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Nukovic JJ, Opancina V, Ciceri E, Muto M, Zdravkovic N, Altin A, Altaysoy P, Kastelic R, Velazquez Mendivil DM, Nukovic JA, Markovic NV, Opancina M, Prodanovic T, Nukovic M, Kostic J, Prodanovic N. Neuroimaging Modalities Used for Ischemic Stroke Diagnosis and Monitoring. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1908. [PMID: 38003957 PMCID: PMC10673396 DOI: 10.3390/medicina59111908] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/16/2023] [Accepted: 10/26/2023] [Indexed: 11/26/2023]
Abstract
Strokes are one of the global leading causes of physical or mental impairment and fatality, classified into hemorrhagic and ischemic strokes. Ischemic strokes happen when a thrombus blocks or plugs an artery and interrupts or reduces blood supply to the brain tissue. Deciding on the imaging modality which will be used for stroke detection depends on the expertise and availability of staff and the infrastructure of hospitals. Magnetic resonance imaging provides valuable information, and its sensitivity for smaller infarcts is greater, while computed tomography is more extensively used, since it can promptly exclude acute cerebral hemorrhages and is more favorable speed-wise. The aim of this article was to give information about the neuroimaging modalities used for the diagnosis and monitoring of ischemic strokes. We reviewed the available literature and presented the use of computed tomography, CT angiography, CT perfusion, magnetic resonance imaging, MR angiography and MR perfusion for the detection of ischemic strokes and their monitoring in different phases of stroke development.
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Affiliation(s)
- Jasmin J. Nukovic
- Faculty of Pharmacy and Health Travnik, University of Travnik, 72270 Travnik, Bosnia and Herzegovina
- Department of Radiology, General Hospital Novi Pazar, 36300 Novi Pazar, Serbia
| | - Valentina Opancina
- Department of Radiology, Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia
- Diagnostic Imaging and Interventional Neuroradiology Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
- Diagnostic and Interventional Neuroradiology Unit, A.O.R.N. Cardarelli, 80131 Naples, Italy
| | - Elisa Ciceri
- Diagnostic Imaging and Interventional Neuroradiology Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
| | - Mario Muto
- Diagnostic and Interventional Neuroradiology Unit, A.O.R.N. Cardarelli, 80131 Naples, Italy
| | - Nebojsa Zdravkovic
- Department of Biomedical Statistics and Informatics, Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Ahmet Altin
- Faculty of Medicine, Dokuz Eylul University, Izmir 35340, Turkey
| | - Pelin Altaysoy
- Faculty of Medicine, Bahcesehir University, Istanbul 34349, Turkey
| | - Rebeka Kastelic
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | | | - Jusuf A. Nukovic
- Faculty of Pharmacy and Health Travnik, University of Travnik, 72270 Travnik, Bosnia and Herzegovina
- Department of Radiology, General Hospital Novi Pazar, 36300 Novi Pazar, Serbia
| | - Nenad V. Markovic
- Department of Surgery, Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Miljan Opancina
- Department of Biomedical Statistics and Informatics, Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia
- Military Medical Academy, Faculty of Medicine, University of Defense, 11000 Belgrade, Serbia
| | - Tijana Prodanovic
- Department of Pediatrics, Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Merisa Nukovic
- Department of Radiology, General Hospital Novi Pazar, 36300 Novi Pazar, Serbia
| | - Jelena Kostic
- Department of Radiology, Medical Faculty, University of Belgrade, 11120 Beograd, Serbia
| | - Nikola Prodanovic
- Department of Surgery, Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia
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Halil E. CT perfusion - an up-to-date element of the contemporary multimodal diagnostic approach to acute ischemic stroke. Folia Med (Plovdiv) 2023; 65:531-538. [PMID: 37655371 DOI: 10.3897/folmed.65.e96954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 02/22/2023] [Indexed: 09/02/2023] Open
Abstract
Acute ischemic stroke is of great clinical and societal importance due to its high incidence and mortality rates, as well as the fact that those who are affected suffer from permanent acquired disability. Modern trends explicitly state that the disease's diagnostic plan should use a multidisciplinary approach. The therapeutic steps that ultimately determine the clinical outcome are defined by an accurate diagnosis of acute ischemic stroke. Highly specialized facilities for the diagnosis and treatment of acute ischemic stroke (Stroke Units) are in operation in countries that make significant investments in healthcare. Imaging the brain parenchyma at risk, or the so-called ischemic penumbra, in acute ischemic stroke is one of the main tasks of the multimodal computed tomography approach. The most rapid method for imaging the ischemic penumbra is computed tomography perfusion (CTP). This modality provides information about the anatomy and the physiologic state of the brain parenchyma.
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Affiliation(s)
- Eray Halil
- Medical University of Plovdiv, Plovdiv, Bulgaria
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3
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Thrombolysis for acute ischaemic stroke: current status and future perspectives. Lancet Neurol 2023; 22:418-429. [PMID: 36907201 DOI: 10.1016/s1474-4422(22)00519-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/06/2022] [Accepted: 12/13/2022] [Indexed: 03/14/2023]
Abstract
Alteplase is currently the only approved thrombolytic agent for treatment of acute ischaemic stroke, but interest is burgeoning in the development of new thrombolytic agents for systemic reperfusion with an improved safety profile, increased efficacy, and convenient delivery. Tenecteplase has emerged as a potential alternative thrombolytic agent that might be preferred over alteplase because of its ease of administration and reported efficacy in patients with large vessel occlusion. Ongoing research efforts are also looking at potential improvements in recanalisation with the use of adjunct therapies to intravenous thrombolysis. New treatment strategies are also emerging that aim to reduce the risk of vessel reocclusion after intravenous thrombolysis administration. Other research endeavors are looking at the use of intra-arterial thrombolysis after mechanical thrombectomy to induce tissue reperfusion. The growing implementation of mobile stroke units and advanced neuroimaging could boost the number of patients who can receive intravenous thrombolysis by shortening onset-to-treatment times and identifying patients with salvageable penumbra. Continued improvements in this area will be essential to facilitate the ongoing research endeavors and to improve delivery of new interventions.
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Nagamoto K, Watanabe R, Kawachino T, Ohishi Y, Yamamoto A, Moritake T, Nihei SI, Kamochi M, Kunugita N. CONTRIBUTION OF ORGAN-BASED TUBE CURRENT MODULATION TO THE REDUCTION OF LENS EXPOSURE DOSE IN HEAD 4D CT IMAGING: A PHANTOM STUDY. RADIATION PROTECTION DOSIMETRY 2022; 198:1377-1386. [PMID: 36062449 DOI: 10.1093/rpd/ncac179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 07/04/2022] [Accepted: 08/02/2022] [Indexed: 06/15/2023]
Abstract
The purpose of this study was to evaluate the effectiveness of organ effect modulation (OEM) in reducing the lens dose in 4D computed tomography (CT) of the head in volume-acquisition (NVA) mode. Six radiophotoluminescent dosemeters were placed on the head of a RANDO phantom. The doses absorbed by the organs and image noise change rate were determined. The lens doses without OEM (i.e. in the OEMoff case) were higher than those with the same target standard deviation and volume-computed tomography dose index (CTDIvol) as in the OEMoff case (p < 0.01). The image noise change rate was 11%. OEM reduced the lens dose during head 4D CT imaging in the NVA mode by 18%. Furthermore, the feasibility of lens dose reduction while ensuring sufficient image quality was confirmed under the condition in which OEM was employed with the same CTDIvol as in the OEMoff case.
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Affiliation(s)
- Keisuke Nagamoto
- Department of Radiology, Hospital of the University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-Ku, Kitakyushu, Fukuoka, Japan
| | - Ryo Watanabe
- Department of Radiology, Hospital of the University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-Ku, Kitakyushu, Fukuoka, Japan
| | - Tomonori Kawachino
- Department of Radiology, Hospital of the University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-Ku, Kitakyushu, Fukuoka, Japan
| | - Yoshitaka Ohishi
- Department of Radiology, Hospital of the University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-Ku, Kitakyushu, Fukuoka, Japan
| | - Aina Yamamoto
- Department of Radiology, Hospital of the University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-Ku, Kitakyushu, Fukuoka, Japan
| | - Takashi Moritake
- Department of Radiation Regulatory Research Group, National Institute of Radiological Sciences, Quantum Life and Medical Science Directorate, National Institute for Quantum and Radiological Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba, Japan
| | - Shun-Ichi Nihei
- Intensive Care Unit, Hospital of the University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka, Japan
| | - Masayuki Kamochi
- Intensive Care Unit, Hospital of the University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka, Japan
| | - Naoki Kunugita
- Department of Occupational and Community Health Nursing School of Health Sciences, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-Ku, Kitakyushu, Fukuoka, Japan
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Deng PP, Wu N, Chen XJ, Chen FL, Xu HS, Bao GS. NIHSS-the Alberta Stroke Program Early CT Score mismatch in guiding thrombolysis in patients with acute ischemic stroke. J Neurol 2021; 269:1515-1521. [PMID: 34318373 PMCID: PMC8315493 DOI: 10.1007/s00415-021-10704-5] [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: 03/18/2021] [Revised: 06/20/2021] [Accepted: 07/09/2021] [Indexed: 11/29/2022]
Abstract
Objective This study investigates the mismatch between the National Institutes of Health Stroke Scale (NIHSS) score and the computed tomography (CT) findings measured by the Alberta Stroke Program Early CT Score (ASPECTS) for predicting the functional outcome and safety of intravenous thrombolysis (IVT) treatment in patients with acute ischemic stroke (AIS). Methods This prospective observational study includes patients with AIS who underwent CT imaging within 4.5 h of the onset of symptoms. Patients were divided into the NIHSS–ASPECTS mismatch (NAM)-positive and NAM-negative groups (group P and N, respectively). The clinical outcome was assessed using the Modified Rankin Scale (mRS). Safety outcomes included progression, symptomatic intracerebral hemorrhage (sICH), intracerebral hemorrhage (ICH), adverse events, clinical adverse events, and mortality. Results A total of 208 patients were enrolled in the study. In group P, IVT treatment was associated with a good functional outcome at 3 months (p = 0.005) and 1 year (p = 0.001). A higher percentage of patients with favorable mRS (0–2) (p = 0.01) and excellent mRS (0–1) (p = 0.011) functional outcomes was obtained at 1 year in group P with IVT treatment. Group N did not benefit from the same treatment (p = 0.352 and p = 0.480 at 3 months and 1 year, respectively). There were no statistically significant differences in sICH, ICH, mortality rates, or other risks between the IVT and conventional treatment groups. Conclusion IVT treatment is associated with a good functional outcome in patients with NAM, without increasing the risks of sICH, ICH, mortality, or other negative outcomes. NAM promises to be an easily obtained indicator for guiding the treatment decisions of AIS.
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Affiliation(s)
- Pan-Pan Deng
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, No. 280 of Mohe street, Baoshan District, Shanghai, 201999, China
| | - Na Wu
- Department of Neurology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Xiao-Jie Chen
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, No. 280 of Mohe street, Baoshan District, Shanghai, 201999, China
| | - Feng-Ling Chen
- Department of Endocrinology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 201999, China
| | - Heng-Shi Xu
- Department of Blood Transfusion, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, No. 280 of Mohe Street, Baoshan District, Shanghai, 201999, China.
| | - Guan-Shui Bao
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, No. 280 of Mohe street, Baoshan District, Shanghai, 201999, China.
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Duan H, Chen L, Shen S, Zhang Y, Li C, Yi Z, Wang Y, Zhang J, Li L. Staged Endovascular Treatment for Symptomatic Occlusion Originating From the Intracranial Vertebral Arteries in the Early Non-acute Stage. Front Neurol 2021; 12:673367. [PMID: 34220682 PMCID: PMC8245001 DOI: 10.3389/fneur.2021.673367] [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: 02/27/2021] [Accepted: 05/19/2021] [Indexed: 11/17/2022] Open
Abstract
Background: The ideal treatment for patients who survive from acute vertebrobasilar artery occlusion but develop aggressive ischemic events despite maximal medical therapy in the early non-acute stage is unknown. This paper reports the technical feasibility and outcome of staged endovascular treatment in a series of such patients with symptomatic intracranial vertebral artery occlusion. Methods: Ten consecutive patients who presented with aggressive ischemic events in the early non-acute stage of intracranial vertebral artery occlusion from Jan 2015 to Nov 2020 were retrospectively reviewed. Among them, eight male and two female patients with a mean age of 66.7 years developed aggressive ischemic events, and the NIHSS score was elevated by a median of 7 points despite medical therapy. All patients received staged endovascular treatment 4–21 days from onset, at an average of 11 days. The strategy of staged treatment was as follows: first, a microwire was passed through the portion of the occlusion, which was then dilated with balloon inflation to maintain the perfusion above TICI grade 2b. Then, with the use of antiplatelet drugs, the residual intravascular thrombus was gradually eliminated by the continuous perfusion and an activated fibrinolytic system, leaving the residual stenosis. A second stage of angioplasty with stent implantation was subsequently performed if residual stenosis was ≥50%. The NIHSS scores and mRS scores were compared between pre- and post-endovascular treatment groups and in the follow-up period. Results: Technical success was achieved in 9 patients who received staged endovascular treatment (perforation occurred in one patient during the first stage). The NIHSS scores were significantly improved, with a median score 7 points lower on discharge compared with the scores for the most severe status. Favorable outcomes with mRS score ≤ 2 were achieved in 7 and 9 patients at the 3-month follow-up and the latest follow-up, respectively, which was better than the preoperative status. Conclusion: Staged endovascular treatment might be a safe, efficient, and viable option in carefully selected patients with symptomatic intracranial vertebral artery occlusion in the early non-acute stage. However, this needs to be confirmed by further investigation, preferably in a large, controlled setting.
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Affiliation(s)
- Hongzhou Duan
- Department of Neurosurgery, Peking University First Hospital, Beijing, China
| | - Li Chen
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shengli Shen
- Department of Neurosurgery, Peking University First Hospital, Beijing, China
| | - Yang Zhang
- Department of Neurosurgery, Peking University First Hospital, Beijing, China
| | - Chunwei Li
- Department of Neurosurgery, Peking University First Hospital, Beijing, China
| | - Zhiqiang Yi
- Department of Neurosurgery, Peking University First Hospital, Beijing, China
| | - Yingjin Wang
- Department of Neurosurgery, Peking University First Hospital, Beijing, China
| | - Jiayong Zhang
- Department of Neurosurgery, Peking University First Hospital, Beijing, China
| | - Liang Li
- Department of Neurosurgery, Peking University First Hospital, Beijing, China
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Mac Grory B, Saldanha IJ, Mistry EA, Stretz C, Poli S, Sykora M, Kellert L, Feil K, Shah S, McTaggart R, Riebau D, Yaghi S, Gaines K, Xian Y, Feng W, Schrag M. Thrombolytic therapy for wake-up stroke: A systematic review and meta-analysis. Eur J Neurol 2021; 28:2006-2016. [PMID: 33772987 DOI: 10.1111/ene.14839] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 03/21/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND PURPOSE According to evidence-based clinical practice guidelines, patients presenting with disabling stroke symptoms should be treated with intravenous tissue plasminogen activator (IV tPA) within 4.5 h of time last known well. However, 25% of strokes are detected upon awakening (i.e., wake-up stroke [WUS]), which renders patients ineligible for IV tPA administered via time-based treatment algorithms, because it is impossible to establish a reliable time of symptom onset. We performed a systematic review and meta-analysis of the efficacy and safety of IV tPA compared with normal saline, placebo, or no treatment in patients with WUS using imaging-based treatment algorithms. METHODS We searched MEDLINE, Web of Science, and Scopus between January 1, 2006 and April 30, 2020. We included controlled trials (randomized or nonrandomized), observational cohort studies (prospective or retrospective), and single-arm studies in which adults with WUS were administered IV tPA after magnetic resonance imaging (MRI)- or computed tomography (CT)-based imaging. Our primary outcome was recovery at 90 days (defined as a modified Rankin Scale [mRS] score of 0-2), and our secondary outcomes were symptomatic intracranial hemorrhage (sICH) within 36 h, mortality, and other adverse effects. RESULTS We included 16 studies that enrolled a total of 14,017 patients. Most studies were conducted in Europe (37.5%) or North America (37.5%), and 1757 patients (12.5%) received IV tPA. All studies used MRI-based (five studies) or CT-based (10 studies) imaging selection, and one study used a combination of modalities. Sixty-one percent of patients receiving IV tPA achieved an mRS score of 0 to 2 at 90 days (95% confidence interval [CI]: 51%-70%, 12 studies), with a relative risk (RR) of 1.21 compared with patients not receiving IV tPA (95% CI: 1.01-1.46, four studies). Three percent of patients receiving IV tPA experienced sICH within 36 h (95% CI: 2.5%-4.1%; 16 studies), which is an RR of 4.00 compared with patients not receiving IV tPA (95% CI: 2.85-5.61, seven studies). CONCLUSIONS This systematic review and meta-analysis suggests that IV tPA is associated with a better functional outcome at 90 days despite the increased but acceptable risk of sICH. Based on these results, IV tPA should be offered as a treatment for WUS patients with favorable neuroimaging findings.
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Affiliation(s)
- Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ian J Saldanha
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA.,Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Eva A Mistry
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Christoph Stretz
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Sven Poli
- Department of Neurology With Focus on Neurovascular Diseases, University Hospital Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, University Hospital Tübingen, Tübingen, Germany
| | - Marek Sykora
- Department of Neurology, St. John's Hospital, Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilians University, Munich, Germany
| | - Katharina Feil
- Department of Neurology, Ludwig Maximilians University, Munich, Germany
| | - Shreyansh Shah
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ryan McTaggart
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Department of Radiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Derek Riebau
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Shadi Yaghi
- Department of Neurology, New York University School of Medicine, New York, New York, USA
| | - Kenneth Gaines
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Ying Xian
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Matthew Schrag
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Macha K, Hoelter P, Siedler G, Knott M, Schwab S, Doerfler A, Kallmünzer B, Engelhorn T. Multimodal CT or MRI for IV thrombolysis in ischemic stroke with unknown time of onset. Neurology 2020; 95:e2954-e2964. [DOI: 10.1212/wnl.0000000000011059] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 08/03/2020] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo investigate differences in procedure times, safety, and efficacy outcomes comparing 2 different protocols to enable thrombolysis in the extended or unknown time window after stroke onset with either multimodal CT or MRI.MethodsPatients with ischemic stroke in the extended or unknown time window who received IV thrombolysis between January 2011 and May 2019 were identified from an institutional registry. Imaging-based selection was done by multimodal CT or MRI according to institutional treatment algorithms.ResultsIV thrombolysis was performed in 100 patients (54.3%) based on multimodal CT imaging and in 84 patients (45.7%) based on MRI. Baseline clinical data, including stroke severity and time from last seen normal to hospital admission, were similar in patients with CT and MRI. Door-to-needle times were shorter in patients with CT-based selection (median [interquartile range] 45 [37–62] minutes vs 75 [59–90] minutes; mean difference [95% confidence interval (CI)] −28 minutes [−35 to −21]). No differences were detected regarding the incidence of symptomatic intracranial hemorrhage (2 [2.0%] vs 4 [4.8%]; adjusted odds ratio [aOR] [95% CI] 0.47 [0.08–2.83]) and favorable outcome at day 90 (25 [33.8%] vs 33 [42.9%]; aOR 0.95 [0.45–2.02]).ConclusionIV thrombolysis in ischemic stroke in the unknown or extended time window appeared safe in CT- and MRI-selected patients, while the use of CT imaging led to faster door-to-needle times.Classification of evidenceThis study provides Class IV evidence that for patients with ischemic stroke in the extended or unknown time window, imaging-based selection for IV thrombolysis by multimodal CT compared to MRI led to shorter door-to-needle times.
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Ajčević M, Furlanis G, Stella AB, Cillotto T, Caruso P, Ridolfi M, Lugnan C, Miladinović A, Ukmar M, Cova MA, Accardo A, Manganotti P, Naccarato M. A CT perfusion based model predicts outcome in wake-up stroke patients treated with recombinant tissue plasminogen activator. Physiol Meas 2020; 41:075011. [PMID: 32531770 DOI: 10.1088/1361-6579/ab9c70] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Advanced neuroimaging has proved to be pivotal in the management of acute ischemic stroke. The use of CT perfusion (CTP) core and penumbra parameters to predict the outcome in wake-up stroke (WUS) patients in everyday clinical scenarios has not yet been investigated. The aim of our study was to investigate the predictive power of CTP parameters on functional and morphological outcomes in WUS patients treated with recombinant tissue plasminogen activator (rTPA). APPROACH We analyzed clinical data and processed CTP images of 83 consecutive WUS patients treated with rTPA. The predictive power of whole-brain CTP features and of the clinical stroke-related parameters to predict the National Institutes of Health Stroke Scale (NIHSS) score at the seventh day and ischemic lesion volume outcome was investigated by means of multivariate regression analysis as well as least absolute shrinkage and selection operator (LASSO) modeling. MAIN RESULTS Multivariate analysis showed that CTP core volume (β = 0.403, p = 0.000), NIHSS at admission (β = 0.323, p = 0.005) and Alberta Stroke Program Early CT (ASPECT) score (β = -0.224, p = 0.012) predict NIHSS at 7 days, while total hypoperfused volume (β = 0.542, p = 0.000) and core volume on CTP (β =0.441, p = 0.000) predict infarct lesion volume at follow-up CT. The LASSO modeling approach confirmed the significant predictive power of CTP core volume, total hypoperfused CTP volume, NIHSS at baseline and ASPECT score, producing a sparse model with adequate reliability (the root mean square error on a previously unseen testing dataset was 3.68). SIGNIFICANCE Our findings highlight the importance of CT multimodal imaging features for decision-making and prediction in the hyperacute phase of WUS. The predictive model supports the hypothesis that an irreversible necrotic core rather than the extent of the penumbra is the main prognostic factor in WUS patients treated with rTPA.
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Affiliation(s)
- Miloš Ajčević
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy. Department of Engineering and Architecture, University of Trieste, Via A. Valerio, 10, 34127, Trieste, Italy
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Zhang YL, Zhang JF, Wang XX, Wang Y, Anderson CS, Wu YC. Wake-up stroke: imaging-based diagnosis and recanalization therapy. J Neurol 2020; 268:4002-4012. [PMID: 32671526 DOI: 10.1007/s00415-020-10055-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 07/02/2020] [Accepted: 07/04/2020] [Indexed: 02/08/2023]
Abstract
Wake-up stroke (WUS) is a subgroup of ischemic stroke in which patients show no abnormality before sleep while wake up with neurological deficits. In addition to the uncertain onset, WUS patients have difficulty to receive prompt and effective thrombolytic or reperfusion therapy, leading to relatively poor prognosis. A number of researches have indicated that CT or MRI based thrombolysis and endovascular therapy might have benefits for WUS patients. This review article narratively discusses the pathogenesis, risk factors, imaging-based diagnosis and recanalization treatments of WUS with the purpose of expanding current treatment options for this group of stroke patients and exploring better therapeutic methods. The result showed that multimodal MRI or CT scan might be the best methods for extending the time window of WUS and, therefore, a large proportion of WUS patients could have favorable prognosis.
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Affiliation(s)
- Yu-Lei Zhang
- Department of Neurology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, People's Republic of China
| | - Jun-Fang Zhang
- Department of Neurology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, People's Republic of China
| | - Xi-Xi Wang
- Department of Neurology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, People's Republic of China
| | - Yan Wang
- Department of Neurology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, People's Republic of China
| | | | - Yun-Cheng Wu
- Department of Neurology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, People's Republic of China.
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Zhao S, Jiang H, Liang ZH, Ju H. Integrating Multi-Omics Data to Identify Novel Disease Genes and Single-Neucleotide Polymorphisms. Front Genet 2020; 10:1336. [PMID: 32038707 PMCID: PMC6993083 DOI: 10.3389/fgene.2019.01336] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/06/2019] [Indexed: 12/15/2022] Open
Abstract
Stroke ranks the second leading cause of death among people over the age of 60 in the world. Stroke is widely regarded as a complex disease that is affected by genetic and environmental factors. Evidence from twin and family studies suggests that genetic factors may play an important role in its pathogenesis. Therefore, research on the genetic association of susceptibility genes can help understand the mechanism of stroke. Genome-wide association study (GWAS) has found a large number of stroke-related loci, but their mechanism is unknown. In order to explore the function of single-nucleotide polymorphisms (SNPs) at the molecular level, in this paper, we integrated 8 GWAS datasets with brain expression quantitative trait loci (eQTL) dataset to identify SNPs and genes which are related to four types of stroke (ischemic stroke, large artery stroke, cardioembolic stroke, small vessel stroke). Thirty-eight SNPs which can affect 14 genes expression are found to be associated with stroke. Among these 14 genes, 10 genes expression are associated with ischemic stroke, one gene for large artery stroke, six genes for cardioembolic stroke and eight genes for small vessel stroke. To explore the effects of environmental factors on stroke, we identified methylation susceptibility loci associated with stroke using methylation quantitative trait loci (MQTL). Thirty-one of these 38 SNPs are at greater risk of methylation and can significantly change gene expression level. Overall, the genetic pathogenesis of stroke is explored from locus to gene, gene to gene expression and gene expression to phenotype.
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Affiliation(s)
- Sheng Zhao
- Department of Radiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Huijie Jiang
- Department of Radiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Zong-Hui Liang
- Department of Radiology, Jian'an District Centre Hospital of Fudan University, Shanghai, China
| | - Hong Ju
- Department of Information Engineering, Heilongjiang Biological Science and Technology Career Academy, Harbin, China
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Wake-up stroke: thrombolysis reduces ischemic lesion volume and neurological deficit. J Neurol 2019; 267:666-673. [PMID: 31720820 DOI: 10.1007/s00415-019-09603-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUNDS Wake-Up Stroke (WUS) patients are generally excluded from thrombolytic therapy (rTPA) due to the unknown time of stroke onset. This study aimed to investigate the effects of rTPA in WUS patients during every day clinical scenarios, by measuring ischemic lesion volume and functional outcomes compared to non-treated WUS patients. METHODS We retrospectively analyzed clinical and imaging data of 149 (75 rTPA; 74 non-rTPA) patients with acute ischemic WUS. Ischemic volume was calculated on follow-up CT and functional outcomes were the NIHSS and mRS comparing rTPA and non-rTPA WUS. Patients were selected using ASPECTS > 6 on CT and/or ischemic penumbra > 50% of hypoperfused tissue on CTP. RESULTS A reduced volume was measured on the follow-up CT for rTPA (1 mL, 0-8) compared to the non-rTPA patients (10 mL, 0-40; p = 0.000). NIHSS at 7 days from admission was significantly lower in the rTPA (1, 0-4) compared to non-rTPA group (3, 1-9; p = 0.015), as was the percentage of improvement (ΔNIHSS) (70% vs 50%; p = 0.002). A higher prevalence of mRS 0-2 was observed in the rTPA compared to the non-rTPA (54% vs 39%; p = 0.060). Multivariate analysis showed that NIHSS at baseline and rTPA treatment are significant predictors of good outcome both in terms of NIHSS at 7 days and ischemic lesion volume on follow-up CT (p < 0.05). CONCLUSIONS rTPA in WUS patients selected with CT and/or CTP resulted in reduced ischemic infarct volume on follow-up CT and better functional outcome without increment of intracranial hemorrhages and in-hospital mortality.
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