | - M Goyal
- From the Department of Clinical Neurosciences (M.A.A., M.N., M.D.H., A.M.D., M.G., B.K.M.).,Calgary Stroke Program, Department of Radiology (M.A.A., M.D.H., A.M.D., M.G., B.K.M.)
| | - B K Menon
- From the Department of Clinical Neurosciences (M.A.A., M.N., M.D.H., A.M.D., M.G., B.K.M.) .,Calgary Stroke Program, Department of Radiology (M.A.A., M.D.H., A.M.D., M.G., B.K.M.).,Department of Community Health Sciences (M.A.A., M.D.H., B.K.M.)
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