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Tan Z, Parsons M, Bivard A, Sharma G, Mitchell P, Dowling R, Bush S, Churilov L, Xu A, Yan B. Comparison of Computed Tomography Perfusion and Multiphase Computed Tomography Angiogram in Predicting Clinical Outcomes in Endovascular Thrombectomy. Stroke 2022; 53:2926-2934. [PMID: 35748291 DOI: 10.1161/strokeaha.122.038576] [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 In patients with acute stroke who undergo endovascular thrombectomy, the relative prognostic power of computed tomography perfusion (CTP) parameters compared with multiphase CT angiogram (mCTA) is unknown. We aimed to compare the predictive accuracy of mCTA and CTP parameters on clinical outcomes. METHODS We included patients with acute ischemic stroke who had anterior circulation large vessel occlusion within 24 hours of onset in Melbourne Brain Centre at the Royal Melbourne Hospital. All patients underwent CTP for endovascular thrombectomy, and the mCTA collateral score was determined using CTP-reconstructed mCTA images. The primary outcome was 90-day functional outcomes defined by modified Rankin Scale. Multivariable logistic regression models analyzed associations between mCTA and CTP parameters and 90-day functional outcomes. The ability to discriminate 90 days-functional outcomes was compared between mCTA collateral score and CTP parameters using receiver operating curve analysis and C statistics. RESULTS One hundred and twenty patients were included. The median age was 69 years (interquartile range, 60-79), the median baseline National Institutes of Health Stroke Scale score was 14 (interquartile range, 9-19). The baseline ischemic core volume, defined by CTP-based relative cerebral blood flow <30%, was associated with excellent functional outcome (modified Rankin Scale score 0-1; odds ratio, 0.942 [-0.897 to -0.989]; P=0.015) and poor functional outcome (modified Rankin Scale score 5-6; odds ratio, 1.032 [1.007-1.056]; P=0.010) at 90 days in the analysis of multivariable regression. There was no significant association between the mCTA score and excellent functional outcome (P=0.58) or poor functional outcome (P=0.155). The relative cerebral blood flow <30%-based regression model best fit the data for the 90-day poor functional outcome (C statistic, 0.834). CONCLUSIONS The CTP-based ischemic core volume may provide better discrimination for 90-day functional outcomes for patients with acute stroke undergoing endovascular thrombectomy than the mCTA collateral score.
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Affiliation(s)
- Zefeng Tan
- Department of Neurology, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China (Z.T., A.X.).,Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.).,Department of Neurology, the First People's Hospital of Foshan, China (Z.T.)
| | - Mark Parsons
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.).,Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Australia (P.M., R.D., S.B., B.Y.)
| | - Andrew Bivard
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.)
| | - Gagan Sharma
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.)
| | - Peter Mitchell
- Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Australia (P.M., R.D., S.B., B.Y.)
| | - Richard Dowling
- Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Australia (P.M., R.D., S.B., B.Y.)
| | - Steven Bush
- Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Australia (P.M., R.D., S.B., B.Y.)
| | - Leonid Churilov
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.)
| | - Anding Xu
- Department of Neurology, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China (Z.T., A.X.)
| | - Bernard Yan
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.).,Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Australia (P.M., R.D., S.B., B.Y.)
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Zhang Y, Zhuang Y, Ge Y, Wu PY, Zhao J, Wang H, Song B. MRI whole-lesion texture analysis on ADC maps for the prognostic assessment of ischemic stroke. BMC Med Imaging 2022; 22:115. [PMID: 35778678 PMCID: PMC9250246 DOI: 10.1186/s12880-022-00845-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/23/2022] [Indexed: 11/28/2022] Open
Abstract
Background This study aims is to explore whether it is feasible to use magnetic resonance texture analysis (MRTA) in order to distinguish favorable from unfavorable function outcomes and determine the prognostic factors associated with favorable outcomes of stroke. Methods The retrospective study included 103 consecutive patients who confirmed unilateral anterior circulation subacute ischemic stroke by computed tomography angiography between January 2018 and September 2019. Patients were divided into favorable outcome (modified Rankin scale, mRS ≤ 2) and unfavorable outcome (mRS > 2) groups according to mRS scores at day 90. Two radiologists manually segmented the infarction lesions based on diffusion-weighted imaging and transferred the images to corresponding apparent diffusion coefficient (ADC) maps in order to extract texture features. The prediction models including clinical characteristics and texture features were built using multiple logistic regression. A univariate analysis was conducted to assess the performance of the mean ADC value of the infarction lesion. A Delong’s test was used to compare the predictive performance of models through the receiver operating characteristic curve. Results The mean ADC performance was moderate [AUC = 0.60, 95% confidence interval (CI) 0.49–0.71]. The texture feature model of the ADC map (tADC), contained seven texture features, and presented good prediction performance (AUC = 0.83, 95%CI 0.75–0.91). The energy obtained after wavelet transform, and the kurtosis and skewness obtained after Laplacian of Gaussian transformation were identified as independent prognostic factors for the favorable stroke outcomes. In addition, the combination of the tADC model and clinical characteristics (hypertension, diabetes mellitus, smoking, and atrial fibrillation) exhibited a subtly better performance (AUC = 0.86, 95%CI 0.79–0.93; P > 0.05, Delong’s). Conclusion The models based on MRTA on ADC maps are useful to evaluate the clinical function outcomes in patients with unilateral anterior circulation ischemic stroke. Energy obtained after wavelet transform, kurtosis obtained after Laplacian of Gaussian transform, and skewness obtained after Laplacian of Gaussian transform were identified as independent prognostic factors for favorable stroke outcomes.
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Affiliation(s)
- Yuan Zhang
- Department of Radiology, Minhang Hospital, Fudan University, 170 Xinsong Road, Shanghai, 201199, People's Republic of China
| | - Yuzhong Zhuang
- Department of Radiology, Minhang Hospital, Fudan University, 170 Xinsong Road, Shanghai, 201199, People's Republic of China
| | - Yaqiong Ge
- Department of Medicine, GE Healthcare, Shanghai, People's Republic of China
| | - Pu-Yeh Wu
- Department of Medicine, GE Healthcare, Beijing, People's Republic of China
| | - Jing Zhao
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, People's Republic of China
| | - Hao Wang
- Department of Radiology, Minhang Hospital, Fudan University, 170 Xinsong Road, Shanghai, 201199, People's Republic of China.
| | - Bin Song
- Department of Radiology, Minhang Hospital, Fudan University, 170 Xinsong Road, Shanghai, 201199, People's Republic of China.
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Risk and Benefit Evaluation: Application of Multiphase Computed Tomography Angiography in Mechanical Thrombectomy for Patients With Acute Ischemic Stroke. J Comput Assist Tomogr 2021; 45:736-742. [PMID: 34469901 DOI: 10.1097/rct.0000000000001219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the collateral circulation in patients with acute ischemic stroke (AIS) by multiphase computed tomography angiography (mCTA) and explore its application value in the risk and benefit assessment after thrombectomy. METHODS Clinical and imaging parameters of AIS patients who underwent thrombectomy were consecutively collected. The 90-day modified Rankin Scale (mRS) score was used as the standard for evaluating the recovery of neurological functions. The receiver operating characteristic curve and correlation analysis were used to evaluate the diagnostic efficacy of collateral circulation in the clinical outcomes at 90 days and the correlation with symptomatic intracerebral hemorrhage (sICH), respectively. RESULTS Thirty of 58 AIS patients (51.7%) had favorable functional recovery (90-day mRS score, ≤2). Significant differences were observed in age, time from symptom onset to groin puncture, National Institutes of Health Stroke Scale score at admission and 24 hours after thrombectomy, mRS score at discharge, collateral circulation score, and target mismatch between the favorable and unfavorable groups (P < 0.05). The diagnostic efficacy of mCTA collateral score (area under the curve, 0.697; 95% confidence interval, 0.563-0.831) was similar to that of computed tomography perfusion target mismatch (area under the curve, 0.740; 95% confidence interval, 0.609-0.872) (DeLong test, P = 0.575). The collateral circulation score was significantly negatively correlated with sICH (ρ = -0.607, P < 0.001). Patients with sICH had lower collateral circulation scores and higher 90-day mRS scores (P < 0.05). CONCLUSIONS The mCTA collateral score has good application value in the risk and benefit evaluation after mechanical thrombectomy, and it is well suited for routine emergency assessment of AIS patients.
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Predicting hemorrhagic transformation after thrombectomy in acute ischemic stroke: a multimodal score of the regional pial collateral. Neuroradiology 2021; 64:493-502. [PMID: 34417857 DOI: 10.1007/s00234-021-02795-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/17/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE This study aims to analyze the multimodal score of the regional pial collateral in predicting hemorrhagic transformation (HT) after mechanical thrombectomy in acute ischemic stroke (AIS). METHODS On the basis of different brain regions and multiphase computed tomography angiography (mCTA), we evaluated the pial arterial filling status in extent, delay, and contrast washout. The prediction models of HT and symptomatic intracerebral hemorrhage (sICH) were established using mCTA (model-H1 and model-S1), CT perfusion (CTP, model-H2 and model-S2), and comprehensive parameters (model-H3 and model-S3). The receiver operating characteristic curve was used to analyze the prediction performance of each model. RESULTS Among the 102 patients with AIS who received thrombectomy, 36 (35.3%) developed HT, and 15 (14.7%) of whom had sICH. In model-H1 and model-S1, washout independently influenced HT (OR, 95%CI 0.398, 0.249-0.634) and sICH (OR, 95%CI 0.552, 0.342-0.892). In model-H2, the relative surface permeability independently influenced HT (OR, 95%CI 1.217, 1.082-1.370). Model-H3 and model-S3 improved the prediction performance (areas under the curve: HT, 0.957; sICH, 0.938). The correlation coefficients between relative cerebral blood volume and the three modes of pial arterial filling status were higher than those of other CTP parameters. The 90-day modified Rankin scale score in the sICH group was significantly increased (P < 0.05). CONCLUSION The multimodal regional pial collateral score has good value in the risk assessment of HT and sICH in patients with AIS after mechanical thrombectomy. The combination of multiple parameters can improve diagnostic performance.
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Qiu W, Kuang H, Ospel JM, Hill MD, Demchuk AM, Goyal M, Menon BK. Automated Prediction of Ischemic Brain Tissue Fate from Multiphase Computed Tomographic Angiography in Patients with Acute Ischemic Stroke Using Machine Learning. J Stroke 2021; 23:234-243. [PMID: 34102758 PMCID: PMC8189856 DOI: 10.5853/jos.2020.05064] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/08/2021] [Indexed: 01/11/2023] Open
Abstract
Background and Purpose Multiphase computed tomographic angiography (mCTA) provides time variant images of pial vasculature supplying brain in patients with acute ischemic stroke (AIS). To develop a machine learning (ML) technique to predict tissue perfusion and infarction from mCTA source images.
Methods 284 patients with AIS were included from the Precise and Rapid assessment of collaterals using multi-phase CTA in the triage of patients with acute ischemic stroke for Intra-artery Therapy (Prove-IT) study. All patients had non-contrast computed tomography, mCTA, and computed tomographic perfusion (CTP) at baseline and follow-up magnetic resonance imaging/non-contrast-enhanced computed tomography. Of the 284 patient images, 140 patient images were randomly selected to train and validate three ML models to predict a pre-defined Tmax thresholded perfusion abnormality, core and penumbra on CTP. The remaining 144 patient images were used to test the ML models. The predicted perfusion, core and penumbra lesions from ML models were compared to CTP perfusion lesion and to follow-up infarct using Bland-Altman plots, concordance correlation coefficient (CCC), intra-class correlation coefficient (ICC), and Dice similarity coefficient.
Results Mean difference between the mCTA predicted perfusion volume and CTP perfusion volume was 4.6 mL (limit of agreement [LoA], –53 to 62.1 mL; P=0.56; CCC 0.63 [95% confidence interval [CI], 0.53 to 0.71; P<0.01], ICC 0.68 [95% CI, 0.58 to 0.78; P<0.001]). Mean difference between the mCTA predicted infarct and follow-up infarct in the 100 patients with acute reperfusion (modified thrombolysis in cerebral infarction [mTICI] 2b/2c/3) was 21.7 mL, while it was 3.4 mL in the 44 patients not achieving reperfusion (mTICI 0/1). Amongst reperfused subjects, CCC was 0.4 (95% CI, 0.15 to 0.55; P<0.01) and ICC was 0.42 (95% CI, 0.18 to 0.50; P<0.01); in non-reperfused subjects CCC was 0.52 (95% CI, 0.20 to 0.60; P<0.001) and ICC was 0.60 (95% CI, 0.37 to 0.76; P<0.001). No difference was observed between the mCTA and CTP predicted infarct volume in the test cohort (P=0.67).
Conclusions A ML based mCTA model is able to predict brain tissue perfusion abnormality and follow-up infarction, comparable to CTP.
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Affiliation(s)
- Wu Qiu
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Hulin Kuang
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Johanna M Ospel
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada.,Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Michael D Hill
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Andrew M Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Mayank Goyal
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Bijoy K Menon
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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Ravindran AV, Killingsworth MC, Bhaskar S. Cerebral collaterals in acute ischaemia: Implications for acute ischaemic stroke patients receiving reperfusion therapy. Eur J Neurosci 2020; 53:1238-1261. [PMID: 32871623 DOI: 10.1111/ejn.14955] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/20/2020] [Accepted: 08/22/2020] [Indexed: 12/21/2022]
Abstract
The cerebral collaterals play an important role in penumbral tissue sustenance after an acute ischaemic stroke. Recent studies have demonstrated the potential role of collaterals in the selection of acute ischaemic stroke patients eligible for reperfusion therapy. However, the understanding of the significance and evidence around the role of collateral status in predicting outcomes in acute ischaemic stroke patients treated with reperfusion therapy is still unclear. Moreover, the use of pre-treatment collaterals in patient selection and prognosis is relatively underappreciated in clinical settings. A focused review of the literature was performed on the various methods of collateral evaluation and the role of collateral status in acute ischaemic stroke patients receiving reperfusion therapy. We discuss the methods of evaluating pre-treatment collaterals in clinical settings. The patient selection based on collateral status as well as the prognostic and therapeutic value of collaterals in acute ischaemic stroke, in settings of intravenous thrombolysis or endovascular therapy alone, and bridge therapy, are summarized. Recommendations for future research and possible pharmacological intervention strategies aimed at collateral enhancement are also discussed. Collaterals may play an important role in identifying acute ischaemic stroke patients who are likely to benefit from endovascular treatment in an extended time window. Future neuroscientific efforts to better improve our understanding of the role of collaterals in acute ischaemia as well as clinical studies to delineate its role in patient selection and acute stroke prognosis are warranted.
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Affiliation(s)
- Abina Vishni Ravindran
- South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW, Australia.,Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,Thrombolysis and Endovascular WorkFLOw Network (TEFLON), Sydney, NSW, Australia
| | - Murray C Killingsworth
- South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW, Australia.,NSW Brain Clot Bank, NSW Health Statewide Biobank and NSW Health Pathology, Sydney, NSW, Australia.,Correlative Microscopy Facility, Ingham Institute for Applied Medical Research and Department of Anatomical Pathology, NSW Health Pathology and Liverpool Hospital, Liverpool, NSW, Australia
| | - Sonu Bhaskar
- South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW, Australia.,Department of Neurology & Neurophysiology, Liverpool Hospital & South West Sydney Local Health District (SWSLHD), Sydney, NSW, Australia.,Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.,NSW Brain Clot Bank, NSW Health Statewide Biobank and NSW Health Pathology, Sydney, NSW, Australia.,Thrombolysis and Endovascular WorkFLOw Network (TEFLON), Sydney, NSW, Australia
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